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  • 51. John, Thomas Wiswa
    et al.
    Mkoka, Dickson Ally
    Frumence, Gasto
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    An account for barriers and strategies in fulfilling women's right to quality maternal health care: a qualitative study from rural Tanzania2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 352Article in journal (Refereed)
    Abstract [en]

    Background: Tanzania has ratified and abides to legal treaties indicating the obligation of the state to provide essential maternal health care as a basic human right. Nevertheless, the quality of maternal health care is disproportionately low. The current study sets to understand maternal health services' delivery from the perspective of rural health workers', and to understand barriers for and better strategies for realization of the right to quality maternal health care. Methods: Semi-structured in-depth interviews were conducted, involving 11 health workers mainly; medical attendants, enrolled nurses and Assistant Medical Officers from primary health facilities in rural Tanzania. Structured observation complemented data from interviews. Interview data were analyzed using thematic analysis guided by the conceptual framework of the right to health. Results: Three themes emerged that reflected health workers' opinion towards the quality of health care services; "It's hard to respect women's preferences", "Striving to fulfill women's needs with limited resources", and "Trying to facilitate women's access to services at the face of transport and cost barriers". Conclusion: Health system has left health workers as frustrated right holders, as well as dis-empowered duty bearers. This was due to the unavailability of adequate material and human resources, lack of motivation and lack of supervision, which are essential for provision of quality maternal health care services. Pregnant women, users of health services, appeared to be also left as frustrated right holders, who incurred out-of-pocket costs to pay for services, which were meant to be provided free.

  • 52.
    Jonsson, Frida
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Rural-urban differences in health among youth in northern Sweden: an outcome-wide epidemiological approach2019In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 78, article id 1640015Article in journal (Refereed)
    Abstract [en]

    The aim of this research was to contribute knowledge about rural-urban differences in health among young northern Swedish women and men. This study was based on the 2014 "Health on Equal Terms" survey, distributed in the four northernmost counties of Sweden, with complementary information on areas of residence classified as rural, semi-urban and urban from total population registers. The analytical sample included 2,691 individuals who were selected using a probabilistic sampling method. Prevalence ratios were calculated in multivariable log-binomial regression analyses to measure the association between place of residence and nine outcomes covering three health dimensions (general, mental and lifestyle behaviours). The results indicated that daily smoking and being overweight were more common, while feelings of stress and psychological distress were less prevalent, among youths in rural as compared to urban areas. After including covariates, this pattern appeared stronger for young women, although the direction of the results also applied to young men, albeit without revealing significant differences. In conclusion, the findings from this study indicate that for youths - particularly young women - the rural setting may imply an increased risk of poor general health and lifestyle behaviours, while simultaneously playing a partially protective role for mental health.

  • 53.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Alm, Erika
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare2019In: Health, ISSN 1363-4593, E-ISSN 1461-7196, Vol. 23, no 1, p. 21-38Article in journal (Refereed)
    Abstract [en]

    The few previous studies investigating regulation of gender in trans-specific healthcare are mainly based on text material and interviews with care-providers or consist solely of theoretical analyses. There is a lack of studies analysing how the regulation of gender is expressed in the care-seeker's own experiences, especially in a Nordic context. The aim of this study is to analyse narratives of individuals with trans experiences (sometimes called transgender people) to examine how gender performances can be regulated in trans-specific care in Sweden. The conceptual framework is inspired by trans studies, a Foucauldian analysis of power, queer phenomenology and the concept of cisnormativity. Fourteen interviews with people with trans experiences are analysed with constructivist grounded theory. The participants' experiences indicate that gender is constructed as norm-conforming, binary and stable in trans-specific healthcare. This gendered position is resisted, negotiated and embraced by the care-seekers. Norms and discourses both inside and outside trans-specific care contribute to the regulation and limit the room for action for care-users. We conclude that a trans-specific care that has a confirming approach to its care-users, instead of the current focus on gender norm conformity, has the potential to increase the self-determination of gender performance and increase the quality of care.

  • 54.
    Linander, Ida
    et al.
    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).
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Alm, Erika
    Hammarström, Anne
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    (Un)safe spaces, affective labour and perceived health among people with trans experiences living in Sweden2019In: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 21, no 8, p. 914-928Article in journal (Refereed)
    Abstract [en]

    Lack of safe space has been connected to ill health among people with trans experiences. This study analyses trans people’s experiences of being in public, semi-public and community spaces using the analytical concept of safety/unsafety in relation to perceived health. The analytic framework draws on the concepts of cisgenderism, orientation, lines and comfort. The material analysed consisted of 18 individual interviews with people with trans experiences, which were analysed using constructivist thematic analysis. The analysis resulted in the identification of three themes: straightening devices creating limited living space, orienting oneself in (cis)gendered spaces and creating safer (?) community spaces for healing. Experiences of unsafety ranged from incidents and fear of different kinds of violence in public and semi-public spaces to the lack of a transpolitically informed agenda in, for example, feminist spaces. Safer spaces helped participants to feel a sense of belonging, to share their experiences and to heal. Experiences of unsafety and discomfort are important as they will help us to understand the health situations of people with trans experiences. It is important to facilitate the creation of safer spaces to improve the health of members of this group.

  • 55.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lauri, M
    Alm, Erika
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Representing the (un)deserving care-seeker and the competent care-provider: a policy analysis of in the Swedish guidelines for trans-specific healthcareManuscript (preprint) (Other academic)
  • 56. Mahiti, Gladys R.
    et al.
    Kiwara, Angwara D.
    Mbekenga, Columba K.
    Hurtig, Anna-Karin
    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.
    "We have been working overnight without sleeping": traditional birth attendants' practices and perceptions of post-partum care services in rural Tanzania2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 8Article in journal (Refereed)
    Abstract [en]

    Background: In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs' practices and perceptions in post-partum care in rural Tanzania.

    Methods: Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data.

    Results: Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system.

    Conclusions: This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA services.

  • 57.
    Mahiti, Gladys Reuben
    et al.
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Mbekenga, Columba K.
    School of Nursing and Midwifery, Agakhan University, Dar es Salaam, Tanzania.
    Kiwara, Angwara Dennis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    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.
    Perceptions about the cultural practices of male partners during postpartum care in rural Tanzania: a qualitative study2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1361184Article in journal (Refereed)
    Abstract [en]

    Background: Men play an important role in maternal health. The postpartum period is a critical stage, yet there is a scarcity of research that explores men's involvement during this stage.

    Objective: The aim of the study was to explore male partners' perceptions of the cultural practices during postpartum care in rural Tanzania.

    Methods: Fourteen focus group discussions were conducted with 93 men, with an age range of 19-65 years, in August 2013. The study was conducted in the Kongwa District, located in the Dodoma region in central Tanzania. Qualitative data were digitally recorded, transcribed verbatim and analyzed using content analysis.

    Results: Four categories emerged, namely: 'Men as providers and, occasionally, care takers', 'Men as decision makers', 'Diverse perceptions of sexual abstinence' and 'Barriers for men in using/accompanying partners to use reproductive and child healthcare services'. The crosscategory theme 'Men during postpartum: remaining powerful but excluded' refers to how men are in a powerful position above women in different aspects of life. Elderly women played an important role in caring for postpartum mothers and their newborns, but men were the ones making the final decision about where to seek care. Traditional practices isolated men from their partners for a certain period, and enforced sexual abstinence for the women during the postpartum period. However, cultural norms permitted men to engage in extramarital relations. Reproductive and child healthcare services were perceived by men as not welcoming the male partners, and local gender norms discouraged men from accompanying their partners to seek services.

    Conclusions: In this study, we found that men perceived their role during the postpartum period as financial providers, decision makers and, occasionally, care givers. Men also held diverse perceptions with regard to sexual abstinence and felt excluded from participating in maternal healthcare services.

  • 58.
    Mahiti, Gladys Reuben
    et al.
    Dar es Salaam, Tanzania.
    Mkoka, Dickson Ally
    Dar es Salaam, Tanzania.
    Kiwara, Angwara Dennis
    Dar es Salaam, Tanzania.
    Mbekenga, Columba Kokusiima
    Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    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.
    Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-9, article id 28567Article in journal (Refereed)
    Abstract [en]

    Background: Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. Design: We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. Results: 'Three categories emerged that reflected women's perceptions of maternal health care services: "mothers perceive that maternal health services are beneficial," "barriers to accessing maternal health services" such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and "ambivalence regarding the quality of maternal health services" reflecting that women had both positive and negative perceptions in relation to quality of health care services offered'. Conclusions: Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women.

  • 59.
    Malm, Desiré
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bishop, Linn
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per
    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.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Validation of a questionnaire to measure youth-friendliness of Swedish youth clinics2017In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, no 4, p. 366-372Article in journal (Refereed)
    Abstract [en]

    Aim: This study presents the validation process of a tool to assess the youth-friendliness of Swedish youth clinics, based on the Youth-Friendly Health Services - World Health Organization Plus (YFHS-WHO+) questionnaire but adapted to the specific context of differentiated services catering only for young people in this country. Methods: The validation process followed five steps: (1) translation, (2) revision by professionals, (3) pretests with young people, (4) back-translation and discussion with the developers of the original YFHS-WHO+ questionnaire and (5) internal consistency and test-retest reliability testing. Results: The final Swedish version, titled Youth-Friendly Health Services-Sweden (YFHS-Swe), differs from the original in terms of adjustments in language and in changes to make it better correspond to the reality of the Swedish youth clinics, while maintaining the meaning and intention of the original questionnaire. The YFHS-Swe questionnaire generated reproducible responses (test-retest coefficient of 0.79 for the total score) and can be considered a measure of a cohesive construct (Cronbach alpha of 0.95 for the total score). Conclusions: The study suggests that the YFHS-Swe questionnaire is a reliable instrument that can be an asset for youth clinics to evaluate their work and make regional and national comparisons between clinics. The YFHS-Swe could also serve as a basis for validating instruments to assess youth-friendliness of differentiated services for young people in other countries.

  • 60. Maquibar, A.
    et al.
    Hurtig, A. K.
    Vives-Cases, C.
    Estalella, I.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mapping training about Gender Based Violence in nurse education programmes in Spain2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 269-Article in journal (Other academic)
    Abstract [en]

    Background: Health care professionals, and nurses especially among them, play an essential role in the health sector response to Gender Based Violence. To be able to successfully address this major public health issue they need specific training in the topic. Therefore, the World Health Organization as well as Spanish institutions and policies, strongly recommend the inclusion of this topic in nursing undergraduate programmes. This study aims to assess how this recommendation has been implemented in the nursing undergraduate programmes offered in all Spanish universities.

    Methods: A systematic review of each subjects’ study guide of the 91 nurse education programmes existing in Spain was conducted searching for the term “violence” to include references under different terminology as “violence against women”, “gender based violence” or “intimate partner violence”.

    Results: Sixty-nine out of the ninety-one nurse education programmes taught in Spain have contents related to violence. Thirty-eight grades included Gender Based Violence in the content of one subject, 21 in two, eight in three and two in four. Only three programmes had a specific subject named “Nursing in Gender Based Violence”. Otherwise, gender violence was part of subjects mainly related with gender and culture (22%), psychology (20%), public health (20%) and women’s health (13%). When analysing results by Autonomous Region, four out of seventeen were found to have gender based violence included in all the grades offered in their area, while two had not any training in the topic. In the remaining regions inclusion varied between these two poles.

    Conclusions: Gender Based Violence has been included in a great percentage of the nursing undergraduate education programmes taught in Spain. Assessing the effect this undergraduate training has on nurses’ response to gender based violence as well as differences in the effect depending on the training programme becomes a challenge for the next years.

    Key messages:

    • Most of the Spanish universities have included training in Gender Based Violence in their nurse education programmes, which might positively affect the Health Sector's response to this health issue.
    • Assessing the effect these different undergraduate training programmes have on nurses’ response to Gender Based Violence becomes a challenge for the next years.
  • 61. Maquibar, Amaia
    et al.
    Estalella, Itziar
    Vives-Cases, Carmen
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Analysing training in gender-based violence for undergraduate nursing students in Spain: A mixed-methods study2019In: Nurse Education Today, ISSN 0260-6917, E-ISSN 1532-2793, Vol. 77, p. 71-76Article in journal (Refereed)
    Abstract [en]

    Background: Health-care professionals, and nurses especially among them, play an essential role in the health sector's response to gender-based violence. To be able to successfully address this major public health issue they need specific training in the topic.

    Objective: To analyse training on gender-based violence that nursing students receive at universities in Spain.

    Design: Mixed-methods approach.

    Setting: Spain.

    Methods: Systematic review of public documents followed by in-depth interviews with university lecturers.

    Results: Eighty per cent (92/115) of nursing training programmes included content regarding gender-based violence. There was great variability in the topics included in the training. Health consequences due to gender based violence exposure and the role of the health sector in addressing these health consequences were the most frequently included topics. Ethical issues and legislation were the least frequent ones, as these were only dealt with in one and 18 training programmes, respectively. In the qualitative analysis of the interviews, two categories were identified: 'Supportive legislation and supportive lecturers are essential for integrating gender-based violence training' and 'Approach to gender-based violence shapes the contents and the subject in which it is incorporated'. The first category refers to the main drivers for training integration, while the second category refers to how lecturers' perceptions influenced the way in which training was implemented.

    Conclusions: As many as 80% of the nursing education programmes included specific training in gender-based violence, although with great variability in the contents among the universities. For this study's participants, enacted legislation, and lecturers interested in the topic and in decision-making positions were key drivers for this extensive implementation. The variability observed across universities might be explained by lecturers' different approaches to gender-based violence and the nursing profession.

  • 62. Maquibar, Amaia
    et al.
    Estalella, Itziar
    University of the Basque Country UPV/EHU.
    Vives-Cases, Carmen
    Alicante University.
    Hurtig, Anna-Karin
    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.
    Mapping and exploring training in gender-based violence for undergraduate nursing students in Spain: A mixed-methods studyManuscript (preprint) (Other academic)
    Abstract [en]

    Background: Health-care professionals, and nurses especially among them, play an essential role in the health sector’s response to gender-based violence. To be able to successfully address this major public health issue they need specific training in the topic.

     

    Objective: To map and explore training on gender-based violence that nursing students receive at universities in Spain.

    Design: Mixed-methods approach

     

    Setting: Spain

     

    Methods: Systematic review of public documents followed by in-depth interviews with university lecturers

     

    Results: Eighty per cent (92/115) of nursing training programmes included content regarding gender-based violence. There was great variability in the topics included in the training. Health consequences due to gender-based violence exposure and the role of the health sector in addressing these health consequences were the most frequently included topics. Ethical issues and legislation were the least frequent ones, as these were only dealt with in one and 18 training programmes, respectively.

    In the qualitative analysis of the interviews, two categories were identified: ‘Supportive legislation and supportive lecturers are essential for integrating gender-based violence training’ and ‘Approach to gender-based violence shapes the contents and the subject in which it is incorporated’. The first category refers to the main drivers for training integration, while the second category refers to how lecturers’ perceptions influenced the way in which training was implemented.

     

    Conclusions: As many as 80% of the nursing education programmes included specific training in gender-based violence, although with great variability in the contents among the universities. For this study’s participants, enacted legislation, and lecturers interested in the topic and in decision-making positions were key drivers for this extensive implementation. The variability observed across universities might be explained by lecturers’ different approaches to gender-based violence and the nursing profession.

  • 63.
    Maquibar, Amaia
    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.
    Vives-Cases, Carmen
    Estalella, Itziar
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nursing students' discourses on gender-based violence and their training for a comprehensive healthcare response: A qualitative study.2018In: Nurse Education Today, ISSN 0260-6917, E-ISSN 1532-2793, Vol. 68, p. 208-212Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Gender-based violence is a worldwide major public health issue with detrimental effects on the health of women. Nurses can play an essential role in its identification, management and prevention. Specific training is essential to be able to successfully address gender-based violence and accordingly, has been incorporated into many university's training programmes for nurses and other health care professionals. Research aimed at exploring attitudes and perceptions of gender-based violence in undergraduate student nurses following these new training programmes is scarce.

    OBJECTIVE: The aim of this qualitative study was to explore third- and fourth-year nursing students' perceptions and attitudes toward gender-based violence.

    DESIGN: A focus groups based qualitative study.

    SETTING: A public University in Spain.

    PARTICIPANTS: Purposive sample of 42 nursing students who joined 7 focus groups.

    METHODS: Focus groups discussions following a semi-structured interview guide. Discussions were transcribed and analysed following critical discourse analysis to identify interpretative repertoires.

    RESULTS: From the analysis, three interpretative repertoires emerged. The first, 'Gender-based violence is something serious', reflected participants' acknowledgment of the social relevance of this type of violence. The second interpretative repertoire, 'Men are defenceless!', related to the perception that national legislation on gender-based violence was discriminatory to men and the perception of a lack of social sensitisation toward intimate partner violence against men. The last one, 'Trained to address gender-based violence but still unprepared' encompassed participants' confidence in their ability to identify gender-based violence but uncertainty as to how to respond to gender-based violence exposed women in terms of professional practice.

    CONCLUSIONS: Participants perceived that training has increased their knowledge and self-confidence in identifying cases. However, training should strongly challenge widespread myths about gender-based violence that could negatively affect their performance as nurses.

  • 64. Maquibar, Amaia
    et al.
    Vives-Cases, Carmen
    Hurtig, Anna-Karin
    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.
    Professionals' perception of intimate partner violence in young people: a qualitative study in northern Spain2017In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, article id 86Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intimate partner violence (IPV) is a public health problem with devastating effects on young women's health. These negative effects increase when the exposure to IPV lasts for a long time and exposure at an early age increases the risk of adult IPV. Despite efforts made in the last few decades, data show little progress has been made towards its reduction. Thus, the aim of the study reported here is to explore professionals' perceptions regarding intimate partner violence (IPV) among young people, focusing on the characteristics of the phenomenon and their perceptions about existing programmes and campaigns aimed at addressing it.

    METHODS: Twelve professionals from education, health and municipal social services were interviewed. All but one of the interviews were recorded and transcribed verbatim. Data were analysed according to the methodology of inductive thematic analysis, with the support of Atlas.ti software. The transcripts were read several times and coded line by line. Afterwards, codes were grouped into themes. The developed themes were refined into two phases with the participation of all the authors.

    RESULTS: From the analysis, the following three themes were identified: "A false sense of gender equity", "IPV among young people: subtle, daily and normalized", and "Mass media campaigns do not fit young people's needs". According to the participants, psychological abuse in the form of controlling behaviour by their partners is the most common type of IPV young women are exposed to, although exposure to other types of IPV was also acknowledged. This violence was described as something subtle, daily and normalized and, consequently, not something that is easy to recognize for the girls that are exposed to it, nor for adults working with young people.

    CONCLUSIONS: The study participants showed good knowledge of the characteristics IPV has among young people. This knowledge was reflected in locally implemented IPV prevention projects, which they considered successful in addressing young people's needs. However, these interventions lacked formal evaluation, political support and continuation. The study participants did not believe that nationwide mass media campaigns realistically reflected the specific characteristics of IPV among young people. Thus, participants perceived these campaigns to be ineffective.

  • 65.
    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.

  • 66.
    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.

  • 67.
    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)
  • 68. 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.

  • 69.
    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.

  • 70.
    Mathias, Kaaren
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Community Health and Development, Emmanuel Hospital Association, New Delhi, India.
    Mathias, Jeph
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kermode, Michelle
    Strengthening community mental health competence: A realist informed case study from Dehradun, North India2018In: Health & Social Care in the Community, ISSN 0966-0410, E-ISSN 1365-2524, Vol. 26, no 1, p. E179-E190Article in journal (Refereed)
    Abstract [en]

    Few accounts exist of programmes in low- and middle-income countries seeking to strengthen community knowledge and skills in mental health. This case study uses a realist lens to explore how a mental health project in a context with few mental health services, strengthened community mental health competence by increasing community knowledge, creating safer social spaces and engaging partnerships for action. We used predominantly qualitative methods to explore relationships between context, interventions, mechanisms and outcomes in the natural setting of a community-based mental health project in Dehradun district, Uttarakhand, North India. Qualitative data came from focus group discussions, participant observation and document reviews of community teams' monthly reports on changes in behaviour, attitudes and relationships among stakeholder groups. Data analysis initially involved thematic analysis of three domains: knowledge, safe social spaces and partnerships for action. By exploring patterns within the identified themes for each domain, we were able to infer the mechanisms and contextual elements contributing to observed outcomes. Community knowledge was effectively increased by allowing communities to absorb new understanding into pre-existing social and cultural constructs. Non-hierarchical informal community conversations allowed organic integration of unfamiliar biomedical knowledge into local explanatory frameworks. People with psycho-social disability and caregivers found increased social support and inclusion by participating in groups. Building skills in respectful communication through role plays and reflexive discussion increased the receptivity of social environments to people with psycho-social disabilities participation, thereby creating safe social spaces. Facilitating social networks through groups increases women's capacity for collective action to promote mental health. In summary, locally appropriate methods contribute most to learning, stigma reduction and help-seeking. The complex social change progress was patchy and often slow. This study demonstrates a participatory, iterative, reflexive project design which is generating evidence indicating substantial improvements in community mental health competence.

  • 71.
    Mkoka, Dickson Ally
    et al.
    Muhimbili Univ Hlth & Allied Sci, Sch Nursing, Dept Clin Nursing, Dar Es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, Angwara
    Muhimbili Univ Hlth & Allied Sci, Sch Publ Hlth & Social Sci, Dept Dev Studies, Dar Es Salaam, Tanzania.
    Mwangu, Mughwira
    Muhimbili Univ Hlth & Allied Sci, Sch Publ Hlth & Social Sci, Dept Dev Studies, Dar Es Salaam, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 108-Article in journal (Refereed)
    Abstract [en]

    Background: Provision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC). Methods: In-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach. Results: Participants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation. Conclusion: The unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

  • 72.
    Mkoka, Dickson Ally
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. School of Nursing, Muhimbili University of Health and Allied Sciences, MUHAS, Dar es Salaam, Tanzania.
    Kiwara, Angwara
    School of Nursing, Muhimbili University of Health and Allied Sciences, MUHAS, Dar es Salaam, Tanzania.
    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.
    Governing the implementation of Emergency Obstetric Care: experiences of Rural District Health Managers, Tanzania2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 333-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many health policies developed internationally often become adopted at the national level and are implemented locally at the district level. A decentralized district health system led by a district health management team becomes responsible for implementing such policies. This study aimed at exploring the experiences of a district health management team in implementing Emergency Obstetric Care (EmOC) related policies and identifying emerging governance aspects.

    METHODS: The study used a qualitative approach in which data was obtained from thirteen individual interviews and one focus group discussion (FGD). Interviews were conducted with members of the district health management team, district health service boards and NGO representatives. The FGD included key informants who were directly involved in the work of implementing EmOC services in the district. Documentary reviews and observation were done to supplement the data. All the materials were analysed using a qualitative content analysis approach.

    RESULTS: Implementation of EmOC was considered to be a process accompanied by achievements and challenges. Achievements included increased institutional delivery, increased number of ambulances, training service providers in emergency obstetric care and building a new rural health centre that provides comprehensive emergency obstetric care. These achievements were associated with good leadership skills of the team together with partnerships that existed between different actors such as the Non-Governmental Organization (NGO), development partners, local politicians and Traditional Birth Attendants (TBAs). Most challenges faced during the implementation of EmOC were related to governance issues at different levels and included delays in disbursement of funds from the central government, shortages of health workers, unclear mechanisms for accountability, lack of incentives to motivate overburdened staffs and lack of guidelines for partnership development.

    CONCLUSION: The study revealed that implementing EmOC is a process accompanied by challenges that require an approach with multiple partners to address them and that, for effective partnership, the roles and responsibilities of each partner should be well stipulated in a clear working framework within the district health system. Partnerships strengthen health system governance and therefore ensure effective implementation of health policies at a local level.

  • 73.
    Mkoka, Dickson Ally
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mahiti, Gladys Reuben
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, Angwara
    Mwangu, Mughwira
    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.
    "Once the government employs you, it forgets you": Health workers' and managers' perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania2015In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 13, article id 77Article in journal (Refereed)
    Abstract [en]

    Background: In many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems' function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention. Methods: In-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director's office). An interview guide was used with questions pertaining to informants' perspective on provision of maternal health care service, working environment, living conditions, handling of staff's financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers' role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach. Results: Overall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers' role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers' claims timely and that there is no transparency and fairness in dealing with health workers' financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers' concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers' knowledge and skills necessary for providing quality maternal health care. Conclusion: Health workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers' financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.

  • 74.
    Mosquera, Paola A
    et al.
    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.
    Goicolea, Isabel
    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.
    Equitable health services for the young?: A decomposition of income-related inequalities in young adults' utilization of health care in Northern Sweden2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 20Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the goal of the Swedish health system to offer health care according to the principle of horizontal equity, little is known about the equality in access to health care use among young people. To explore this issue, the present study aimed i) to assess horizontal inequity in health care utilization among young people in Northern Sweden; and ii) to explore the contribution of different factors to explain the observed inequalities.

    METHODS: Participants (N = 3016 youths aged 16-25 years) came from the "Health on Equal terms" survey conducted in 2014 in the four northernmost counties in Sweden. Concentration indices (C) and horizontal inequity indices (HI) were calculated to measure inequalities in the utilization of two health care services (general practitioners (GP) and youth clinics). The HI was calculated based on health care utilization and variables representing socioeconomic status (household income), health care needs factors and non-need factors affecting health care use. A decomposition analysis was carried out to explain the income-related inequalities.

    RESULTS: Results showed a significant positive income-related inequality for youth clinic utilization in women (C = 0.166) and total sample (C = 0.097), indicating that services were concentrated among the better-off. In contrast, general practitioner visits showed inequality pointing toward a higher utilization among less affluent individuals; significant in women (C = -0.079), men (C = -0.101) and pooled sample (C = -0.097). After taking health care needs into consideration, the utilization of youth clinics remained significantly pro-rich in women (HI = 0.121) and total sample (HI = 0.099); and consistently pro-poor for the GP visits in the pooled sample (HI = -0.058). The decomposition analyses suggest that socioeconomic inequalities explain a considerable portion of the pro-rich utilization of youth clinics services among young women. The corresponding analyses for GP visits showed that need factors and socioeconomic conditions accounted for the pro-poor concentration of GP visits.

    CONCLUSION: The distribution of GP visits among young people in Northern Sweden slightly favored the low-income group, and thus seems to meet the premises of horizontal equity. In contrast, the findings suggest substantial pro-rich horizontal inequity in the utilization of youth clinics among young women, which are largely rooted in socioeconomic inequalities.

  • 75.
    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.

  • 76. Otero-Garcia, Laura
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gea-Sánchez, Montserrat
    Sanz-Barbero, Belen
    Access to and use of sexual and reproductive health services provided by midwives among rural immigrant women in Spain: midwives' perspectives2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, article id 22645Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There insufficient information regarding access and participation of immigrant women in Spain in sexual and reproductive health programs. Recent studies show their lower participation rate in gynecological cancer screening programs; however, little is known about the participation in other sexual and reproductive health programs by immigrant women living in rural areas with high population dispersion.

    OBJECTIVES: The objective of this study is to explore the perceptions of midwives who provide these services regarding immigrant women's access and participation in sexual and reproductive health programs offered in a rural area.

    DESIGN: A qualitative study was performed, within a larger ethnographic study about rural primary care, with data collection based on in-depth interviews and field notes. Participants were the midwives in primary care serving 13 rural basic health zones (BHZ) of Segovia, a region of Spain with high population dispersion. An interview script was designed to collect information about midwives' perceptions on immigrant women's access to and use of the healthcare services that they provide. Interviews were recorded and transcribed with participant informed consent. Data were analyzed based on the qualitative content analysis approach and triangulation of results with fieldwork notes.

    RESULTS: Midwives perceive that immigrants in general, and immigrant women in particular, underuse family planning services. This underutilization is associated with cultural differences and gender inequality. They also believe that the number of voluntary pregnancy interruptions among immigrant women is elevated and identify childbearing and childrearing-related tasks and the language barrier as obstacles to immigrant women accessing the available prenatal and postnatal healthcare services.

    CONCLUSIONS: Immigrant women's underutilization of midwifery services may be linked to the greater number of unintended pregnancies, pregnancy terminations, and the delay in the first prenatal visit, as discerned by midwives. Future research should involve samples of immigrant women themselves, to provide a deeper understanding of the current knowledge, attitudes, and practices of the immigrant population regarding reproductive and sexual health to provide better health services.

  • 77. Otero-García, Laura
    et al.
    Briones-Vozmediano, Erica
    Vives-Cases, Carmen
    García-Quinto, Marta
    Sanz-Barbero, Belén
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Public Health Research Group, University of Alicante, Alicante, Spain.
    A qualitative study on primary health care responses to intimate partner violence during the economic crisis in Spain2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 6, p. 1000-1005Article in journal (Refereed)
    Abstract [en]

    Background: The objective of this study was to explore how health professionals perceived the effect of the economic crisis and associated austerity measures on the detection of and cares for intimate partner violence (IPV) in primary care in Spain.

    Methods: Qualitative study designed using semi-structured interviews carried out with 145 health professionals in 16 primary health care centres in different regions of Spain. An inductive thematic analysis was made of the transcriptions.

    Results: Three main themes were identified: 'Women endure more violence during times of economic crisis', 'Fewer resources, fewer professionals and less time to respond to IPV' and 'Professionals' motivation as a requirement to respond to IPV'. Professionals perceived that economic precariousness triggered violence against women and made women more hesitant to put an end to violent relationships. They also reported that the austerity measures applied to primary health care negatively affected their ability to detect and adequately care for cases of IPV due to a heavy workload, reduced human resources, difficulties in training and the loss of resources to which women could be referred. To counteract these obstacles, health professionals' motivation played a vital role in the response to IPV.

    Conclusions: Institutional efforts to organize awareness programmes and training in order to improve and promote early diagnosis, care and rehabilitation of these women cannot stop during times of crisis and primary health care centres should facilitate health professionals' access to these programmes.

  • 78. 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.

  • 79. Pérez-Urdiales, Iratxe
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    ¿Cómo acceden las mujeres inmigrantes a los servicios sanitarios en el País Vasco?: Percepciones de profesionales sanitarias2018In: Atención Primaria, ISSN 0212-6567, E-ISSN 1578-1275, Vol. 50, no 6, p. 368-376Article in journal (Refereed)
    Abstract [en]

    Objective: To determine the perception of health professionals working in alternative health centres on the barriers and facilitators in the access by immigrant women to general public health services and sexual and reproductive health in the Basque Country.

    Location: Basque Country.

    Design: Analysis of qualitative content based on 11 individual interviews. Participants: Health professionals working in alternative health centres of Primary Care and sexual and reproductive health.

    Method: Data collection was performed between September and December 2015 in four alternative health centres. After transcription, the units of meaning, codes and categories were identified.

    Results: Four categories emerged from the analysis, which represented how the characteristics of immigrant women (Tell me how you are and I will tell you how to access), the attitude of the administrative and health staff ("When they are already taken care of"), the functioning of the health system (Inflexible, passive and needs-responsive health system), and health policies ("If you do not meet the requirements, you do not go in. The law is the law") influence access to health services of immigrant women.

    Conclusions: This study shows that there are a considerable number of barriers and few facilitators to the access by immigrant women to public health and sexual and reproductive health services in the Basque Country. The alternative health centres were presented as favouring the improvement of the health of the immigrant population and in their access.

  • 80.
    Pérez-Urdiales, Iratxe
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How do immigrant women access the public healthcare services in the Basque Country (Spain)?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 477-478Article in journal (Other academic)
    Abstract [en]

    Background: Immigrant women face diverse barriers in order to access the public healthcare services in Spain. Furthermore, in 2012, a legislative change made the access conditions more difficult to fulfil for immigrants. Besides the public healthcare system, “free clinics” exist, which provide health attention to immigrant men and women who are not eligible for accessing it.

    Objective: To explore the perception of healthcare professionals working in free clinics in regards to the barriers and facilitators that immigrant women face to access the public healthcare general services and sexual and reproductive health services in the Basque Country (Spain).

    Methods: Qualitative study based on 11 individual interviews with healthcare professionals working in four different free clinics. A qualitative content analysis was done identifying meaning units, codes and categories.

    Results: Four categories emerged from the analysis that represent how the personal characteristics of the immigrant women (Tell me who you are and I will let you know how you will access); the attitude of the staff at the healthcare system (“Once they have been attended, everything is fine. The problem is with the administrative staff”); the organization of the healthcare system (The healthcare system is bureaucratic and passive), and health policies (“If you do not fulfil the requirements, you are just out. The law is the law”) influence the access of immigrant women to the public healthcare services.

    Conclusions: The results of this study show that there are a great number of barriers and few facilitators for the access of immigrant women to the public healthcare general services and sexual and reproductive health services in the Basque Country. The barriers based on the personal characteristics of the immigrant women, which vary based on their origin, were the most largely recognized, whereas the legal barriers were considered the most restrictive ones and difficult to overcome.

    Key messages:

    • Immigrant women face personal, institutional and legal barriers to access public health services.
    • Legal requirements are considered the main barriers to access public health services.
  • 81.
    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.

  • 82.
    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)
  • 83. Rodríguez, Gabriel Jesús
    et al.
    Córdoba-Doña, Juan Antonio
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Consejería de Salud de la Junta de Andalucía. Delegación Territorial de Cádiz, Espana.
    Escolar-Pujolar, Antonio
    Aguilar-Diosdado, Manuel
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Familia, economía y servicios sanitarios: claves de los cuidados en pacientes con diabetes y amputación de miembros inferiores. Estudio cualitativo en Andalucía: [Family, socioeconomic status and health services: Clues to health care in diabetic patients with lower limb amputations in Andalusia. A qualitative study]2018In: Atención Primaria, ISSN 0212-6567, E-ISSN 1578-1275, Vol. 50, no 10, p. 611-620Article in journal (Refereed)
    Abstract [en]

    Aim: To examine the experience of diabetic care in patients undergoing lower limb amputation.

    Design: A qualitative study using the phenomenological approach.

    Setting: Cadiz Health District.

    Participants: A total of 16 patients (11 men and 5 women) diagnosed with diabetes mellitus type 2 and with non-traumatic lower limb amputation.

    Methods: Semi-structured interviews were performed, followed by a content analysis according Graneheim and Lundman.

    Results: Four categories were identified: 1. The family is the cornerstone for diabetic care. 2. The socio-economic and working conditions determine the quality of self-care. 3. The patient-health professional interaction facilitates patient care. 4. Limitations in the provision of health services.

    Conclusion: Family, economic and working conditions, along with health system-related factors are the most important elements in the care of patients with diabetes and amputations. Social, economic and working conditions determine diabetic complications. In order to enhance health care impact on the prevention of diabetes mellitus complications, health system policy makers must take these facts seriously into consideration and in a more personalised manner.

  • 84. 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.

  • 85. Salazar, Mariano
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öhman, Ann
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS). Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Respectable, Disreputable, or Rightful? Young Nicaraguan Women's Discourses on Femininity, Intimate Partner Violence, and Sexual Abuse: A Grounded Theory Situational Analysis2016In: Journal of Aggression, Maltreatment & Trauma, ISSN 1092-6771, E-ISSN 1545-083X, Vol. 25, no 3, p. 315-332Article in journal (Refereed)
    Abstract [en]

    This situational analysis study aims to position the discourses that young Nicaraguan women use in their understanding of femininities, male intimate partner violence (IPV), and men's sexual violence toward women (SA). Eight focus group discussions with a total of 59 women were conducted. Positional maps were used to display the data. The findings show a dominant discourse that portrays femininity as enacting attributes habitually bestowed to men such as independence and agency, while still upholding key patriarchal conceptions (respectability) limiting women's agency. Tolerance of IPV and SA by nonpartners varies depending on women's perceived respectability and agency. Most important, we identified a pro-women's rights resistance discourse that constructs femininity and advocates nonviolence from a human rights perspective.

  • 86.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    "Closer to the Unfair Reality": Magnitude and Spatial Analysis of Femicides in Ecuador2019In: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, article id UNSP 0886260519863721Article in journal (Refereed)
    Abstract [en]

    During the last 5 years, Ecuador has published a series of progressive laws aiming to protect girls and women against any type of violence. While these efforts are of extreme importance, concerns were raised by national nongovernmental organizations that the official numbers might be biased due to the restricted definition of femicide applied. The main objective of this study was to assess the magnitude and spatial distribution of the femicide rate by province in Ecuador in 2017. Data on cases were collected by a national network of nongovernmental organizations. Age-specific population data were obtained from the National Institute of Statistics for the year 2017. Thematic maps of overall and age-specific femicide rates were also constructed. Moran's index was used to identify clusters of provinces with similar risks for the occurrence of the outcome. The total number of femicides during 2017 was 155, but age could not be recorded in 9 of those cases. More than one-third of the cases (36.99%) occurred in young women aged 15 to 24 years. The total rate was 1.99/100,000 women. When the femicide definition was restricted to women 15 years and above, the total rate increased to 2.41 cases/100,000. The femicide rate in Orellana boosted to 10.21 cases/100,000 in the age group of 15 years and older, the highest in the country. No pattern of spatial autocorrelation was observed. Femicides in Ecuador is a big public health problem, particularly in certain Amazon provinces. The observed rate for women above the age of 15 years (2.41) places Ecuador among the countries in the Latin American and the Caribbean region with the highest femicide rates. While progressive policies have been implemented in the last years, more educational interventions are needed at all societal levels to eradicate this kind of violence.

  • 87.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Frumence, Gasto
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, A
    Mwangu, M
    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.
    "Doctors ready to be posted are jobless on the street..." the deploymnet process and shortage of doctors in TanzaniaManuscript (preprint) (Other academic)
  • 88.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, Angwara
    Mwangu, Mughwira
    Anaeli, Amani
    Nyamhanga, Tumaini
    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.
    Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 260Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Retention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors' and district health managers' perspectives.

    METHODS: A qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.

    RESULTS: None of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services. Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.

    CONCLUSIONS: Retention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies.

  • 89.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Kiwara, Angwara
    Mwangu, Mughwira
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    "Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.2019In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, no 1, article id 11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

    METHODS: A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

    RESULTS: Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

    CONCLUSIONS: Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

  • 90.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O.BOX 65454, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, Angwara
    Mwangu, Mughwira
    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.
    Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania2019In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, article id 33Article in journal (Refereed)
    Abstract [en]

    Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s’ health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s’ health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities’ autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

  • 91.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Kiwara, Angwara
    Gasto, Frumence
    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.
    Training and deployment of medical doctors in Tanzania post-1990s health sector reforms: assessing the achievements2017In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 15, article id 27Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The shortage of a skilled health workforce is a global crisis. International efforts to combat the crisis have shown few benefits; therefore, more country-specific efforts are required. Tanzania adopted health sector reforms in the 1990s to ensure, among other things, availability of an adequate skilled health workforce. Little is documented on how the post-reform training and deployment of medical doctors (MDs) have contributed to resolving Tanzania's shortage of doctors. The study aims to assess achievements in training and deployment of MDs in Tanzania about 20 years since the 1990s health sector reforms.

    METHODS: We developed a human resource for health (HRH) conceptual model to study achievements in the training and deployment of MDs by using the concepts of supply and demand. We analysed secondary data to document the number of MDs trained in Tanzania and abroad, and the number of MDs recommended for the health sector from 1992 to 2011. A cross-sectional survey conducted in all regions of the country established the number of MDs available by 2011.

    RESULTS: By 1992, Tanzania had 1265 MDs working in the country. From 1992 to 2010, 2622 MDs graduated both locally and abroad. This translates into 3887 MDs by 2011. Tanzania needs between 3326 and 5535 MDs. Our survey captured 1299 MDs working throughout the country. This number is less than 40% of all MDs trained in and needed for Tanzania by 2011. Maldistribution favouring big cities was evident; the eastern zone with less than 30% of the population hosts more than 50% of all MDs. No information was available on the more than 60% of MDs uncaptured by our survey.

    CONCLUSIONS: Two decades after the reforms, the number of MDs trained in Tanzania has increased sevenfold per year. Yet, the number and geographical distribution of MDs practicing in the country has remained the same as before the reforms. HRH planning should consider the three stages of health workforce development conceptualized under the demand and supply model. Auditing and improvement of the HRH database is highly recommended in dealing with Tanzania's MD crisis.

  • 92.
    Thomée, Suzanne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Malm, Desiré
    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.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Waenerlund, Anna-Karin
    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.
    Challenges and strategies for sustaining youth-friendly health services: a qualitative study from the perspective of professionals at youth clinics in northern Sweden2016In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 13, article id 147Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Youth-friendly health-care services - those that are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations - are beneficial for youth health, but not easy to implement and sustain. Sweden is among the few countries where youth-friendly health-care services have been integrated within the public health system and sustained for a long time. This study explores the challenges and strategies in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden.

    METHODS: Eleven semi-structured interviews with various health-care professionals working in youth clinics in northern Sweden were conducted. The interviews were transcribed verbatim, and analysed using thematic analysis in relation to the World Health Organization domains of youth friendliness.

    RESULTS: Four themes emerged from the analysis of the data: 1) 'Meeting youths on their own terms - the key to ensuring a holistic and youth-centred care' was related to the acceptability and appropriateness of the services; 2) 'Organizational challenges and strategies in keeping professionals' expertise on youth updated' referred to the domain of effectiveness; 3) 'Youth clinics are accessible for those who know and can reach them' was related to the domains of accessibility and equity, and 4) 'The challenge of combining strong directions and flexibility in diverse local realities' focused on the struggle to sustain the youth clinics organization and their goals within the broader health system.

    CONCLUSIONS: Professionals working in youth clinics are perceived as motivated, interested and knowledgeable about youth, and the clinics ensure confidentiality and a youth-centred and holistic approach. Challenges remain, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics are perceived as an indisputable part of the Swedish health system, but organizational challenges are also pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.

  • 93.
    Torres, Virgilio Mariano Salazar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center for Demography and Health Research, Nicaraguan National Autonomous University, León, Nicaragua.
    Goicolea, Isabel
    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).
    Edin, Kerstin
    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).
    Öhman, Ann
    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).
    'Expanding your mind': the process of constructing gender-equitable masculinities in young Nicaraguan men participating in reproductive health or gender training programs2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Traditional forms of masculinity strongly influence men's and women's wellbeing.

    OBJECTIVE: This study has two aims: (i) to explore notions of various forms of masculinities in young Nicaraguan men participating in programs addressing sexual health, reproductive health, and/or gender equality and (ii) to find out how these young men perceive their involvement in actions aimed at reducing violence against women (VAW).

    DESIGN: A qualitative grounded theory study. Data were collected through six focus groups and two in-depth interviews with altogether 62 young men.

    RESULTS: Our analysis showed that the informants experienced a process of change, labeled 'Expanding your mind', in which we identified four interrelated subcategories: The apprentice, The responsible/respectful man, The proactive peer educator, and 'The feminist man'. The process showed how an increased awareness of gender inequities facilitated the emergence of values (respect and responsibility) and behavior (thoughtful action) that contributed to increase the informant's critical thinking and agency at individual, social, and political levels. The process was influenced by individual and external factors.

    CONCLUSIONS: Multiple progressive masculinities can emerge from programs challenging patriarchy in this Latin American setting. The masculinities identified in this study show a range of attitudes and behaviors; however, all lean toward more equitable gender relations. The results suggest that learning about sexual and reproductive health does not directly imply developing more gender-equitable attitudes and behaviors or a greater willingness to prevent VAW. It is paramount that interventions to challenge machismo in this setting continue and are expanded to reach more young men.

  • 94. Torrubiano-Domínguez, J
    et al.
    Vives-Cases, C
    San-Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sanz-Barbero, B
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Alicante, Dept Community Nursing Prevent Med & Publ Hlth &, Publ Hlth Res Grp, E-03080 Alicante, Spain.
    Álvarez-Dardet, C
    No effect of unemployment on intimate partner-related femicide during the financial crisis: a longitudinal ecological study in Spain2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 990Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Spain's financial crisis has been characterized by an increase in unemployment. This increase could have produced an increase in deaths of women due to intimate partner-related femicides (IPF). This study aims to determine whether the increase in unemployment among both sexes in different regions in Spain is related to an increase in the rates of IPF during the current financial crisis period.

    METHODS: An ecological longitudinal study was carried out in Spain's 17 regions. Two study periods were defined: pre-crisis period (2005-2007) and crisis period (2008-2013). IPF rates adjusted by age and unemployment rates for men and women were calculated. We fitted multilevel linear regression models in which observations at level 1 were nested within regions according to a repeated measurements design.

    RESULTS: Rates of unemployment have progressively increased in Spain, rising above 20 % from 2008 to 2013 in some regions. IPF rates decreased in some regions during crisis period with respect to pre-crisis period. The multilevel analysis does not support the existence of a significant relationship between the increase in unemployment in men and women and the decrease in IPF since 2008.

    DISCUSSION: The increase in unemployment in men and women in Spain does not appear to have an effect on IPF. The results of the multilevel analysis discard the hypothesis that the increase in the rates of unemployment in women and men are related to an increase in IPF rates.

    CONCLUSIONS: The decline in IPF since 2008 might be interpreted as the result of exposure to other factors such as the lower frequency of divorces in recent years or the medium term effects of the integral protection measures of the law on gender violence that began in 2005.

  • 95. Tsegay, Yalem
    et al.
    Gebrehiwot, Tesfay
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lemma, Hailemariam
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study2013In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 12, no 30Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15-49 years in Tigray, Ethiopia.

    METHODS: The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation.

    RESULTS: The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband's occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands' occupation.

    CONCLUSIONS: A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.

  • 96. Vives Cases, Carmen
    et al.
    Torrubiano Dominguez, Jordi
    Carrasco Portino, Mercedes
    Espinar-Ruiz, Eva
    Gil-Gonzalez, Diana
    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.
    Validation of the Spanish Version of Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS)2015In: Revista Española de Salud Pública, ISSN 1135-5727, Vol. 89, no 2, p. 173-U112Article in journal (Refereed)
    Abstract [en]

    Background: At the international level PREMIS - "Physician Readiness to Manage Intimate Partner Violence Survey"- is amongst the most comprehensive instruments to evaluate primary health care professionals' readiness. The aim of this study is to assess the reliability, internal consistency and construct validity of the Spanish version of this questionnaire. Methods: After translation, back translation and assessment of content validity of the questionnaire, 200 questionnaires were distributed to medical doctors and nurses working in 15 primary health care centres located in 4 autonomous regions (Comunidad Valenciana, Castilla Leon, Murcia, Cantabria), in 2013. Cronbach's alpha, intraclass correlation and rho Spearman coefficients were calculated. Results: the Spanish version of PREMIS encompasses 64 items. Cronbach's alpha coefficient was greater than or close to 0.7 in most of indices. Intraclass correlation coefficient of 0.87 and Spearman coefficient of 0.67 showed a high reliability. All correlations for the scale of Opinions, which is the only one that was considered factorial structure of the questionnaire PREMIS, were higher than 0.30. Conclusions: the Spanish version of PREMIS obtained good internal validity, high reliability and predictive self-reported capacity of medical practitioners and nurses in Intimate Partner Violence cases in PHC centers.

  • 97. Vives Cases, Carmen
    et al.
    Torrubiano Domínguez, Jordi
    Carrasco Portiño, Mercedes
    Espinar-Ruiz, Eva
    Gil-González, Diana
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Validación de la versión española del cuestionario: physician readiness to manage intimate partner violence survey (PREMIS)2015In: Revista Española de Salud Pública, ISSN 1135-5727, Vol. 89, no 2, p. 173-190Article in journal (Refereed)
    Abstract [es]

    BACKGROUND: At the international level PREMIS -"Physician Readiness to Manage Intimate Partner Violence Survey"- is amongst the most comprehensive instruments to evaluate primary health care professionals' readiness. The aim of this study is to assess the reliability, internal consistency and construct validity of the Spanish version of this questionnaire.

    METHODS: After translation, back translation and assessment of content validity of the questionnaire, 200 questionnaires were distributed to medical doctors and nurses working in 15 primary health care centres located in 4 autonomous regions (Comunidad Valenciana, Castilla León, Murcia, Cantabria), in 2013. Cronbach's alpha, intraclass correlation and rho Spearman coefficients were calculated.

    RESULTS: the Spanish version of PREMIS encompasses 64 items. Cronbach's alpha coefficient was greater than or close to 0.7 in most of indices. Intraclass correlation coefficient of 0.87 and Spearman coefficient of 0.67 showed a high reliability. All correlations for the scale of Opinions, which is the only one that was considered factorial structure of the questionnaire PREMIS, were higher than 0.30.

    CONCLUSIONS: the Spanish version of PREMIS obtained good internal validity, high reliability and predictive self-reported capacity of medical practitioners and nurses in Intimate Partner Violence cases in PHC centers.

  • 98. Vives-Cases, Carmen
    et al.
    Eriksson, Malin
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öhman, Ann
    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).
    Gender and health inequalities: intersections with other relevant axes of oppression2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 30292Article in journal (Other academic)
  • 99. Vives-Cases, Carmen
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sanz-Barbero, Belen
    Gill, Aisha K.
    Baldry, Anna Costanza
    Schroettle, Monika
    Stoeckl, Heidi
    Expert Opinions on Improving Femicide Data Collection across Europe: A Concept Mapping Study2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 2, article id e0148364Article in journal (Refereed)
    Abstract [en]

    Femicide, defined as the killings of females by males because they are females, is becoming recognized worldwide as an important ongoing manifestation of gender inequality. Despite its high prevalence or widespread prevalence, only a few countries have specific registries about this issue. This study aims to assemble expert opinion regarding the strategies which might feasibly be employed to promote, develop and implement an integrated and differentiated femicide data collection system in Europe at both the national and international levels. Concept mapping methodology was followed, involving 28 experts from 16 countries in generating strategies, sorting and rating them with respect to relevance and feasibility. The experts involved were all members of the EU-Cost-Action on femicide, which is a scientific network of experts on femicide and violence against women across Europe. As a result, a conceptual map emerged, consisting of 69 strategies organized in 10 clusters, which fit into two domains: "Political action" and "Technical steps". There was consensus among participants regarding the high relevance of strategies to institutionalize national databases and raise public awareness through different stakeholders, while strategies to promote media involvement were identified as the most feasible. Differences in perceived priorities according to the level of human development index of the experts' countries were also observed.

  • 100. Vives-Cases, Carmen
    et al.
    Goicolea, Isabel
    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.
    Sanz-Barbero, Belen
    Davó-Blanes, MCarmen
    La Parra-Casado, Daniel
    Priorities and strategies for improving Roma women's access to primary health care services in cases on intimate partner violence: a concept mapping study2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 96Article in journal (Refereed)
    Abstract [en]

    Background: With an explicit focus on Roma women in Spain (Kale/Spanish Gypsies), this study aims to integrate key informants' opinions about the main actions needed to improve primary health care services' and professionals' responses to Roma women in an Intimate Partner Violence (IPV) situation. Methods: Concept mapping study. A total of 50 (brainstorming phase), 36 (sorting and rating phase) and 16 (interpretation phase) participants from Roma civil society groups, primary health care professionals and other related stakeholders (social services, academic experts and other IPV NGOs representatives) from different cities in Spain were involved in the different study phases. Results: Among the 55 action proposals generated, ten priority actions were identified through consensus as most important for improving primary health care's response to Romani women in an IPV situation, and these included primary, secondary and tertiary prevention activities. Conclusion: Results indicated that efforts to address this challenge should take an integrated approach that reinforces the primary health care response to IPV in general, while also promoting more specific actions to address barriers to access that affect all Roma women and those who experience IPV in particular.

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