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  • 51.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mechanisms for achieving adolescent-friendly services: a realist evaluation approach2012Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, s. 18748-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth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

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

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

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

  • 52.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Coe, Anna-Britt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Developing and sustaining adolescent-friendly health services: a multiple case study from Ecuador and Peru2017Inngår i: Global Public Health, ISSN 1744-1692, E-ISSN 1744-1706, Vol. 12, nr 8, s. 1004-1017Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 53.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hultstrand Ahlin, Cecilia
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Accessibility and factors associated with utilization of mental health services in youth health centers: a qualitative comparative analysis in northern Sweden2018Inngår i: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, artikkel-id 69Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 54.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Univ Alicante, Grp Invest Salud Publ, E-03080 Alicante, Spain.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Vives-Cases, Carmen
    Using realist evaluation to assess primary healthcare teams' responses to intimate partner violence in Spain2015Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 29, nr 6, s. 431-436Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 55.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Univ Alicante, Dept Community Nursing Prevent Med & Publ Hlth &, Publ Hlth Res Grp, E-03080 Alicante, Spain.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Marchal, Bruno
    Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: a realist case-study2015Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, artikkel-id 228Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 56.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain.
    Marchal, Bruno
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Briones-Vozmediano, Erica
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Why do certain primary health care teams respond better to intimate partner violence than others?: A multiple case study2019Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 33, nr 2, s. 169-176Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 57.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Unintended pregnancy in the amazon basin of Ecuador: a multilevel analysis2010Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 9, s. 14-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 58.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Grupo de Investigación de Salud Pública, Universidad de Alicante, Spain.
    Vives-Cases, Carmen
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Briones-Vozmediano, Erica
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Grupo de Investigación de Salud Pública, Universidad de Alicante, Spain ; .
    Otero-Garcia, Laura
    Garca-Quinto, Marta
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches2015Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 8, artikkel-id e0135167Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

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

    Methods

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

    Results

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

    Conclusions

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

  • 59.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Kegels, Guy
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol2013Inngår i: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8, s. 36-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

  • 60.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Adolescent pregnancies and girls' sexual and reproductive rights in the Amazon Basin of Ecuador: an analysis of providers' and policy makers' discourses2010Inngår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 10, nr 12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 61.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Risk factors for pregnancy among adolescent girls in Ecuador's Amazon basin: a case-control study2009Inngår i: Revista panamericana de salud pùblica, ISSN 1020-4989, E-ISSN 1680-5348, Vol. 26, nr 3, s. 221-228Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 62.
    Gustafsson, Per E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bozorgmehr, Kayvan
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    What role does adolescent neighborhood play for adult health?: A cross-classified multilevel analysis of life course models in Northern Sweden2017Inngår i: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 46, s. 137-144Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study examined whether, and by which life course models, adolescent neighborhood environment relate to health in mid-adulthood. Data came from the Northern Swedish Cohort (n=1001), surveyed at age 16, 21, 30 and 42 years including functional somatic symptoms at age 42, and individual disadvantage neighborhood disadvantage at all four ages. Results from cross-classified multilevel models showed that 12.7% of age 42 health variance was explained by an interaction of age 16 and age 42 neighborhood of residence. Our study thus suggests that health variation by neighborhood in mid-adulthood may partly depend on neighborhood of residence in adolescence.

  • 63.
    Gustafsson, Per E
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    When does hardship matter for health? Neighborhood and individual disadvantages and functional somatic symptoms from adolescence to mid-life in the Northern Swedish Cohort.2014Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, nr 6, s. e99558-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    A large body of research has shown that health is influenced by disadvantaged living conditions, including both personal and neighborhood conditions. Little is however known to what degree the health impact of different forms of disadvantage differ along the life course. The present study aims to examine when, during the life course, neighborhood and individual disadvantages relate to functional somatic symptoms. Participants (n = 992) came from The Northern Swedish Cohort and followed from age 16, 21, 30 until 42 years. Functional somatic symptoms, socioeconomic disadvantage, and social and material adversity were measured through questionnaires and linked to register data on neighborhood disadvantage. Data was analyzed with longitudinal and cross-sectional multilevel models. Results showed that neighborhood disadvantage, social and material adversity and gender all contributed independently to overall levels of symptoms across the life course. Cross-sectional analyses also suggested that the impact of disadvantage differed between life course periods; neighborhood disadvantage was most important in young adulthood, and the relative importance of material versus social adversity increased as participants grew older. In summary, the study suggests that disadvantages from different contextual sources may affect functional somatic health across the life course, but also through life course specific patterns.

  • 64.
    Gustafsson, Per E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Janlert, Urban
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Theorell, Töres
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Westerlund, Hugo
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Life-course accumulation of neighborhood disadvantage and allostatic load: empirical integration of three social determinants of health frameworks2014Inngår i: American Journal of Public Health, ISSN 0090-0036, E-ISSN 1541-0048, Vol. 104, nr 5, s. 904-910Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: We examined if the accumulation of neighborhood disadvantages from adolescence to mid-adulthood were related to allostatic load, a measure of cumulative biological risk, in mid-adulthood, and explored whether this association was similar in women and men.

    METHODS: Data were from the participants in the Northern Swedish Cohort (analytical n = 818) at ages 16, 21, 30, and 43 years in 1981, 1986, 1995, and 2008. Personal living conditions were self-reported at each wave. At age 43 years, 12 biological markers were measured to operationalize allostatic load. Registered data for all residents in the cohort participants' neighborhoods at each wave were used to construct a cumulative measure of neighborhood disadvantage. Associations were examined in ordinary least-squares regression models.

    RESULTS: We found that cumulative neighborhood disadvantage between ages 16 and 43 years was related to higher allostatic load at age 43 years after adjusting for personal living conditions in the total sample (B = 0.11; P = .004) and in men (B = 0.16; P = .004), but not in women (B = 0.07; P = .248).

    CONCLUSIONS: Our findings suggested that neighborhood disadvantage acted cumulatively over the life course on biological wear and tear, and exemplified the gains of integrating social determinants of health frameworks.

  • 65.
    Gustafsson, Per E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Janlert, Urban
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Theorell, Töres
    Westerlund, Hugo
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Residential Selection across the Life Course: Adolescent Contextual and Individual Determinants of Neighborhood Disadvantage in Mid-Adulthood.2013Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, nr 11, artikkel-id e80241Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Numerous cross-sectional studies have examined neighborhood effects on health. Residential selection in adulthood has been stressed as an important cause of selection bias but has received little empirical attention, particularly its determinants from the earlier life course. The present study aims to examine whether neighborhood, family, school, health behaviors and health in adolescence are related to socioeconomic disadvantage of one's neighborhood of residence in adulthood.

    METHODS: Based on the prospective Northern Swedish Cohort (analytical N = 971, 90.6% retention rate), information was collected at age 16 years concerning family circumstances, school adjustment, health behaviors and mental and physical health. Neighborhood register data was linked to the cohort and used to operationalize aggregated measures of neighborhood disadvantage (ND) at age 16 and 42. Data was analyzed with linear mixed models, with ND in adulthood regressed on adolescent predictors and neighborhood of residence in adolescence as the level-2 unit.

    RESULTS: Neighborhood disadvantage in adulthood was clustered by neighborhood of residence in adolescence (ICC = 8.6%). The clustering was completely explained by ND in adolescence. Of the adolescent predictors, ND (b = .14 (95% credible interval = .07-.22)), final school marks (b = -.18 (-.26--.10)), socioeconomic disadvantage (b = .07 (.01-.14)), and, with borderline significance, school peer problems (b = .07 (-.00-.13)), were independently related to adulthood ND in the final adjusted model. In sex-stratified analyses, the most important predictors were school marks (b = -.21 (-.32--.09)) in women, and neighborhood of residence (ICC = 15.5%) and ND (b = .20 (.09-.31)) in men.

    CONCLUSIONS: These findings show that factors from adolescence - which also may impact on adult health - could influence the neighborhood context in which one will live in adulthood. This indicates that residential selection bias in neighborhood effects on health research may have its sources in early life.

  • 66.
    Gustafsson, Per E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastián, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mosquera, Paola A.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Meddling with middle modalities: a decomposition approach to mental health inequalities between intersectional gender and economic middle groups in northern Sweden2016Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, artikkel-id 32819Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Intersectionality has received increased interest within population health research in recent years, as a concept and framework to understand entangled dimensions of health inequalities, such as gender and socioeconomic inequalities in health. However, little attention has been paid to the intersectional middle groups, referring to those occupying positions of mixed advantage and disadvantage.

    OBJECTIVE: This article aimed to 1) examine mental health inequalities between intersectional groups reflecting structural positions of gender and economic affluence and 2) decompose any observed health inequalities, among middle groups, into contributions from experiences and conditions representing processes of privilege and oppression.

    DESIGN: Participants (N=25,585) came from the cross-sectional 'Health on Equal Terms' survey covering 16- to 84-year-olds in the four northernmost counties of Sweden. Six intersectional positions were constructed from gender (woman vs. men) and tertiles (low vs. medium vs. high) of disposable income. Mental health was measured through the General Health Questionnaire-12. Explanatory variables covered areas of material conditions, job relations, violence, domestic burden, and healthcare contacts. Analysis of variance (Aim 1) and Blinder-Oaxaca decomposition analysis (Aim 2) were used.

    RESULTS: Significant mental health inequalities were found between dominant (high-income women and middle-income men) and subordinate (middle-income women and low-income men) middle groups. The health inequalities between adjacent middle groups were mostly explained by violence (mid-income women vs. men comparison); material conditions (mid- vs. low-income men comparison); and material needs, job relations, and unmet medical needs (high- vs. mid-income women comparison).

    CONCLUSIONS: The study suggests complex processes whereby dominant middle groups in the intersectional space of economic affluence and gender can leverage strategic resources to gain mental health advantage relative to subordinate middle groups.

  • 67.
    Gustafsson, Per
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Cumulative contextual and individual disadvantages over the life course and adult functional somatic symptoms in Sweden2015Inngår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, nr 4, s. 592-597Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND:: Disadvantage, originating in one's residential context or in one's past life course, has been shown to impact on health in adulthood. There is however little research on the accumulated health impact of both neighbourhood and individual conditions over the life course. This study aims to examine whether the accumulation of contextual and individual disadvantages from adolescence to middle-age predicts functional somatic symptoms (FSS) in middle-age, taking baseline health into account.

    METHODS:: The sample is the age 16, 21, 30 and 42 surveys of the prospective Northern Swedish Cohort, with analytical sample size n = 910 (85% of the original cohort). FSS at age 16 and 42, and cumulative socioeconomic disadvantage, social adversity and material adversity between 16 and 42 years were operationalized from questionnaires, and cumulative neighbourhood disadvantage between 16 and 42 years from register data.

    RESULTS:: Results showed accumulation of disadvantages jointly explained 9-12% of FSS variance. In the total sample, cumulative neighbourhood and socioeconomic disadvantage significantly predicted FSS at age 42 in the total sample. In women, neighbourhood disadvantage but not socioeconomic disadvantage contributed significantly, whereas in men, socioeconomic but not neighbourhood disadvantage contributed significantly. In all analyses, associations were largely explained by the parallel accumulation of social and material adversities, but not by symptoms at baseline.

    CONCLUSION:: In conclusion, the accumulation of diverse forms of disadvantages together plays an important role for somatic complaints in adulthood, independently of baseline health.

  • 68. Hernandez, Alison
    et al.
    Lorena Ruano, Ana
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Flores, Walter
    Pathways to accountability in rural Guatemala: a qualitative comparative analysis of citizen-led initiatives for the right to health of indigenous populations2019Inngår i: World Development, ISSN 0305-750X, E-ISSN 1873-5991, Vol. 113, s. 392-401Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 69. Hernandez, Alison
    et al.
    Ruano, Ana Lorena
    Marchal, Bruno
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Flores, Walter
    Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity2017Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, artikkel-id 26Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.

  • 70.
    Hernández, Alison
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Supporting the performance of rural nurses: a concept mapping study with regional health system actors in GuatemalaManuskript (preprint) (Annet vitenskapelig)
    Abstract [en]

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

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

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

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

  • 71.
    Hernández, Alison
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala2012Inngår i: ISRN Nursing, ISSN 2090-5483, E-ISSN 2090-5491, Vol. 2012, s. 648769-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 72.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala2015Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, artikkel-id 91Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 73.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala2014Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, nr 1, s. 112-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

  • 74.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis2014Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, s. 23190-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction : Strengthening health service delivery to the rural poor is an important means of redressing inequities. Meso-level managers can help enhance efficiency in the utilization of existing resources through the application of practical tools to analyze routinely collected data reflecting inputs and outputs. This study aimed to assess the efficiency and change in productivity of health posts over two years in a rural department of Guatemala.

    Methods : Data envelopment analysis was used to measure health posts' technical efficiency and productivity change for 2008 and 2009. Input/output data were collected from the regional health office of Alta Verapaz for 34 health posts from the 19 districts comprising the health region.

    Results : Technical efficiency varied widely across health posts, with mean scores of 0.78 (SD=0.24) and 0.75 (SD=0.21) in 2008 and 2009, respectively. Overall, productivity increased by 4%, though 47% of health posts experienced a decline in productivity. Results were combined on a bivariate plot to identify health posts at the high and low extremes of efficiency, which should be followed up to determine how and why their production processes are operating differently.

    Conclusions : Assessing efficiency using the data that are available at the meso-level can serve as a first step in strengthening performance. Further work is required to support managers in the routine application of efficiency analysis and putting the results to use in guiding efforts to improve service delivery and increase utilization.

  • 75.
    Hurtig, Anna Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Soto, Alejandro
    Shingre, Angel
    Zambrano, Diocles
    Guerrero, Walter
    Pesticide use among farmers in the Amazon basin of Ecuador.2003Inngår i: Archives of Environmental Health: An International Journal, ISSN 0003-9896, Vol. 58, nr 4, s. 223-8Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Pesticide use is one of the most significant occupational exposures for agricultural workers in the Amazon basin of Ecuador. A structured questionnaire was developed focusing on sociodemographic characteristics, knowledge and experience of adverse health effects related to pesticide use, details of work practices, and an inventory of pesticides used on the farm. Of the 112 farmers interviewed, 111 (99.1%) used pesticides. Paraquat was most commonly used (77.4%), followed by glyphosate (65.7%). Respondents had good knowledge about the acute health effects of pesticides and their exposure routes. Risk behaviors were identified as frequent pesticide use, washing pesticide equipment in water sources used by humans, inadequate disposal of empty pesticide containers, eating and drinking during pesticide application, and using inadequate protective clothing. Training and educational campaigns on pesticide use should be encouraged for this cohort, along with suggestions for alternative methods of pest control.

  • 76.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Epidemiology on the side of the angels...Or the people?2003Inngår i: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 32, nr 4, s. 658-9; author reply 659Artikkel i tidsskrift (Fagfellevurdert)
  • 77.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Epidemiology vs epidemiology: the case of oil exploitation in the Amazon basin of Ecuador.2005Inngår i: Int J Epidemiol, ISSN 0300-5771, Vol. 34, nr 5, s. 1170-2Artikkel i tidsskrift (Fagfellevurdert)
  • 78.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Incidence of childhood leukemia and oil exploitation in the Amazon basin of Ecuador.2004Inngår i: International journal of occupational and environmental health, ISSN 1077-3525, Vol. 10, nr 3, s. 245-50Artikkel i tidsskrift (Fagfellevurdert)
  • 79.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    The People's Health Movement: what is it and should we care?2005Inngår i: Scand J Public Health, ISSN 1403-4948, Vol. 33, nr 3, s. 236-8Artikkel i tidsskrift (Fagfellevurdert)
  • 80.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Geographical differences in cancer incidence in the Amazon basin of Ecuador in relation to residence near oil fields.2002Inngår i: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 31, nr 5, s. 1021-7Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Since 1972, oil companies have extracted more than 2 billion barrels of crude oil from the Ecuadorian Amazon, releasing billions of gallons of untreated wastes and oil directly into the environment. This study aimed to determine if there was any difference in overall and specific cancer incidence rates between populations living in proximity to oil fields and those who live in areas free from oil exploitation.

    METHODS: Cancer cases from the provinces of Sucumbios, Orellana, Napo and Pastaza during the period 1985-1998 were included in the study. The exposed population was defined as those living in a county (n = 4) where oil exploitation had been ongoing for a minimum of 20 years up to the date of the study. Non-exposed counties were identified as those (n = 11) without oil development activities. Relative risks (RR) along with 95% CI were calculated for men and women as ratios of the age-adjusted incidence rates in the exposed versus non-exposed group.

    RESULTS: The RR of all cancer sites combined was significantly elevated in both men and women in exposed counties. Significantly elevated RR were observed for cancers of the stomach, rectum, skin melanoma, soft tissue and kidney in men and for cancers of the cervix and lymph nodes in women. An increase in haematopoietic cancers was also observed in the population under 10 years in the exposed counties in both males and females.

    CONCLUSION: Study results are compatible with a relationship between cancer incidence and living in proximity to oil fields. An environmental monitoring and cancer surveillance system in the area is recommended.

  • 81.
    Hurtig, Anna-Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gynecologic and breast malignancies in the Amazon basin of Ecuador, 1985-1998.2002Inngår i: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 76, nr 2, s. 199-201Artikkel i tidsskrift (Fagfellevurdert)
  • 82.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Deo, Prakash R.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens2015Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, s. 1-15Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 83.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Deo, Prakash Ramchandra
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The emergence of maternal health as a political priority in Madhya Pradesh, India: a qualitative study2013Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, s. 181-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Politics plays a critical role in agenda setting in health affairs; therefore, understanding the priorities of the political agenda in health is very important. The political priority for safe motherhood has been investigated at the national level in different countries. The objective of this study was to explore why and how maternal health became a political priority at sub-national level in the state of Madhya Pradesh in India.

    Methods: This study followed a qualitative design. Data were collected by carrying out interviews and review of documents. Semi-structured interviews were carried out with twenty respondents from four stakeholder groups: government officials, development partners, civil society and academics. Data analysis was performed using thematic analysis. The analysis was guided by Kingdon's multiple streams model.

    Results: The emergence of maternal health as a political priority in Madhya Pradesh was the result of convergence in the developments in different streams: the development of problem definition, policy generation and political change. The factors which influenced this process were: emerging evidence of the high magnitude of maternal mortality, civil society's positioning of maternal mortality as a human rights violation, increasing media coverage, supportive policy environment and launch of the National Rural Health Mission (NRHM), the availability of effective policy solutions, India's aspiration of global leadership, international influence, maternal mortality becoming a hot debate topic and political transition at the national and state levels. Most of these factors first became important at national level which then cascaded to the state level. Currently, there is a supportive policy environment in the state for maternal health backed by greater political will and increased resources. However, malnutrition and population stabilization are the competing priorities which may push maternal health off the agenda.

    Conclusions: The influence of the events and factors evolving from international and national levels significantly contributed to the development of maternal health as a priority in Madhya Pradesh. This led to several opportunities in terms of policies, guidelines and programmes for improving maternal health. These efforts were successful to some extent in improving maternal health in the state but several implementation challenges still require special attention.

  • 84.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis2011Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 10, nr 1, s. 59-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background Improving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC).

    Methods This study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study.

    Results The results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mother's education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services.

    Conclusions We found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions.

  • 85.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Swedish Research School for Global Health, Umeå University and United Nations Population Fund, Bhopal, India.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Technical efficiency of public district hospitals in Madhya Pradesh, India: a data envelopment analysis2013Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Scarcity of resources for healthcare is a well-acknowledged problem. In this context, efficient utilization of existing financial and human resources becomes crucial for strengthening the healthcare delivery. The assessment of efficiency of health facilities can guide decision makers in ensuring the optimum utilization of available resources.

    Objective: The objective of this study was to evaluate the technical efficiency (TE) of the public district hospitals in Madhya Pradesh, India, with special emphasis on maternal healthcare services, using data envelopment analysis (DEA).

    Methods: Data from 40 district hospitals from January to December 2010 were collected from the health management information system and other records of the department of health and family welfare of the state. DEA was performed with input orientation and variable returns to scale assumption.

    Results: TE and scale efficiency scores of the district hospitals were 0.90 (SD = 0.14) and 0.88 (SD = 0.15), respectively. Of the total district hospitals in the study, 20 (50%) were technically efficient constituting the 'best practice frontier'. The other half were technically inefficient, with an average TE score of 0.79 (SD = 0.12) meaning that these hospitals could produce the same outputs by using 21% less inputs from current input levels. Twenty-six (65%) district hospitals were found to be scale inefficient, manifesting a mean score of 0.81 (SD = 0.16).

    Conclusions: Half of the district hospitals in the study were operating inefficiently. Decision makers and administrators in the state should identify the causes of the observed inefficiencies and take appropriate measures to increase efficiency of these hospitals.

  • 86.
    Johansson, Klara
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    Neighbourhood disadvantage and individual adversities in adolescence and total alcohol consumption up to mid-life: Results from the Northern Swedish Cohort2015Inngår i: Health & place, ISSN 1873-2054, Vol. 33, s. 187-194Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study tests if neighbourhood socioeconomic disadvantage and family social and material adversities during adolescence are independently related to total alcohol consumption from adolescence through to mid-life. Self-reports from the Northern Swedish Cohort (effective sample=950) at ages 16, 18, 21, 30 and 42 was combined with register data on the socioeconomic composition of neighbourhoods at age 16. Total volume of alcohol consumed between age 16-42 was estimated based on the five survey waves, and self-reported social and material adversities were computed as composite variables. Neighbourhood socioeconomic disadvantage at age 16 was associated with alcohol consumption age 16-42 for men but not for women. Social adversities at age 16 were associated with alcohol consumption age 16-42 for both women and men, but material adversity or parental class was not. In conclusion, neighbourhood socioeconomic disadvantage in adolescence has a significant relationship with later alcohol consumption among men, even independently from individual factors. On family level, social factors but not socioeconomic factors in adolescence independently predict later alcohol consumption.

  • 87.
    Jonsson, F.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Strömsten, Lotta M. J.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Paths of adversity linking adolescent socioeconomic conditions to adult functional somatic symptoms2016Konferansepaper (Fagfellevurdert)
  • 88.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Rural-urban differences in health among youth in northern Sweden: an outcome-wide epidemiological approach2019Inngår i: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 78, artikkel-id 1640015Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 89.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Are neighbourhood inequalities in adult health explained by socio-economic and psychosocial determinants in adolescence and the subsequent life course in northern Sweden?: A decomposition analysis2018Inngår i: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 52, s. 127-134Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study explains neighbourhood deprivation inequalities in adult health for a northern Swedish cohort by examining the contribution of socio-economic and psychosocial determinants from adolescence (age 16), young adulthood (age 21) and midlife (age 42) to the disparity. Self-reported information from 873 participants was drawn from questionnaires, with complementary neighbourhood register data. The concentration index was used to estimate the inequality while decomposition analyses were run to attribute the disparity to its underlying determinants. The results suggest that socio-economic and psychosocial factors in midlife explain a substantial part, but also that the inequality can originate from conditions in adolescence and young adulthood.

  • 90.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stromsten, Lotta M. J.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarstrom, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Life Course Pathways of Adversities Linking Adolescent Socioeconomic Circumstances and Functional Somatic Symptoms in Mid-Adulthood: A Path Analysis Study2016Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, nr 5, artikkel-id e0155963Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    While research examining the health impact of early socioeconomic conditions suggests that effects may exist independently of or jointly with adult socioeconomic position, studies exploring other potential pathways are few. Following a chain of risk life course model, this prospective study seeks to examine whether pathways of occupational class as well as material and social adversities across the life course link socioeconomic disadvantage in adolescent to functional somatic symptoms in mid-adulthood. Applying path analysis, a multiple mediator model was assessed using prospective data collected during 26 years through the Northern Swedish Cohort. The sample contained 987 individuals residing in the municipality of Lulea, Sweden, who participated in questionnaire surveys at age 16, 21, 30 and 42. Socioeconomic conditions (high/low) in adolescence (age 16) were operationalized using the occupation of the parents, while occupational class in adulthood (manual/nonmanual) was measured using the participant's own occupation at age 21 and 30. The adversity measurements were constructed as separate age specific parcels at age 21 and 30. Social adversity included items pertaining to stressful life events that could potentially harm salient relationships, while material adversity was operationalized using items concerning unfavorable financial and material circumstances. Functional somatic symptoms at age 42 was a summary measure of self-reported physical symptoms, palpitation and sleeping difficulties that had occurred during the last 12 months. An association between socioeconomic conditions at age 16 and functional somatic symptoms at age 42 (r = 0.068) which was partially explained by people's own occupational class at age 21 and then material as well as social adversity at age 30 was revealed. Rather than proposing a direct and independent health effect of the socioeconomic conditions of the family, the present study suggests that growing up in an unfavorable socioeconomic environment might be a source for a chain of adverse material and social living situations, which in turn affects adult health.

  • 91.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Intragenerational social mobility and functional somatic symptoms in a northern Swedish context: analyses of diagonal reference models2017Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, artikkel-id 1Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Research indicate that social class mobility could be potentially important for health, but whether this is due to the movement itself or a result of people having been integrated in different class contexts is, to date, difficult to infer. In addition, although several theories suggest that transitions between classes in the social hierarchy can be stressful experiences, few studies have empirically examined whether such movements may have health effects, over and above the implications of "being" in these classes. In an attempt to investigate whether intragenerational social mobility is associated with functional somatic symptoms in mid-adulthood, the current study tests three partially contrasting theories.

    METHOD: The dissociative theory suggests that mobility in general and upward mobility in particular may be linked to psychological distress, while the falling from grace theory indicates that downward mobility is especially stressful. In contrast, the acculturation theory holds that the health implications of social mobility is not due to the movement itself but attributed to the class contexts in which people find themselves. Diagonal Reference Models were used on a sample of 924 individuals who in 1981 graduated from 9(th) grade in the municipality of Luleå, Sweden. Social mobility was operationalized as change in occupational class between age 30 and 42 (measured in 1995 and 2007). The health outcome was functional somatic symptoms at age 42, defined as a clustering self-reported physical symptoms, palpitation and sleeping difficulties during the last 12 months.

    RESULTS: Overall mobility was not associated with higher levels of functional somatic symptoms compared to being immobile (p = 0.653). After controlling for prior and current class, sex, parental social position, general health, civil status, education and unemployment, the association between downward mobility was borderline significant (p = 0.055) while upward mobility was associated with lower levels of functional somatic symptoms (p = 0.03).

    CONCLUSION: The current study did not find unanimous support for any of the theories. Nevertheless, it sheds light on the possibility that upward mobility may be beneficial to reduce stress-related health problems in mid-life over and above the exposure to prior and current class, while downward mobility can be of less importance for middle-age health complaints.

  • 92.
    Khatami, Alireza
    et al.
    Center for Research and Training in Skin Deseases and Leprosy, Tehran, Iran.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Skin disease: a neglected public health problem2009Inngår i: Dermatologic clinics, ISSN 0733-8635, E-ISSN 1558-0520, Vol. 27, nr 2, s. 99-101Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Skin diseases are among the most common health problems in humans. Considering their significant impact on the individual, the family, the social life of patients, and their heavy economical burden, the public health importance of these diseases is underappreciated. This article discusses the importance of dermatologic public health and makes recommendations for better addressing this neglected topic.

  • 93.
    Kunna, Rasha
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stewart Williams, Jennifer
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Research Centre for Generational Health and Ageing Faculty of Health, University of Newcastle.
    Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health (SAGE)2017Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, nr 1, artikkel-id 79Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Globally people are living longer and enduring non-communicable diseases (NCDs) many of which co-occur as multimorbidity. Demographic and socioeconomic factors are determinants of inequalities and inequities in health. There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana.

    METHODS: The data source is the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 (2007-2010). Nationally representative cross-sectional data collected from adults in China (n = 11,814) and Ghana (n = 4,050) are analysed. Country populations are ranked by a socioeconomic index based on ownership of household assets. The study uses a decomposed concentration index (CI) of single and multiple NCD morbidity (multimorbidity) covering arthritis, diabetes, angina, stroke, asthma, depression, chronic lung disease and hypertension. The CI quantifies the extent of overall inequality on each morbidity measure. The decomposition utilises a regression-based approach to examine individual contributions of demographic and socioeconomic factors, or determinants, to the overall inequality.

    RESULTS: In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China (single morbidity CI = -0.0365: 95% CI = -0.0689,-0.0040; multimorbidity CI = -0.0801: 95% CI = -0.1233,-0.0368;). In Ghana inequalities were significant and more highly concentrated among the rich (single morbidity CI = 0.1182; 95% CI = 0.0697, 0.1668; multimorbidity CI = 0.1453: 95% CI = 0.0794, 0.2083). In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multimorbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multimorbidity.

    CONCLUSIONS: The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

  • 94. La Parra-Casado, Daniel
    et al.
    Mosquera, Paola A.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Nursing I, University of the Basque Country, 48940 Bilbao, Spain.
    Socioeconomic Inequalities in the Use of Healthcare Services: Comparison between the Roma and General Populations in Spain2018Inngår i: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, nr 1, artikkel-id 121Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This paper explores whether the principles of horizontal and vertical equity in healthcare are met by the Spanish national health system in the case of the Roma and general populations. The 2011/2012 Spanish National Health Survey (n = 21,650) and the 2014 National Health Survey of the Spanish Roma Population (n = 1167) were analyzed. Use of healthcare services was measured in terms of visits to a general practitioner (GP), visits to an emergency department, and hospitalizations. Healthcare need was measured using (a) self-rated health and (b) the reported number of chronic diseases. The Roma reported worse self-rated health and a higher prevalence of chronic diseases. A redistributive effect (increased healthcare service use among Roma and those in lower socio-economic classes) was found for hospitalizations and emergency visits. This effect was also observed in GP visits for women, but not for men. Vertical inequity was observed in the general population but not in the Roma population for GP visits. The results suggest the existence of horizontal inequity in the use of GP services (Roma women), emergency department visits (Roma and general population), and hospitalizations (Roma population) and of vertical inequity in the use of GP services among the general population.

  • 95.
    Lemma, Hailemariam
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Löfgren, Curt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Adherence to a six-dose regimen of artemether-lumefantrine among uncomplicated Plasmodium falciparum patients in the Tigray Region, Ethiopia2011Inngår i: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 10, s. 349-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In 2004, Ethiopia switched its first-line treatment of uncomplicated Plasmodium falciparum malaria from sulphadoxine-pyrimethamine to a fixed artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). Patient adherence to AL regimen is a major determining factor to achieve the desired therapeutic outcome. The aim of this study was to measure patient adherence levels to the six-dose AL regimen for the treatment of uncomplicated P. falciparum malaria and to identify its determinant factors in rural areas of the Tigray region, Ethiopia

    METHODS: The study was conducted under routine health service delivery at health posts level. Patients/caregivers were not informed about their home visit and were traced on the day after they finished the AL regimen. By combining the response to a structured questionnaire and the tablet count from the blister, adherence level was classified into three categories: definitely non-adherent, probably non-adherent and probably adherent. Reasons for being definitely non-adherent were also assessed. For the purpose of examine risk factors, definitely non-adherent and probably non-adherent was merged into a non-adherent group. Variables found significantly associated (p < 0.05) with the adherence level on the univariate analysis were fitted into a multivariate logistic regression model.

    RESULTS: Out of the total initially enrolled 180 patients, 86.1% completed the follow-up. Out of these, 38.7% were classified as probably adherent, 34.8% as probably non-adherent, and 26.5% were definitely non-adherent. The most common reasons that definitely non-adherents gave for not taking the full dose were "too many tablets" (37.3%) and to "felt better before finished the treatment course" (25.5%). The adherence of the patients was associated with the ownership of a radio (adjusted odd ratio, AOR: 3.8; 95% CI: 1.66-8.75), the belief that malaria can be treated traditionally (AOR: 0.09; 95% CI: 0.01-0.78) and a delay of more than one day in seeking treatment after the onset of fever (AOR: 5.39; 95% CI: 1.83-15.88).

    CONCLUSION: The very low adherence to AL found in this study raises serious concerns for the malaria control in the region. The implementation of a monitoring adherence system is essential to ensure long-term treatment efficacy.

  • 96.
    Lemma, Hailemariam
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Löfgren, Curt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Barnabas, Gebreab
    Cost-effectiveness of three malaria treatment strategies in rural Tigray, Ethiopia where both Plasmodium falciparum and Plasmodium vivax co-dominate2011Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 9, s. 2-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Malaria transmission in Ethiopia is unstable and the disease is a major public health problem. Both, p.falciparum (60%) and p.vivax (40%) co-dominantly exist. The national guideline recommends three different diagnosis and treatment strategies at health post level: i) the use of a p.falciparum/vivax specific RDT as diagnosis tool and to treat with artemether-lumefantrine (AL), chloroquine (CQ) or referral if the patient was diagnosed with p.falciparum, p.vivax or no malaria, respectively (parascreen pan/pf based strategy); ii) the use of a p.falciparum specific RDT and AL for p.falciparum cases and CQ for the rest (paracheck pf based strategy); and iii) the use of AL for all cases diagnosed presumptively as malaria (presumptive based strategy). This study aimed to assess the cost-effectiveness of the recommended three diagnosis and treatment strategies in the Tigray region of Ethiopia.

    METHODS: The study was conducted under a routine health service delivery following the national malaria diagnosis and treatment guideline. Every suspected malaria case, who presented to a health extension worker either at a village or health post, was included. Costing, from the provider's perspective, only included diagnosis and antimalarial drugs. Effectiveness was measured by the number of correctly treated cases (CTC) and average and incremental cost-effectiveness calculated. One-way and two-way sensitivity analyses were conducted for selected parameters.

    RESULTS: In total 2,422 subjects and 35 health posts were enrolled in the study. The average cost-effectiveness ratio showed that the parascreen pan/pf based strategy was more cost-effective (US$1.69/CTC) than both the paracheck pf (US$4.66/CTC) and the presumptive (US$11.08/CTC) based strategies. The incremental cost for the parascreen pan/pf based strategy was US$0.59/CTC to manage 65% more cases. The sensitivity analysis also confirmed parascreen pan/pf based strategy as the most cost-effective.

    CONCLUSION: This study showed that the parascreen pan/pf based strategy should be the preferred option to be used at health post level in rural Tigray. This finding is relevant nationwide as the entire country's malaria epidemiology is similar to the study area.

  • 97.
    Leonardsson, Malin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. The Swedish Board of Student Finance, Sundsvall, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Prevalence and predictors of help-seeking for women exposed to spousal violence in India - a cross-sectional study2017Inngår i: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 17, artikkel-id 99Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Spousal violence against women is prevalent in India (29%). Studies from various countries have shown that few women exposed to intimate partner violence or spousal violence seek help, especially in low-income countries. The objective of this study was to estimate the prevalence and predictors of help-seeking among women in India who have experienced various types of spousal violence.

    Methods: Cross-sectional data on 19,125 married, separated, divorced or widowed women in India who had experienced physical or sexual violence at the hands of their husbands were obtained from the India National Family Health Survey III 2005–2006. Bivariate and multivariate logistic regression analyses were carried out.

    Results: Less than one fourth (23.7%) of married, separated, divorced or widowed women in India who had experienced some form of physical or sexual spousal violence had sought help, but only 1% had sought help from formal institutions. Help-seeking was most prevalent in women who had been exposed to a combination of physical, sexual and emotional abuse (48.8%) and the least prevalent in women who had experienced sexual violence only (1.5%). Experience of severe violence and violence resulting in injury were the strongest predictors of help-seeking. Having education, being Christian or an acknowledged adherent of another minority religion - mainly Buddhism and Sikhism (Islam not included), getting married after the age of 21 and living in the South region were also associated with seeking help. Women in the North and Northeast regions were less likely to seek help, as were women with children and women who thought that a husband could be justified in hitting his wife.

    Conclusions: Very few Indian women who experience spousal violence seek help. The characteristics of the violence are the strongest predictors of help-seeking, but sociodemographic factors are also influential. We recommend efforts to ensure educational attainment for girls, prevention of child marriages, and that police officers and health care staff should be educated about intimate partner violence and in how to respond to women who seek help. It is important to tackle norms and attitudes surrounding violence against women, as well as attitudes to women who disclose violence.

  • 98. Lorena Ruano, Ana
    et al.
    Shadmi, Efrat
    Furler, John
    Rao, Krishna
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Uribe, Manuela Villar
    Shi, Leiyu
    Looking forward to the next 15 years: innovation and new pathways for research in health equity2017Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, artikkel-id 35Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research. Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH's ability to continue supporting the dissemination of health equity research for years to come.

  • 99.
    Lusey, Hendrew G.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. World Council of Churches, The Ecumenical HIV and AIDS Initiative in Africa, Regional Coordination Office for Central Africa, Kinshasa, Democratic Republic of Congo.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin E.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Church representatives' perspectives on masculinities in the context of HIV: the case of the Ecumenical HIV and AIDS Initiative in Africa2016Inngår i: African Journal of AIDS Research, ISSN 1608-5906, E-ISSN 1727-9445, Vol. 15, nr 3, s. 273-281Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Despite a growing body of literature related to church leaders challenging dominant norms of masculinities that may enable the spread of HIV, research on masculinity issues among African church representatives who are policy makers is scarce. The objectives of this study were to explore the perspectives on masculinities held by church representatives within the Ecumenical HIV and AIDS Initiative in Africa (EHAIA) and to identify strategies they used to transform masculinities in their respective churches. Qualitative interviews were carried out with 14 church representatives belonging to the EHAIA International Reference Group. These interviews were analysed using thematic analysis and four themes were identified: "barriers to challenge masculinities" may contribute to the spread of HIV; "counterproductive conservative church leadership" fails to challenge dominant forms of masculinities; "facilitators to challenge masculinities" perceived as slowly changing men and "an evolving hope for gender equality" would be perceived in certain marital relationships. The latter two were viewed as positive approaches resulting from masculinity workshops and male priests disclosing their HIV-positive status. This research highlights strategies that may help male church-goers challenge masculinities, support gender equality and, improve the lives of men and women in the context of HIV.

  • 100.
    Lusey, Hendrew
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. World Council Churches, Ecumen HIV & AIDS Initiat Africa EHAIA, Kinshasa, DEM REP CONGO and .
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Dahlgren, Lars
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Edin, Kerstin E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen. Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Conflicting discourses of church youths on masculinity and sexuality in the context of HIV in Kinshasa, Democratic Republic of Congo2014Inngår i: SAHARA-J: Journal of Social Aspects of HIV/AIDS, ISSN 1729-0376, E-ISSN 1813-4424, Vol. 11, nr 1, s. 84-93Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Masculinity studies are fairly new and young churchgoers are an under-researched group in the current Congolese church context. In response to this knowledge gap, this paper attempts to explore discourses of young churchgoers from deprived areas of Kinshasa regarding masculinity and sexuality in the era of HIV. A series of 16 semi-structured interviews were conducted with unmarried young churchgoers from the Salvation Army, Protestant and Revival churches. The interviews were tape-recorded, transcribed verbatim and analysed using discourse analysis. Five main discourses emerged: 'we are aware of the church message on sex', 'young men need sex', 'young women need money', 'to use or not to use condoms' and 'we trust in the church message'. Although all informants knew and heard church messages against premarital sex, many of them were sexually active. The perception was that young men were engaged in sexual activities with multiple partners as a result of sexual motivations surrounding masculinity and sexual potency, while young women sought multiple partners through transactional and intergenerational sex for economic reasons. These sexual practices of young people conflicted with church messages on sexual abstinence and faithfulness. However, a small number of participants challenged current gender norms and suggested alternative ways of being a man or a woman. To elucidate these alternatives, we suggest that church youths and church leaders might take concrete actions to deconstruct misconceptions about being men. In this way, they can possibly enhance a frank and fruitful dialogue on sex, sexuality and gender to promote positive masculinities and constructive partnerships to prevent HIV.

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