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  • 101.
    Lusey, Hendrew
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Nursing. World Council of Churches, Ecumenical HIV and AIDS Initiative and Advocacy (EHAIA), Kinshasa Gombe, Democratic Republic of Congo.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edin, Kerstin E.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Prevalence and correlates of gender inequitable norms among young, church-going women and men in Kinshasa, Democratic Republic of Congo2018In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 18, article id 887Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Prolonged political instability may have exacerbated gender inequitable beliefs in the Democratic Republic of Congo (DRC). The aim of this study was to assess attitudes related to gender-equitable norms and its determinants among young, church-going women and men in Kinshasa, DRC.

    METHOD: Data were collected through a cross-sectional survey with 291 church-going women and 289 men aged 18-24 years old, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality, and responses to issues related to the gender-equitable men (GEM) scale. The GEM scale is a 24 item-questionnaire developed to measure attitudes towards gender equitable norms. Logistic regression was applied to discover the associations between the independent variables and the GEM outcome.

    RESULTS: Our study reflected the existence of attitudes hampering gender equality that were endorsed by both women and men. For example, 91.4% of women and 83% of men agreed with the statement "a woman's most important role is to take care of her home and cook for her family". Similarly, 88.3% of women and 82.9% of men concurred with the idea that men need more sex than women. These findings coexisted with a few equitable norms, because 93.7% of women and 92.3% of men agreed that a man and a woman should decide together if they want to have children. A positive association was found in both women and men between being educated, being single and separated and having supportive attitudes towards gender equality and a higher GEM scale score. Residency in Camp Luka and Masina was also a significant social determinant associated with equitable gender norms among men whilst job status was only significant among women.

    CONCLUSION: While both women and men had high levels of gender inequitable norms, those with more education, single, and with supportive attitudes to gender equality had high GEM scale scores. The results highlight an urgent need for the church to challenge and change gender norms among church youths.

  • 102.
    Lusey, Hendrew
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Nursing. World Council of Churches, Central Africa Regional Coordinator of the Ecumenical HIV and AIDS Initiative in Africa (EHAIA), Kinshasa Gombe, Democratic Republic of Congo.
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edin, Kerstin E.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Factors associated with gender equality among church-going young men in Kinshasa, Democratic Republic of Congo: a cross-sectional study2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 213Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 103.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: perceptions of stakeholders2010In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 10, p. Article nr 322-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2006, researchers and decision-makers launched a five year project, Response to Accountable Priority Setting for Trust in Health Systems (REACT) to improve planning and priority setting through implementing the Accountability for Reasonableness framework in Mbarali District in Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees.

    METHODS: Individual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions asking respondents to describe their perceptions regarding the applicability and feasibility of each condition of the Accountability for Reasonableness framework to priority setting. Interviews were analysed using thematic framework analysis. Documentary data was used to support, verify and highlight key issues that emerged.

    RESULTS: Almost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority setting and health service delivery in their context. However, a few aspects of the Accountability for Reasonableness framework were seen as difficult to implement given the socio-political conditions and traditions in Tanzania. Respondents mentioned budget ceilings and guidelines, low level of public awareness, unreliable and untimely funding as well as limited capacity of the district to generate local resources as the major contextual factors that hamper the full implementation of the framework in their context.

    CONCLUSION: This study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting process in the contexts of resource poor settings. However, the full implementation of Accountability for Reasonableness framework would require a proper capacity-building plan to all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the public that will live with the consequences of priority setting decisions.

  • 104.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark .
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O.Box 235, Iringa, Tanzania .
    Olsen, Öystein E
    Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania .
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation2011In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 6, p. Article nr 11-Article in journal (Refereed)
    Abstract [en]

    Background: Despite the growing importance of the Accountability for Reasonableness (A4R) framework in priority setting worldwide, there is still an inadequate understanding of the processes and mechanisms underlying its influence on legitimacy and fairness, as conceived and reflected in service management processes and outcomes. As a result, the ability to draw scientifically sound lessons for the application of the framework to services and interventions is limited. This paper evaluates the experiences of implementing the A4R approach in Mbarali District, Tanzania, in order to find out how the innovation was shaped, enabled, and constrained by the interaction between contexts, mechanisms and outcomes.

    Methods: This study draws on the principles of realist evaluation - a largely qualitative approach, chiefly concerned with testing and refining programme theories by exploring the complex interactions of contexts, mechanisms, and outcomes. Mixed methods were used in data collection, including individual interviews, non-participant observation, and document reviews. A thematic framework approach was adopted for the data analysis.

    Results: The study found that while the A4R approach to priority setting was helpful in strengthening transparency, accountability, stakeholder engagement, and fairness, the efforts at integrating it into the current district health system were challenging. Participatory structures under the decentralisation framework, central government's call for partnership in district-level planning and priority setting, perceived needs of stakeholders, as well as active engagement between researchers and decision makers all facilitated the adoption and implementation of the innovation. In contrast, however, limited local autonomy, low level of public awareness, unreliable and untimely funding, inadequate accountability mechanisms, and limited local resources were the major contextual factors that hampered the full implementation.

    Conclusion: This study documents an important first step in the effort to introduce the ethical framework A4R into district planning processes. This study supports the idea that a greater involvement and accountability among local actors through the A4R process may increase the legitimacy and fairness of priority-setting decisions. Support from researchers in providing a broader and more detailed analysis of health system elements, and the socio-cultural context, could lead to better prediction of the effects of the innovation and pinpoint stakeholders' concerns, thereby illuminating areas that require special attention to promote sustainability.

  • 105.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    San Sebastiån, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
    Olsen, Øystein E
    DBL-Centre for Health Research and Development and Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania.
    Shayo, Elizabeth
    National Institute for Medical Research (NIMR), P.O. Box 9653, Dar Es Salaam, Tanzania.
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Decentralized health care priority-setting in Tanzania: evaluating against the accountability for reasonableness framework2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 71, no 4, p. 751-759Article in journal (Refereed)
    Abstract [en]

    Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting in the district was observed. The results indicate that, while Tanzania has a decentralized public health care system, the reality of the district level priority-setting process was that it was not nearly as participatory as the official guidelines suggest it should have been. Priority-setting usually occurred in the context of budget cycles and the process was driven by historical allocation. Stakeholders' involvement in the process was minimal. Decisions (but not the reasoning behind them) were publicized through circulars and notice boards, but there were no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level in the contexts of low-income countries. Second, it provides guidance to decision-makers on how to improve fairness, legitimacy, and sustainability of the priority-setting process.

  • 106.
    Maluka, Stephen Oswald
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastián, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Shayo, Elizabeth
    National Institute of Medical Research (NIMR), Dar es Salaam, United Republic of Tanzania.
    Byskov, Jens
    DBL—Centre for Health Research and Development, University of Copenhagen, Copenhagen, Denmark.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar es Salaam, United Republic of Tanzania.
    Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality2011In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 26, no 2, p. e102-e120Article in journal (Refereed)
    Abstract [en]

    During the 1990s, Tanzania like many other developing countries adopted health sector reforms. The most common policy change under the health sector reforms has been decentralization, which involves the transfer of power and authority from the central level to local authorities. Based on the case study of Mbarali district in Tanzania, this paper uses a policy analysis approach to analyse the implementation of decentralized health care priority setting. Specifically, the paper examines the process, actors and contextual factors shaping decentralized health care priority setting processes. The analysis and conclusion are based on a review of documents, key informant interviews, focus group discussion, and notes from non-participant observation. The findings of the study indicate that local institutional contexts and power asymmetries among actors have a greater influence on the prioritization process at the local level than expected and intended. The paper underlines the essentially political character of the decentralization process and reiterates the need for policy analysts to pay attention to processes, institutional contexts, and the role of policy actors in shaping the implementation of the decentralization process at the district level. Copyright (c) 2010 John Wiley & Sons, Ltd.

  • 107.
    Mamani-Ortiz, Yercin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastián Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Armaza Céspedes, Ada Ximena
    Luizaga López, Jenny Marcela
    Illanes Velarde, Daniel Elving
    Mosquera Méndez, Paola A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, no 1, article id 153Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 108.
    Mamani-Ortiz, Yercin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Aniceto Arce Avenue, 371 Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Armaza, Ada X.
    Luizaga, Jenny M.
    Illanes, Daniel E.
    Ferrel, Marcia
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Prevalence and determinants of cardiovascular disease risk factors using the WHO STEPS approach in Cochabamba, Bolivia2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 786Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular diseases (CVDs) are considered the number one cause of death worldwide, especially in low- and middle-income countries, Bolivia included. Lack of reliable estimates of risk factor distribution can lead to delay in implementation of evidence-based interventions. However, little is known about the prevalence of risk factors in the country. The aim of this study was to assess the prevalence of preventable risk factors associated with CVDs and to identify the demographic and socioeconomic factors associated with them in Cochabamba, Bolivia.

    Methods: A cross-sectional community-based study was conducted among youth and adults (N = 10,704) with permanent residence in Cochabamba, selected through a multistage sampling technique, from July 2015 to November 2016. An adapted version of the WHO STEPS survey was used to collect information. The prevalence of relevant behavioural risk factors and anthropometric measures were obtained. The socio-demographic variables included were age, ethnicity, level of education, occupation, place of residence, and marital status. Proportions with 95% confidence intervals were first calculated, and prevalence ratios were estimated for each CVD risk factor, both with crude and adjusted models.

    Results: More than half (57.38%) were women, and the mean age was 37.89 ± 18 years. The prevalence of behavioural risk factors were: current smoking, 11.6%; current alcohol consumption, 42.76%; low consumption of fruits and vegetables, 76.73%; and low level of physical activity, 64.77%. The prevalence of overweight was 35.84%; obesity, 20.49%; waist risk or abdominal obesity, 54.13%; and raised blood pressure, 17.5%. Indigenous populations and those living in the Andean region showed in general a lower prevalence of most of the risk factors evaluated.

    Conclusion: We provide the first CVD risk factor profile of people living in Cochabamba, Bolivia, using a standardized methodology. Overall, findings suggest that the prevalence of CVD risk factors in Cochabamba is high. This result highlights the need for interventions to improve early diagnosis, monitoring, management, and especially prevention of these risk factors.

  • 109.
    Mathias, Kaaren
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. New Delhi, India .
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kermode, Michelle
    Victoria, Australia.
    Singh, Lawrence
    Uttarakhand, India.
    Shidhaye, Rahul
    New Delhi, India.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cross-sectional study of depression and help-seeking in Uttarakhand, North India2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 11, article id e008992Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study sought to use a population-based cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.

    SETTING: This study was conducted in Sahaspur and Raipur, administrative blocks of Dehradun district, Uttarakhand, in July 2014.

    PARTICIPANTS: A population-based sample of 960 people over the age of 18 years was selected in 30 randomised clusters after being stratified by rural:urban census ratios.

    PRIMARY OUTCOME MEASURES: The survey used a validated screening tool, Patient Health Questionnaire, to identify people with depression, and collected information regarding socioeconomic variables and help-seeking behaviours. Depression prevalence and health seeking behaviours were calculated, and multivariable logistic regression was used to assess associations between risk factors and depression.

    RESULTS: Prevalence of depression was 6% (58/960), with a further 3.9% (37/960) describing a depressive episode of over 2 weeks in the past 12 months. Statistically significant adjusted OR for depression of more than 2 were found for people who were illiterate, classified as Scheduled Caste/Tribe or Other Backward Castes, living in temporary material housing and who had recently taken a loan. While over three quarters of people with depression (79%) had attended a private or government general medical practitioner in the past 3 months, none had received talking therapy (100% treatment gap) and two people (3.3%) had been prescribed antidepressants.

    CONCLUSIONS: There are clear associations between social, educational and economic disadvantage and depression in this population. Strategies that address the social determinants of depression, such as education, social exclusion, financial protection and affordable housing for all are indicated. To address the large treatment gap in Uttarakhand, we must ensure access to primary and secondary mental health providers who can recognise and appropriately manage depression.

  • 110.
    Mathias, Kaaren
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Emmanuel Hospital Association, New Delhi, India; Landour community hospital, Mussoorie, Uttarakhand 248 179, India.
    Kermode, M.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Seefeldt, L.
    Shidhaye, R.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Social distance and community attitudes towards people with psycho-social disabilities in  Uttarakhand, India2018In: Community mental health journal, ISSN 0010-3853, E-ISSN 1573-2789, Vol. 54, no 3, p. 343-353Article in journal (Refereed)
    Abstract [en]

    Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

  • 111.
    Mathias, Kaaren
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kermode, M
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Davar, B
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    An asymmetric burden gendered experiences of caregivers of people with psycho-social disabilities in North IndiaIn: Transcultural Psychiatry, ISSN 1363-4615, E-ISSN 1461-7471Article in journal (Refereed)
  • 112. Mathias, Kaaren
    et al.
    Kermode, Michelle
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Davar, Bhargavi
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    An asymmetric burden: experiences of men and women as caregivers of people with psycho-social disabilities in rural North India2019In: Transcultural Psychiatry, ISSN 1363-4615, E-ISSN 1461-7471, Vol. 56, no 1, p. 76-102Article in journal (Refereed)
    Abstract [en]

    Caring for a family member with a psycho-social disability can be both rewarding and burdensome. This study analyses the experiences of caregivers of people with psychosocial disabilities (PPSDs) in rural communities in North India using relational gender theory. In-depth interviews with 18 female and male caregivers of PPSDs probed the social, emotional and health impacts of their caregiving role. Nine themes were identified that were grouped under three meta-themes: intra-personal, inter-personal and institutional impacts. Under the intra-personal meta-theme, all caregivers experienced high tension, with women describing almost overwhelming stress. Women minimised their role as caregivers, and felt negative and hopeless about their futures, while men had a more positive view of the future and themselves. Embodied experiences of psychological and social distress were consistently described by women, but not by men. Within the interpersonal meta-theme, men experienced opportunity for social connection and social support that was seldom available to women. Interpersonal violence with other household members was described by both men and women. Within the institutional meta-theme, both men and women described strength in unity, and gestures leading to the reordering of gender relations. These findings underline the significant and diffuse impacts of a gender order that values males and disadvantages females as caregivers of PPSDs, with the asymmetry of a greater burden for women. The findings point to the urgent need for global mental health policies that support and empower caregivers and that strengthen gender equality.

  • 113.
    Mathias, Kaaren
    et al.
    Landour Community Hospital, Landour, Uttarakhand.
    Kermode, Michelle
    Landour Community Hospital, Landour, Uttarakhand.
    San Sebastian, Miguel
    Landour Community Hospital, Landour, Uttarakhand.
    Koschorke, Mirja
    Landour Community Hospital, Landour, Uttarakhand.
    Goicolea, Isabel
    Landour Community Hospital, Landour, Uttarakhand.
    Under the banyan tree: exclusion and inclusion of people with mental disorders in rural North India2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 446Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Social exclusion is both cause and consequence of mental disorders. People with mental disorders (PWMD) are among the most socially excluded in all societies yet little is known about their experiences in North India. This qualitative study aims to describe experiences of exclusion and inclusion of PWMD in two rural communities in Uttar Pradesh, India.

    METHODS: In-depth interviews with 20 PWMD and eight caregivers were carried out in May 2013. Interviews probed experiences of help-seeking, stigma, discrimination, exclusion, participation, agency and inclusion in their households and communities. Qualitative content analysis was used to generate codes, categories and finally 12 key themes.

    RESULTS: A continuum of exclusion was the dominant experience for participants, ranging from nuanced distancing, negative judgements and social isolation, and self-stigma to overt acts of exclusion such as ridicule, disinheritance and physical violence. Mixed in with this however, some participants described a sense of belonging, opportunity for participation and support from both family and community members.

    CONCLUSIONS: These findings underline the urgent need for initiatives that increase mental health literacy, access to services and social inclusion of PWMD in North India, and highlight the possibilities of using human rights frameworks in situations of physical and economic violence. The findings also highlight the urgent need to reduce stigma and take actions in policy and at all levels in society to increase inclusion of people with mental distress and disorders.

  • 114. Medina, Widman
    et al.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Quizhpe, Edy
    Romero, Cristian
    Dental caries in 6-12-year-old indigenous and non-indigenous schoolchildren in the Amazon basin of Ecuador.2008In: Brazilian dental journal, ISSN 1806-4760, Vol. 19, no 1, p. 83-6Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to evaluate the caries experience among 6-12-year-old indigenous (Naporunas) and non-indigenous (recent settlers of mixed ethnic origin) schoolchildren, living in the Amazon basin of Ecuador. Cross-sectional data were obtained from 1,449 clinical exams according to the World Health Organization criteria. Nine (7.6%) indigenous and 3 (4.5%) non-indigenous children had no caries experience in their primary dentition at the age of 6. The mean dmft value (SD) among indigenous and non-indigenous children aged 6 was 6.40 (3.36) and 8.36 (3.93), respectively. Sixty-four (54.2%) indigenous and 29 (43.3%) non-indigenous children had no caries experience in their permanent first molars at the age of 6. Only 7 (6.26%) indigenous and 2 (2.60%) non-indigenous children were caries-free at the age of 12. The mean DMFT values (SD) for 12-year-olds were 4.47 (2.85) among indigenous and 5.25 (2.89) among non-indigenous children. Fillings were almost non existent. Caries rates were high among both groups, with untreated carious lesions predominating in all ages. The data of indigenous children suggest adoption of a non-traditional diet. An appropriate oral health response based primarily on prevention and health promotion is needed.

  • 115.
    Mosquera Mendez, Paola A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Vega, Roman
    Martinez, Jorge
    Labonte, Ronald
    Sanders, David
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis2012In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, article id 84Article in journal (Refereed)
    Abstract [en]

    Background: Colombia has a highly segmented and fragmented national health system that contributes to inequitable health outcomes. In 2004 the district government of Bogota initiated a Primary Health Care (PHC) strategy to improve health care access and population health status. This study aims to analyse the contribution of the PHC strategy to the improvement of health outcomes controlling for socioeconomic variables.

    Methods: A longitudinal ecological analysis using data from secondary sources was carried out. The analysis used data from 2003 and 2007 (one year before and 3 years after the PHC implementation). A Primary Health Care Index (PHCI) of coverage intensity was constructed. According to the PHCI, localities were classified into two groups: high and low coverage. A multivariate analysis using a Poisson regression model for each year separately and a Panel Poisson regression model to assess changes between the groups over the years was developed. Dependent variables were infant mortality rate, under-5 mortality rate, infant mortality rate due to acute diarrheal disease and pneumonia, prevalence of acute malnutrition, vaccination coverage for diphtheria, pertussis, tetanus (DPT) and prevalence of exclusive breastfeeding. The independent variable was the PHCI. Control variables were sewerage coverage, health system insurance coverage and quality of life index.

    Results: The high PHCI localities as compared with the low PHCI localities showed significant risk reductions of under-5 mortality (13.8%) and infant mortality due to pneumonia (37.5%) between 2003 and 2007. The probability of being vaccinated for DPT also showed a significant increase of 4.9%. The risk of infant mortality and of acute malnutrition in children under-5 years was lesser in the high coverage group than in the low one; however relative changes were not statistically significant.

    Conclusions: Despite the adverse contextual conditions and the limitations imposed by the Colombian health system itself, Bogota's initiative of a PHC strategy has successfully contributed to the improvement of some health outcomes.

  • 116.
    Mosquera Mendez, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Vega, Roman
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Martinez, Jorge
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Labonte, Ronald
    Faculty of Medicine, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada.
    Sanders, David
    School of Public Health, University of the Western Cape, Bellville, South Africa.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The impact of primary healthcare in reducing inequalities in child health outcomes, Bogota, Colombia: an ecological analysis2012In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 11, article id 66Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 117.
    Mosquera Mendez, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Hernández, Jineth
    Vega, Román
    Labonte, Ronald
    Sanders, David
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Challenges of implementing a primary health care strategy in a context of a market-oriented health care system: the experience of Bogota, Colombia2014In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, no 4, p. E347-E367Article in journal (Refereed)
    Abstract [en]

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

  • 118.
    Mosquera Mendéz, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Vega, Roman
    Martinez, Jorge
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota-Colombia: a cross-sectional study2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 315-Article in journal (Refereed)
    Abstract [en]

    Background: The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogota city.

    Methods: The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.

    Results: The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation-rated as critical by users; the distribution of financial resources-rated as critical by health managers; and, accessibility-rated as intermediate by users.

    Conclusions: The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.

  • 119.
    Mosquera, Paola A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population2018In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 102Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 120.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Are health inequalities rooted in the past? Income inequalities in metabolic syndrome decomposed by childhood conditions2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 2, p. 223-233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Early life is thought of as a foundation for health inequalities in adulthood. However, research directly examining the contribution of childhood circumstances to the integrated phenomenon of adult social inequalities in health is absent. The present study aimed to examine whether, and to what degree, social conditions during childhood explain income inequalities in metabolic syndrome in mid-adulthood.

    METHODS: The sample (N = 12 481) comprised all 40- and 50-year-old participants in the Västerbotten Intervention Program in Northern Sweden 2008, 2009 and 2010. Measures from health examinations were used to operationalize metabolic syndrome, which was linked to register data including socioeconomic conditions at age 40-50 years, as well as childhood conditions at participant age 10-12 years. Income inequality in metabolic syndrome in middle age was estimated by the concentration index and decomposed by childhood and current socioeconomic conditions using decomposition analysis.

    RESULTS: Childhood conditions jointed explained 7% (men) to 10% (women) of health inequalities in middle age. Adding mid-adulthood sociodemographic factors showed a dominant contribution of chiefly current income and educational level in both gender. In women, the addition of current factors slightly attenuated the contribution of childhood conditions, but with paternal income and education still contributing. In contrast, the corresponding addition in men removed all explanation attributable to childhood conditions.

    CONCLUSIONS: Despite that the influence of early life conditions to adult health inequalities was considerably smaller than that of concurrent conditions, the study suggests that early interventions against social inequalities potentially could reduce health inequalities in the adult population for decades to come.

  • 121.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Income-related inequalities in cardiovascular disease from mid-life to old age in a Northern Swedish cohort: a decomposition analysis2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 149, p. 135-144Article in journal (Refereed)
    Abstract [en]

    While the social determinants of cardiovascular disease (CVD) are fairly well-known, the determinants of socioeconomic inequalities in CVD are scarcely studied and almost completely based on cross-sectional designs in which the changing circumstances across the life course are not taken into account. The present study seeks to incorporate a life course approach to the social determinants of socioeconomic inequalities in CVD. The specific aims were to 1) examine how income-related inequalities in CVD change over two decades of the mid-late life course, and 2) identify the key social determinants of the inequalities at each time period. The cohort (N = 44,039) comprised all individuals aged 40-60 years in 1990 who during 1990-2010 were enrolled in the county-wide preventive effort :"Västerbotten Intervention Program" (VIP). The cohort was followed over these two decades by Swedish population register data linked within the Umeå SIMSAM Lab micro data infrastructure. First-time hospitalization for CVD and mean earned income were used to calculate the concentration index (C) during four periods of 5-6 years. The C for each period was decomposed by sociodemographic factors, using Wagstaff-type decomposition analysis. Results suggest that inequalities in CVD increase gradually from mid-life to old age; from initially non-significant to particularly marked among the elderly. The decomposition showed that, from middle to old age, educational and employment inequalities underwent a transition from initially dominant to a moderate role in explaining the health inequalities, coupled with an increasing importance of age and a stable role of income. In conclusion, the study illustrates the need for incorporating a dynamic life course perspective into research, policy and practice concerned with equity in health.

  • 122.
    Murillo, Pilar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Departamento de Enfermería I, Escuela de Enfermería, Universidad del País Vasco, Leioa, España.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Grupo de Investigación en Salud Pública, Universidad de Alicante, Alicante, España.
    Factores asociados a la respuesta a la violencia del compañero íntimo en atención primaria de salud en España2018In: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 32, no 5, p. 433-438Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To analyse the Spanish primary care professionals' readiness to respond to intimate partner violence (IPV) in primary care and identify possible determinants that could facilitate a better response.

    METHOD: A cross-sectional study with a non-probabilistic sampling by convenience was performed among healthcare professionals working in 15 primary care centres in Spain. The Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), the version validated and translated into Spanish, was the instrument used to collect information about knowledge, opinions and practices regarding intimate partner violence. Descriptive analysis and, simple and multiple linear regression analysis were performed.

    RESULTS: A total of 265 completed questionnaires were received, with a response rate of 80.3%. An exposure-response effect was observed, where at higher hours of training a higher score was obtained on the questionnaire sections (p <0.05). Age, type of profession, years of experience in primary care, hours of IPV training and reading the protocol showed positive association with knowledge (perceived preparation, perceived knowledge, actual knowledge), opinions (staff preparation, legal requirements, self-efficacy, workplace issues, constraints, understanding of the victim) and practice of healthcare professionals.

    CONCLUSIONS: Reading the regional/national protocol for action and receiving training in IPV were the most important interventions associated to a better primary care professionals' readiness to respond to IPV in Spanish primary care settings.

  • 123.
    Njozing, Barnabas N
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Voices from the frontline: counsellors’ perspectives on TB/HIV collaborative activities in the Northwest Region, Cameroon2011In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, p. 328-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The overlapping epidemiology of tuberculosis (TB) and human immunodeficiency virus (HIV) infections prompted the World Health Organisation in 2004 to recommend collaboration between national TB and HIV programmes. The goal of this collaboration is to decrease the burden of both infections in the population. This policy was subsequently adopted by the national TB and HIV programmes in Cameroon with TB and HIV nurses/counsellors acting as frontline implementers of the collaborative activities in the 10 regions of the country.

    METHODS: Qualitative research interviews were conducted with 30 nurses/counsellors in four approved treatment centres providing comprehensive TB and HIV/AIDS services in the Northwest region of Cameroon. The aim was to explore their experiences in counselling, in delivering joint TB and HIV services, and the constraints to effective collaboration between TB and HIV services. To complement the findings from the counsellors' interviews, as part of an emergent design, further interviews with 2 traditional healers and non-participant observations in two HIV support group meetings were conducted.

    RESULTS: According to the respondents, counselling was regarded as a call to serve humanity irrespective of the reasons for choosing the profession. In addition, the counselling training and supervision received, and the skills acquired, have altogether contributed to build patients' trust in the healthcare system. Teamwork among healthcare workers and other key stakeholders in the community involved in TB/HIV prevention and control was used as a strategy to improve joint service delivery and patients' uptake of services. Several constraints to effective collaboration between TB and HIV services were identified, including shortage of human resources, infrastructure and drug supplies, poor patients' adherence to treatment and the influence of traditional healers who relentlessly dissuade patients from seeking mainstream medical care.

    CONCLUSIONS: In order to achieve a sustainable collaboration between TB and HIV services, adequate planning, investment and strengthening of the health system including human resources, infrastructure and ensuring uninterrupted supplies of medicines are essential. A multidisciplinary approach to service delivery particularly focusing on harnessing the enormous potentials of traditional healers in TB/HIV prevention and control would also be indispensible.

  • 124.
    Njozing, Barnabas N
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. St. Mary Soledad Catholic Hospital, Mankon, Bamenda, P.O.Box 157, Cameroon.
    Edin, Kerstin E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    San Sebástian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    “If the patients decide not to tell what can we do?”: TB/HIV counsellors’ dilemma on partner notification for HIV2011In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 11, article id 6Article in journal (Refereed)
    Abstract [en]

    Background: There is a global consensus towards universal access to human immunodeficiency virus (HIV) services consequent to the increasing availability of antiretroviral therapy. However, to benefit from these services, knowledge of one's HIV status is critical. Partner notification for HIV is an important component of HIV counselling because it is an effective strategy to prevent secondary transmission, and promote early diagnosis and prompt treatment of HIV patients' sexual partners. However, counsellors are often frustrated by the reluctance of HIV-positive patients to voluntarily notify their sexual partners. This study aimed to explore tuberculosis (TB)/HIV counsellors' perspectives regarding confidentiality and partner notification. Methods: Qualitative research interviews were conducted in the Northwest Region of Cameroon with 30 TB/HIV counsellors in 4 treatment centres, and 2 legal professionals between September and December 2009. Situational Analysis (positional map) was used for data analysis. Results: Confidentiality issues were perceived to be handled properly despite concerns about patients' reluctance to report cases of violation due to apprehension of reprisals from health care staffs. All the respondents encouraged voluntary partner notification, and held four varying positions when confronted with patients who refused to voluntarily notify their partners. Position one focused on absolute respect of patients' autonomy; position two balanced between the respect of patients' autonomy and their partners' safety; position three wished for protection of sexual partners at risk of HIV infection and legal protection for counsellors; and position four requested making HIV testing and partner notification routine processes. Conclusion: Counsellors regularly encounter ethical, legal and moral dilemmas between respecting patients' confidentiality and autonomy, and protecting patients' sexual partners at risk of HIV infection. This reflects the complexity of partner notification and demonstrates that no single approach is optimal, but instead certain contextual factors and a combination of different approaches should be considered. Meanwhile, adopting a human rights perspective in HIV programmes will balance the interests of both patients and their partners, and ultimately enhance universal access to HIV services.

  • 125.
    Njozing, Nwarbébé Barnabas
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. St Mary Soledad Catholic Hospital, Mankon, Bamenda, Cameroon .
    Miguel, San Sebastian
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tih, Pius Muffih
    Cameroon Baptist Convention Health Board, Nkwen, Bamenda, Cameroon.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest Region, Cameroon2010In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 10, p. Article nr 129-Article in journal (Refereed)
    Abstract [en]

    Background: Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection is a major source of morbidity and mortality globally. The World Health Organization (WHO) has recommended that HIV counselling and testing be offered routinely to TB patients in order to increase access to HIV care packages. We assessed the uptake of provider-initiated testing and counselling (PITC), antiretroviral (ART) and co-trimoxazole preventive therapies (CPT) among TB patients in the Northwest Region, Cameroon.

    Methods: A retrospective cohort study using TB registers in 4 TB/HIV treatment centres (1 public and 3 faith-based) for patients diagnosed with TB between January 2006 and December 2007 to identify predictors of the outcomes; HIV testing/serostatus, ART and CPT enrolment and factors that influenced their enrolment between public and faith-based hospitals.

    Results: A total of 2270 TB patients were registered and offered pre-HIV test counselling; 2150 (94.7%) accepted the offer of a test. The rate of acceptance was significantly higher among patients in the public hospital compared to those in the faith-based hospitals (crude OR 1.97; 95% CI 1.33 - 2.92) and (adjusted OR 1.92; 95% CI 1.24 - 2.97). HIV prevalence was 68.5% (1473/2150). Independent predictors of HIV-seropositivity emerged as: females, age groups 15-29, 30-44 and 45-59 years, rural residence, previously treated TB and smear-negative pulmonary TB. ART uptake was 50.3% (614/1220) with 17.2% (253/1473) of missing records. Independent predictors of ART uptake were: previously treated TB and extra pulmonary TB. Finally, CPT uptake was 47.0% (524/1114) with 24% (590/1114) of missing records. Independent predictors of CPT uptake were: faith-based hospitals and female sex.

    Conclusion: PITC services are apparently well integrated into the TB programme as demonstrated by the high testing rate. The main challenges include improving access to ART and CPT among TB patients and proper reporting and monitoring of programme activities.

  • 126.
    Olofsson, Sofia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jegannathan, Bhoomikumar
    Mental health in primary health care in a rural district of Cambodia: a situational analysis2018In: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, article id 7Article in journal (Refereed)
    Abstract [en]

    Background: While mental and substance use disorders are common worldwide, the treatment gap is enormous in low and middle income countries. Primary health care is considered to be the most important way for people to get mental health care. Cambodia is a country with a long history of war and has poor mental health and limited resources for care. The aim of this study was to conduct a situational analysis of the mental health services in the rural district of Lvea Em, Kandal Province, Cambodia.

    Methods: A cross-sectional situational analysis was done to understand the mental health situation in Lvea Em District comparing it with the national one. The Programme for improving mental health care (PRIME) tool was used to collect systematic information about mental health care from 14 key informants in Cambodia. In addition, a separate questionnaire based on the PRIME tool was developed for the district health care centres (12 respondents). Ethical approval was obtained from the National Ethics Committee for Health Research in Cambodia.

    Results: Mental health care is limited both in Lvea Em District and the country. Though national documents containing guidelines for mental health care exist, the resources available and health care infrastructure are below what is recommended. There is no budget allocated for mental health in the district; there are no mental health specialists and the mental health training of health care workers is insufficient. Based on the limited knowledge from the respondents in the district, mental health disorders do exist but no documentation of these patients is available. Respondents discussed how community aspects such as culture, history and religion were related to mental health. Though there have been improvements in understanding mental health, discrimination and abuse against people with mental health disorders seems still to be present.

    Conclusions: There are very limited mental health care services with hardly any budget allocated to them in Lvea Em District and Cambodia overall. There is dire need for scaling up and integrating mental health into primary health care to improve the population's access to and quality service of Cambodian mental care.

  • 127. Paulander, Johan
    et al.
    Olsson, Henrik
    Lemma, Hailemariam
    Getachew, Asefaw
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Knowledge, attitudes and practice about malaria in rural Tigray, Ethiopia2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    Objective: To assess the knowledge, attitude and practice (KAP) regarding malaria and their determinants in a rural population of northern Ethiopia.

    Methods: The study was conducted in the district of Samre Saharti, Tigray, northern Ethiopia. A structured questionnaire collecting socio-demographic and malaria-related KAP information was administered to the mothers from a representative sample of households.

    Results: A total of 1652 questionnaires were available for analysis. Most of the respondents (92.7%) were able to mention at least one symptom of malaria. Mosquito as a cause of malaria was recognized by nearly half of the respondents (48.8%). Most of the households had a bednet (85.9%). To have a literate person at home, to belong to the lowland stratum, to have received some type of health education and to own a radio were associated with the knowledge of malaria. A strong association remained between living in the lowland stratum, to own a radio and to live close to the health post and the use of ITN. Being a housewife, lack of health education and to live further than 60 minutes walking distance to the health post were related to a delay on treatment finding.

    Conclusion: This study has identified some aspects which the MCP might need to improve. The knowledge about malaria transmission should be strengthened. Promotion of literacy and participation in health education are vital components in terms of malaria knowledge and practice. Issues related to geographical location and accessibility to health post should be also carefully examined.

  • 128. Perez-Urdiales, Iratxe
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Irazusta, Amaia
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 59Article in journal (Refereed)
    Abstract [en]

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

  • 129.
    Pérez-Urdiales, Iratxe
    et al.
    Department of Nursing I, University of the Basque Country (UPV/EHU), Biscay, Spain.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Nursing I, University of the Basque Country (UPV/EHU), Biscay, Spain.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Free clinic utilisation by immigrants after the introduction of a restrictive health policy in the Basque Country (Spain)2018In: Public Health, ISSN 0033-3506, E-ISSN 1476-5616, Vol. 163, p. 9-15Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Policies restricting healthcare access for immigrants were applied in times of reduced public funding for welfare in Spain. This study aimed to assess the impact of the implementation of a more restrictive health policy in the Basque Country region, Decree 114/2012, on the number of consultations attended at a free clinic, where the majority of patients are undocumented immigrants.

    STUDY DESIGN: Interrupted time series.

    METHODS: A negative binomial regression model was applied in two phases to the number of healthcare consultations during the period 2007-2017 (n = 9272) to estimate the level and trend changes associated with the implementation of the policy. Data were analysed separately by sex and adjusted for consultations' seasonality and unemployment rate and the sex-specific percentage of migrant population in Biscay province as confounding factors.

    RESULTS: Different trends of attendance between men and women were observed during the whole period, constituting 76.94% and 23.06% of all consultations, respectively. After the implementation of the decree, the number of consultations for women per trimester decreased and increased for men by 1%, although it was not statistically significant in either of the trends.

    CONCLUSIONS: No clear relationship between the implementation of the Basque Decree 114/2012 and an increase in the attendance of immigrants in a free clinic during the studied period was found.

  • 130. Quizhpe, Edy
    et al.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Llamas, Ana
    [Prevalence of anaemia in schoolchildren in the Amazon area of Ecuador].2003In: Revista panamericana de salud pùblica, ISSN 1020-4989, E-ISSN 1680-5348, Vol. 13, no 6, p. 355-61Article in journal (Refereed)
    Abstract [es]

    OBJECTIVE: To determine the prevalence of anemia in rural school-age children in the Amazon region of Ecuador.

    METHODS: We carried out a cross-sectional study during May to October 2000 in two cantons of the province of Orellana, in northeastern Ecuador, involving 626 children from 17 schools. Demographic and anthropometric data (weight and height) were collected, values for hemoglobin and for zinc erythrocyte protoporphyrin were determined, and feces samples were analyzed to check for infestation by parasites.

    RESULTS: The general prevalence of anemia was 16.6% among the schoolchildren; of the affected children, 75.5% of them had iron-deficiency anemia. The prevalence of moderate chronic undernutrition was 28.8% and that of serious chronic undernutrition was 9.3%. There was also a prevalence of moderate acute undernutrition of 8.4% and of severe acute undernutrition of 3.4%. Parasitic infections were very frequent (82.0%). The most common parasites were Entamoeba coli (30.3%) and Ascaris lumbricoides (25.0%). There were no relationships between the prevalence of either anemia or of iron-deficiency anemia and any of the indicators of nutrition or of parasitic infection.

    CONCLUSIONS: Anemia is not a serious public health problem in the population studied. Nevertheless, the high prevalence of chronic undernutrition among the children points to the need to improve their diets. The lack of association between the prevalence of undernutrition and anemia could be due to low iron bioavailability or absorption rather than insufficient intake. Studies are needed to evaluate the customary diet of this population.

  • 131.
    Ram Jat, Tej
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Deo, PR
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sociocultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lensIn: Article in journal (Refereed)
  • 132.
    Ramadani, Royasia Viki
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study aimed to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) and whether this relationship is influenced by the level of income in Northern Sweden. Overweight and obesity are rising major public health problems which also affect HRQoL. While socioeconomic inequalities in health are persisting or increasing in many countries, including Sweden, little attention has been paid to the more complex roles of income in relation to health.

    METHODS: Data were drawn from a 2014 cross-sectional survey from Northern Sweden (Health on Equal Terms), comprising individuals aged 20-84 years ( N = 20,082 individuals included for analysis). BMI and HRQoL were self-reported and individual disposable income in 2012 was retrieved from population registers. Multiple linear regressions were performed with HRQoL scores regressed on BMI and income, their interaction and additional covariates.

    RESULTS: The underweight, overweight and obesity groups reported significantly lower HRQoL compared to the normal weight group. Moreover, the relationship between BMI and HRQoL varied significantly by level of income, with a stronger association among those with the lowest level of income.

    CONCLUSIONS: Income has a role as an effect modifier in the relationship between BMI and HRQoL that can be construed as an indirect income inequality. Efforts to promote HRQoL in populations should consider the different impact of being overweight and obese in different socioeconomic groups.

  • 133.
    Randive, Bharat
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    De Costa, Ayesha
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India2014In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 123, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR). Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities. These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered.

  • 134. Rodríguez-Blanes, Gloria M.
    et al.
    Vives-Cases, Carmen
    Miralles-Bueno, Juan José
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Grupo de Investigación de Salud Pública, Universidad de Alicante, Alicante, España.
    Detección de violencia de compañero íntimo en atención primaria de salud y sus factores asociados2017In: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 31, no 5, p. 410-415Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Intimate partner violence (IPV) against women is a significant public health and human rights problem. Primary care professionals play a key role in detecting and addressing this issue. The aim of this study is to determine the frequency of IPV and its associated factors in primary care by means of a screening questionnaire and to describe the main actions taken in identified cases.

    METHODS: Cross-sectional study in 15 health centres in four autonomous regions of Spain with a total of 265 health professionals. The information was collected through the self-administered PREMIS questionnaire (Physician Readiness to Manage Intimate Partner Violence Survey), which includes variables concerning screening questions, sociodemographic factors, level of training/knowledge about IPV, perceptions and actions. A descriptive and analytical study was conducted.

    RESULTS: 67.2% of participants said they ask about IPV during consultations. The most frequent actions were: referring patients to other departments, individual counselling and information delivery. ≥21hours of training, an advanced training level, knowledge of policies and programmes and the implementation of an appropriate protocol and reference resources were all factors that increased the likelihood of investigating IPV. The asking of questions increases in line with professionals' perceived level of training in IPV and the provision of a case management protocol.

    CONCLUSIONS: Two thirds of health professional respondents said they inquire about IPV. Given the influence of training in IPV and awareness of the resources to address the issue, it is essential to continue investing in the IPV training of healthcare personnel.

  • 135.
    Ruano, Ana Lorena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastían, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    'If no one else stands up, you have to': a story of community participation and water in rural Guatemala2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. Article nr 6412-Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 136.
    Ruano, Ana Lorena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernández, Alison
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala2012In: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 70, p. 18-Article in journal (Refereed)
    Abstract [en]

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

  • 137.
    Ruano, Ana Lorena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The process of social participation in primary health care: the case of Palencia, Guatemala2014In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, no 1, p. 93-103Article in journal (Refereed)
    Abstract [en]

    Background In 2008, the World Health Organization issued a callback to the principles of primary health care, which renewed interests in social participation in health. In Guatemala, social participation has been the main policy for the decentralization process since the late 1990s and the social development council scheme has been the main means for participation for the country's population since 2002.

    Aim The aim of this study was to explore the process of social participation at a municipal-level health commission in the municipality of Palencia, Guatemala.

    Methods Analysis of legal and policy documents and in-depth interviews with institutional and community-level stakeholders of the commission.

    Results The lack of clear guidelines and regulations means that the stakeholders own motivations, agendas and power resources play an important part in defining the roles of the participants. Institutional stakeholders have the human and financial power to make policies. The community-level stakeholders are token participants with little power resources. Their main role is to identify the needs of their communities and seek help from the authorities. Satisfaction and the perceived benefits that the stakeholders obtain from the process play an important part in maintaining the commission's dynamic, which is unlikely to change unless the stakeholders perceive that the benefit they obtain does not outweigh the effort their role entails.

    Conclusion Without more uniformed mechanisms and incentives for municipalities to work towards the national goal of equitable involvement in the development process, the achievements will be fragmented and will depend on the individual stakeholder's good will.

  • 138.
    Salazar, Mariano
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Violence against women and unintended pregnancies in Nicaragua: a population-based multilevel study2014In: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 14, p. 26-Article in journal (Refereed)
    Abstract [en]

    Background: Despite an increased use of contraceptive methods by women, unintended pregnancies represent one of the most evident violations of women's sexual and reproductive rights around the world. This study aims to measure the association between individual and community exposure to different forms of violence against women (physical/sexual violence by the partner, sexual abuse by any person, or controlling behavior by the partner) and unintended pregnancies.

    Methods: Data from the 2006/2007 Nicaraguan Demographic and Health Survey were used. For the current study, 5347 women who reported a live birth in the five years prior to the survey and who were married or cohabitating at the time of the data collection were selected. Women's exposure to controlling behaviors by their partners was measured using six questions from the WHO Multi-Country Study on Women's Health and Domestic Violence against Women. Area-level variables were constructed by aggregating the individual level exposures to violence into an exposure measurement of the municipality as a whole (n = 142); which is the basic political division in Nicaragua. Multilevel logistic regression was used to analyze the data.

    Results: In total, 37.1% of the pregnancies were reported as unintended. After adjusting for all variables included in the model, individual exposure to controlling behavior by a partner (AOR = 1.28, 95% CrI = 1.13-1.44), ever exposure to sexual abuse (AOR = 1.31, 95% CrI = 1.03-1.62), and ever exposure to physical/sexual intimate partner violence (AOR = 1.44, 95% CrI = 1.24-1.66) were significantly associated with unintended pregnancies. Women who lived in municipalities in the highest tertile of controlling behavior by a partner had 1.25 times higher odds of reporting an unintended pregnancy than women living in municipalities in the lowest tertile (AOR = 1.25, 95% CrI = 1.03-1.48).

    Conclusions: Nicaraguan women often experience unintended pregnancies, and the occurrence of unintended pregnancies is significantly associated with exposure to different forms of violence against women at both the individual and the municipality level. National policies aiming to facilitate women's ability to exercise their reproductive rights must include actions aimed at reducing women's exposures to violence against women.

  • 139.
    San Sebastian Chasco, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Review of health research on indigenous populations in Latin America, 1995-2004.2007In: Salud Publica Mex, ISSN 0036-3634, Vol. 49, no 4, p. 316-320Article in journal (Refereed)
  • 140.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Socioeconomic inequalities in functional somatic symptoms by social and material conditions at four life course periods in Sweden: a decomposition analysis2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 8, p. 1-10, article id e006581Article in journal (Refereed)
    Abstract [en]

    Objective: Socioeconomic inequalities in health are deemed a worldwide public health problem, but current research is lacking on key points including determinants of socioeconomic differences in health, and not the least variations of these determinants over the life course. Using a 26-year prospective Swedish community-based cohort, we aim at decomposing socioeconomic inequalities in functional somatic symptoms by social and material life circumstances, at 4 periods of the life course. Design: Repeated cross-sectional study. Setting: Participants came from the Northern Swedish Cohort (n= 1001), who completed questionnaires about occupational class, social and material living conditions, and symptoms at ages 16, 21, 30 and 42. Socioeconomic inequalities were estimated and decomposed using the Blinder-Oaxaca decomposition analysis. Results: Inequalities in symptoms between blue-collar and white-collar socioeconomic groups increased along the life course in the sample. In the decomposition analysis, a high proportion of the gap between socioeconomic groups could be explained by social and material living conditions at ages 16 (84% explained), 30 (45%) and 42 (68%), but not at age 21. Specific social (parental illness at age 16 and violence at ages 30 and 42) and material (parental unemployment at age 16, and own unemployment and financial strain at ages 30 and 42) factors contributed jointly to the health gaps. Conclusions: Socioeconomic inequalities in functional somatic symptoms increased along the life course in this Swedish cohort. A considerable portion of the social gaps in health was explained by concurrent social and material conditions, and the importance of specific adversities was dependent on the life course stage. Our findings suggest that socioeconomic inequalities in functional somatic symptoms may be reduced by addressing both social and material living conditions of disadvantaged families, and also that the life course stage needs to be taken into consideration.

  • 141.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Oil development and health in the Amazon basin of Ecuador: the popular epidemiology process.2005In: Soc Sci Med, ISSN 0277-9536, Vol. 60, no 4, p. 799-807Article in journal (Refereed)
  • 142.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    A new leadership for UNICEF: do values matter?2005In: Lancet, ISSN 1474-547X, Vol. 365, no 9465, p. 1136-7Article in journal (Other academic)
  • 143.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Cancer among indigenous people in the Amazon Basin of Ecuador, 1985-2000.2004In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 16, no 5, p. 328-33Article in journal (Refereed)
  • 144.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Is GATS a concern for the Swedish healthcare system?2007In: Scand J Public Health, ISSN 1403-4948, p. 1-4Article in journal (Refereed)
  • 145.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Moving on from NAFTA to the FTAA?: the impact of trade agreements on social and health conditions in the Americas.2004In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 16, no 4, p. 272-8Article in journal (Refereed)
  • 146.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Oil exploitation in the Amazon basin of Ecuador: a public health emergency.2004In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 15, no 3, p. 205-11Article in journal (Refereed)
  • 147.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Sachiapi Tapusa: health research in the Amazon bwsin of Ecuador, 1998-2003 [in spanish]2005Report (Other (popular science, discussion, etc.))
  • 148.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Breilh, Jaime
    Peralta, Arturo Quizhpe
    [The People's Health Movement: health for all now.]2005In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 18, no 1, p. 45-9Article in journal (Refereed)
  • 149.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Rasanathan, Kumanan
    Is trade liberalization of services the best strategy to achieve health-related Millennium Development Goals in Latin America? A call for caution.2006In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 20, no 5, p. 341-6Article in journal (Refereed)
  • 150.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Do cardiovascular disease prevention programs in northern Sweden impact on population health?: An interrupted time series analysis2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 202Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013.

    Methods: An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers.

    Results: Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences.

    Conclusions: Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

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