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  • 1.
    Baltussen, Rob
    et al.
    Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
    Mikkelsen, Evelinn
    Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
    Tromp, Noor
    Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Byskov, Jens
    University of Copenhagen, Frederiksberg, Denmark.
    Olsen, Oystein
    Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway.
    Bærøe, Kristine
    4Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway.
    Hontelez, Jan A
    Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
    Singh, Jerome
    7Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
    Norheim, Ole F
    Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway.
    Balancing efficiency, equity and feasibility of HIV treatment in South Africa: development of programmatic guidance2013Ingår i: Cost effectiveness and resource allocation : C/E, ISSN 1478-7547, Vol. 11, nr 1, artikel-id 26Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment.Hence, decisions on the design of the present HIV treatment programme in South Africa can be considered suboptimal. We argue there are two fundamental reasons to this. First, while there is a rapidly growing evidence-base to guide priority setting decisions on HIV treatment, its included studies typically consider only one criterion at a time and thus fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process but it seems no adequate participatory processes are in place to incorporate stakeholders' views and evidences of all sorts.We propose an alternative approach that provides a better evidence base and outlines a fair policy process to improve priority setting in HIV treatment. The approach integrates two increasingly important frameworks on health care priority setting: accountability for reasonableness (A4R) to foster procedural fairness, and multi-criteria decision analysis (MCDA) to construct an evidence-base on the feasibility, efficiency, and equity of programme options including trade-offs. The approach provides programmatic guidance on the choice of treatment strategies at various decisions levels based on a sound conceptual framework, and holds large potential to improve HIV priority setting in South Africa.

  • 2. Briones-Vozmediano, Erica
    et al.
    Maquibar, Amaia
    Vives-Cases, Carmen
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS). 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.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group of the University of Alicante, Spain.
    Health-Sector Responses to Intimate Partner Violence: fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?2018Ingår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 33, nr 10, s. 1653-1678Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

  • 3. Buitron, Diego
    et al.
    Hurtig, Anna-Karin
    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.
    [Nutritional status of Naporuna children under five in the Amazon region of Ecuador]2004Ingår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 15, nr 3, s. 151-9Artikel i tidskrift (Övrigt vetenskapligt)
  • 4. Bukachi, Salome A
    et al.
    Onyango-Ouma, Washington
    Siso, Jared Maaka
    Nyamongo, Isaac K
    Mutai, Joseph K
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Olsen, Øystein Evjen
    Byskov, Jens
    Healthcare priority setting in Kenya: a gap analysis applying the accountability for reasonableness framework2014Ingår i: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, nr 4, s. 342-361Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies, national government, budgetary requirements, traditions and local culture influence the process. The four conditions of A4R are present within the priority setting process, albeit to varying degrees and referred to by different terms. There exists an opportunity for A4R to provide a guiding approach within which its four conditions can be strengthened and assessed to establish whether conformance helps improve on the priority setting process.

  • 5. Byskov, Jens
    et al.
    Bloch, Paul
    Blystad, Astrid
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Fylkesnes, Knut
    Kamuzora, Peter
    Kombe, Yeri
    Kvåle, Gunnar
    Marchal, Bruno
    Martin, Douglas K
    Michelo, Charles
    Ndawi, Benedict
    Ngulube, Thabale J
    Nyamongo, Isaac
    Olsen, Oystein E
    Onyango-Ouma, Washington
    Sandøy, Ingvild F
    Shayo, Elizabeth H
    Silwamba, Gavin
    Songstad, Nils Gunnar
    Tuba, Mary
    Accountable priority setting for trust in health systems: the need for research into a new approach for strengthening sustainable health action in developing countries2009Ingår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 7, s. 23-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed. Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met. REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance. This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

  • 6. Byskov, Jens
    et al.
    Maluka, Stephen Oswald
    Marchal, Bruno
    Shayo, Elizabeth H.
    Bukachi, Salome
    Zulu, Joseph M.
    Blas, Erik
    Michelo, Charles
    Ndawi, Benedict
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA Enhancing Fairness and Legitimacy"2017Ingår i: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 6, nr 2, s. 115-118Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context -until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.

  • 7. Byskov, Jens
    et al.
    Marchal, Bruno
    Maluka, Stephen
    Zulu, Joseph M
    Bukachi, Salome A.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Blystad, Astrid
    Kamuzora, Peter
    Michelo, Charles
    Nyandieka, Lillian N
    Ndawi, Benedict
    Bloch, Paul
    Olsen, Oystein E
    The accountability for reasonableness approach to guide priority setting in health systems within limited resources: findings from action research at district level in Kenya, Tanzania, and Zambia2014Ingår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 12, artikel-id 49Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). Methods: This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. Results: The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. Conclusions: District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

  • 8.
    Coe, Anna-Britt
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Goicolea, Isabel
    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.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Understanding how young people do activism: Youth strategies on sexual health in Ecuador and Peru2015Ingår i: Youth & society, ISSN 0044-118X, E-ISSN 1552-8499, Vol. 47, nr 1, s. 3-28Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    While social movement research employs “tactical repertoire” to emphasize protest tactics directed at the state, literature on youth activism globally indicates that young people do politics outside the realm of formal political spheres. Youth activism on body politics in Latin America offers evidence that enhances conceptual tools intended for understanding how young people make claims and towards whom they make them. This paper takes young activists’ strategies as its point of departure through a study that explored how young people perceived their activism to advance sexual health in Ecuador and Peru. Young activists employed a range of interconnected strategies that went beyond protests directed at the state, including responding to adult allies, carrying out social advocacy among youth, building organizations, carrying out political advocacy and developing themselves as activists. Strategies were shaped by the degree to which young activists negotiated alternative notions of ‘youth’ with different actors.

  • 9.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Rojas, Ernesto
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Goicolea, Isabel
    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.
    Illanes, Daniel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessment of a Leishmaniasis Reporting System in Tropical Bolivia Using the Capture-Recapture Method2018Ingår i: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 98, nr 1, s. 134-138Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study evaluates the level of underreporting of the National Program of Leishmaniasis Control (NPLC) in two communities of Cochabamba, Bolivia during the period 2013-2014. Montenegro skin test-confirmed cases of cutaneous leishmaniasis (CL) were identified through active surveillance during medical campaigns. These cases were compared with those registered in the NPLC by passive surveillance. After matching and cleaning data from the two sources, the total number of cases and the level of underreporting of the National Program were calculated using the capture-recapture analysis. This estimated that 86 cases of CL (95% confidence interval [CI]: 62.1-110.8) occurred in the study period in both communities. The level of underreporting of the NPLC in these communities was very high: 73.4% (95% CI: 62.1-110.8). These results can be explained by the inaccessibility of health services and centralization of the NPLC activities. This information is important to establish priorities among policy-makers and funding organizations as well as implementing adequate intervention plans.

  • 10.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute of Biomedical Research, Faculty of Medicine, San Simon University, Aniceto Arce Avenue 371, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Rojas, Ernesto
    Goicolea, Isabel
    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.
    Illanes, Daniel
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Risk factors for cutaneous leishmaniasis in the rainforest of Bolivia: a cross-sectional study2018Ingår i: Tropical Medicine and Health, ISSN 1348-8945, E-ISSN 1349-4147, Vol. 46, artikel-id 9Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Cutaneous leishmaniasis (CL) is an endemic disease in Bolivia, particularly in the rainforest of Cochabamba, in the municipality of Villa Tunari. The precarious, dispersed, and poorly accessible settlements in these farming communities make it difficult to study them, and there are no epidemiological studies in the area. The aim of the present study was to identify the risk factors associated with cutaneous leishmaniasis.

    Methods: A cross-sectional study was conducted in August 2015 and August 2016 in two communities of Villa Tunari, Cochabamba. The cases were diagnosed through clinical examinations, identification of the parasite by microscopic examination, and the Montenegro skin test. Risk factors were identified through logistic regression.

    Results: A total of 274 participants (40.9% female and 59.1% male) were surveyed, of which 43% were CL positive. Sex was the only factor associated with CL with three times more risk for men than for women; this finding suggests a sylvatic mechanism of transmission in the area.

    Conclusions: It is advisable to focus on education and prevention policies at an early age for activities related to either leisure or work. Further research is needed to assess the influence of gender-associated behavior for the risk of cutaneous leishmaniasis.

  • 11.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, 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.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach2019Ingår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 19, nr 1, artikel-id 12Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Leishmaniasis is a neglected tropical disease endemic in Bolivia that disproportionately affects people with little social and political capital. Although the treatment is provided free of charge by the Bolivian government, there is an under-utilization of treatments in relation to the estimated affected population. This study explores the experiences of patients with leishmaniasis and the challenges faced when searching for diagnosis and treatment in Bolivia using a human rights approach.

    Methods: We conducted open-ended interviews with 14 participants diagnosed with leishmaniasis. The qualitative data were analysed using thematic analysis and were interpreted under a human rights approach to health care.

    Results: Four themes emerged during data analysis: (1) the decision for seeking a cure takes time; (2) the severity of symptoms and disruption of functioning drives the search for Western medicine; (3) the therapeutic journey between Western and traditional medicine; and (4) accessibility barriers to receive adequate medical treatment. This study showed that access to health care limitations were the most important factors that prevented patients from receiving timely diagnosis and treatment. Cultural factors played a secondary role in their decision to seek medical care.

    Conclusions: Accessibility barriers resulted in a large pilgrimage between public health care and traditional medicinal treatments for patients with leishmaniasis. This pilgrimage and the related costs are important factors that determine the decision to seek health care. This study contributes to the understanding of the under-utilisation problems of medical services in leishmaniasis and other similar diseases in remote and poor populations.

  • 12. Feder, Gene
    et al.
    Rohde, Jon E
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Janlert, Urban
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Jimba, Masamine
    Materia, Enrico
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Goldin, Stephen
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Barn- och ungdomspsykiatri.
    Stafford, Tom
    Edvardsson, Berit
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hilt, Bjorn
    Parkinson, Stuart
    Birch, Marion
    Jones, Anna
    Archibald, Kathy
    Pastore, John O
    Reed Elsevier and the international arms trade.2005Ingår i: Lancet, ISSN 1474-547X, Vol. 366, nr 9489, s. 889; discussion 889-90Artikel i tidskrift (Refereegranskat)
  • 13.
    Frumence, Gasto
    et al.
    Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Nyamhanga, Tumaini
    Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Mwangu, Mughwira
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Challenges to the implementation of health sector decentralization in Tanzania: experiences from Kongwa district council2013Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, s. 20983-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: During the 1990s, the government of Tanzania introduced the decentralization by devolution (D by D) approach involving the transfer of functions, power and authority from the centre to the local government authorities (LGAs) to improve the delivery of public goods and services, including health services. Objective: This article examines and documents the experiences facing the implementation of decentralization of health services from the perspective of national and district officials. Design: The study adopted a qualitative approach, and data were collected using semi-structured interviews and were analysed for themes and patterns. Results: The results showed several benefits of decentralization, including increased autonomy in local resource mobilization and utilization, an enhanced bottom-up planning approach, increased health workers' accountability and reduction of bureaucratic procedures in decision making. The findings also revealed several challenges which hinder the effective functioning of decentralization. These include inadequate funding, untimely disbursement of funds from the central government, insufficient and unqualified personnel, lack of community participation in planning and political interference. Conclusion: The article concludes that the central government needs to adhere to the principles that established the local authorities and grant more autonomy to them, offer special incentives to staff working in the rural areas and create the capacity for local key actors to participate effectively in the planning process.

  • 14. Frumence, Gasto
    et al.
    Nyamhanga, Tumaini
    Mwangu, Mughwira
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Participation in health planning in a decentralised health system: experiences from facility governing committees in the Kongwa district of Tanzania2014Ingår i: Global Public Health, ISSN 1744-1692, E-ISSN 1744-1706, Vol. 9, nr 10, s. 1125-1138Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Tanzania introduced the decentralisation of its health systems in the 1990s in order to provide opportunities for community participation in health planning. Health facility governing committees (HFGCs) were then established to provide room for communities to participate in the management of health service delivery. The objective of this study was to explore the challenges and benefits for the participation of HFGCs in health planning in a decentralised health system. Data were collected using semi-structured interviews and focus group discussions (FGDs). A total of 13 key informants were interviewed from the council and lower-level health facilities. Five FGDs were conducted from five health facilities in one district. Data generated were analysed for themes and patterns. The results of the study suggest that HFGCs are instrumental organs in health planning at the community level and there are several benefits resulting from their participation including an opportunity to address community needs and mobilisation of resources. However, there are some challenges associated with the participation of HFGCs in health planning including a low level of education among committee members and late approval of funds for running health facilities. In conclusion, HFGCs potentially play a significant role in health planning. However, their participation is ineffective due to their limited capacities and disabling environment.

  • 15. Frumence, Gasto
    et al.
    Nyamhanga, Tumaini
    Mwangu, Mughwira
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The dependency on central government funding of decentralised health systems: experiences of the challenges and coping strategies in the Kongwa District, Tanzania2014Ingår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, nr 39Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Decentralised health systems in Tanzania depend largely on funding from the central government to run health services. Experience has shown that central funding in a decentralised system is not an appropriate approach to ensure the effective and efficient performance of local authorities due to several limitations. One of the limitations is that funds from the central government are not disbursed on a timely basis, which in turn, leads to the serious problem of shortage of financial resources for Council Health Management Teams (CHMT). This paper examines how dependency on central government funding in Tanzania affects health activities in Kongwa district council and the strategies used by the CHMT cope with the situation.

    Methods: The study adopted a qualitative approach and data were collected using semi-structured interviews and focus group discussions. One district in the central region of Tanzania was strategically selected. Ten key informants involved in the management of health service delivery at the district level were interviewed and one focus group discussion was held, which consisted of members of the council health management team. The data generated were analysed for themes and patterns.

    Results: The results showed that late disbursement of funds interrupts the implementation of health activities in the district health system. This situation delays the implementation of some activities, while a few activities may not be implemented at all. However, based on their prior knowledge of the anticipated delays in financial disbursements, the council health management team has adopted three main strategies to cope with this situation. These include obtaining supplies and other services on credit, borrowing money from other projects in the council, and using money generated from cost sharing.

    Conclusion: Local government authorities (LGAs) face delays in the disbursement of funds from the central government. This has necessitated introduction of informal coping strategies to deal with the situation. National-level policy and decision makers should minimise the bureaucracy involved in allocating funds to the district health systems to reduce delays.

  • 16.
    Gaitonde, Rakhal
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India.
    Muraleedharan, V. R.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings2019Ingår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, artikel-id 44Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Accountability is increasingly being demanded of public services and is a core aspect of most recent frameworks of health system strengthening. Community-based accountability is an increasingly used strategy, and wasa core aspect of India's flagship National Rural Health Mission (NRHM; 2005-2014). Research on policy implementation has called for policy analysts to go beyond the superficial articulation of a particular policy intervention to study the underlying meaning this has for policy-makers and other actors of the implementation process and to the way in which problems sought to be addressed by the policy have been identified and problematised'.

    Methods: This research, focused on state level officials and health NGO leaders, explores the meanings attached to the concept of accountability among a number of key actors during the implementation of the NRHM in the south Indian state of Tamil Nadu. The overall research was guided by an interpretive approach to policy analysis and the problematisation lens. Through in-depth interviews we draw on the interviewees' perspectives on accountability.

    Results: The research identifies three distinct perspectives on accountability among the key actors involved in the implementation of the NRHM. One perspective views accountability as the achievement of pre-set targets, the other as efficiency in achieving these targets, and the final one as a transformative process that equalises power differentials between communities and the public health system. We also present the ways in which these differences in perspectives are associated with different programme designs.

    Conclusions: This research underlines the importance of going beyond the statements of policy to exploring the underlying beliefs and perspectives in order to more comprehensively understand the dynamics of policy implementation; it further points to the impacts of these perspectives on the design of initiatives in response to the policy.

  • 17.
    Gaitonde, Rakhal
    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.
    Muraleedharan, V R
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Community Action for Health in India's National Rural Health Mission: One policy, many paths2017Ingår i: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 188, s. 82-90Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

  • 18.
    Gangane, Nitin
    et al.
    Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Anshu, Anshu
    Manvatkar, Shiva
    Ng, Nawi
    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.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Prevalence and Risk Factors for Patient Delay Among Women With Breast Cancer in Rural India2016Ingår i: Asia-Pacific journal of public health, ISSN 1941-2479, Vol. 28, nr 1, s. 72-82Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Delay in seeking health care by women with breast cancer increases mortality risk. This study was conducted in rural India to identify risk factors associated with patient delay. A total of 212 women with primary breast cancer diagnosed between 2010 and 2012 were interviewed. Sociodemographic characteristics, time interval between seeking medical attention and appearance of symptoms, and reasons for delay were inquired. Patient delay was defined as more than 3 months between date of first symptoms and medical consultation. Logistic regression was applied to assess associations between potential risk factors and patient delay. Almost half the women with breast cancer experienced patient delay. Age more than 60 years (odds ratio = 4.9, 95% confidence interval = 1.3-18.0) was significantly associated with patient delay. Only 6.6% of patients had heard about breast self-examination. Significantly higher number of patients with delay presented with advanced clinical stage (P = .000). Health education programs should be introduced with specific strategies to shorten patient delay.

  • 19.
    Gangane, Nitin
    et al.
    Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Khairkar, Pravin
    Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Hurtig, Anna-Karin
    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.
    Quality of Life Determinants in Breast Cancer Patients in Central Rural India2017Ingår i: Asian Pacific Journal of Cancer Prevention, ISSN 1513-7368, Vol. 18, nr 12, s. 3325-3332Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Breast cancer is the most frequently diagnosed cancer among women throughout world, with incidence rates increasing in India. Improved survival in breast cancer patients has resulted in their quality of life (QOL) becoming an important issue. Identifying determinants for QOL may provide insights into how to improve their living conditions. This study aimed to assess socio-demographic and clinical factors, as well as the role of self-efficacy, in relation to QOL among women with breast cancer in rural India. Methods: A total of 208 female patients with infiltrating carcinoma of the breast participated in the study. A questionnaire was administered that included sections for socio-demographic characteristics, clinical stage of the cancer and patient delay in seeking health care. A standardized instrument to measure self-efficacy was applied. To assess QOL, the WHOQOL – BREF instrument was used. Results: The overall mean score for QOL was 59.3. For domain 1 (physical health) the mean score across all groups was 55.5, for psychological health 58.2, for social relationships 63.2 and for environmental factors, 60.4. The environmental domain in QOL was negatively associated with lower education. Being divorced/widowed/unmarried had a negative association with the psychological health and social relationship dimensions, whereas higher income was positively associated with QOL parameters such as psychology, social relationships and environmental factors. Self-efficacy was positively associated with all four domains of QOL. Conclusions: The present study demonstrated a moderate QOL in women with breast cancer in rural India. Young age, lack of education and being without a partner were negatively related to QOL, and employment as casual and industrial workers, high monthly family income and higher self-efficacy were positively associated with QOL. A comprehensive public health initiative is required, including social, financial and environmental support, that can provide better QOL for breast cancer survivors.

  • 20.
    Gangane, Nitin
    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.
    Hurtig, Anna-Karin
    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.
    System delay of diagnosis and treatment experienced by women with breast cancer in rural IndiaIngår i: Artikel i tidskrift (Refereegranskat)
  • 21.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Carson, Dean
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). Demography and Growth Planning, Northern Institute, Charles Darwin University, Darwin, Australia; Centre for Rural Medicine, Storuman, Sweden.
    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.
    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.
    Health care access for rural youth on equal terms?: A mixed methods study protocol in northern Sweden2018Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, artikel-id 6Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The purpose of this paper is to propose a protocol for researching the impact of rural youth health service strategies on health care access. There has been no published comprehensive assessment of the effectiveness of youth health strategies in rural areas, and there is no clearly articulated model of how such assessments might be conducted. The protocol described here aims to gather information to; i) Assess rural youth access to health care according to their needs, ii) Identify and understand the strategies developed in rural areas to promote youth access to health care, and iii) Propose actions for further improvement. The protocol is described with particular reference to research being undertaken in the four northernmost counties of Sweden, which contain a widely dispersed and diverse youth population.

    METHODS: The protocol proposes qualitative and quantitative methodologies sequentially in four phases. First, to map youth access to health care according to their health care needs, including assessing horizontal equity (equal use of health care for equivalent health needs,) and vertical equity (people with greater health needs should receive more health care than those with lesser needs). Second, a multiple case study design investigates strategies developed across the region (youth clinics, internet applications, public health programs) to improve youth access to health care. Third, qualitative comparative analysis of the 24 rural municipalities in the region identifies the best combination of conditions leading to high youth access to health care. Fourth, a concept mapping study involving rural stakeholders, care providers and youth provides recommended actions to improve rural youth access to health care.

    DISCUSSION: The implementation of this research protocol will contribute to 1) generating knowledge that could contribute to strengthening rural youth access to health care, as well as to 2) advancing the application of mixed methods to explore access to health care.

  • 22.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Searching for best practices of youth friendly services - a study protocol using qualitative comparative analysis in Sweden2016Ingår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, artikel-id 321Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Swedish youth clinics constitute one of the most comprehensive and consolidated examples of a nationwide network of health care services for young people. However, studies evaluating their 'youth-friendliness' and the combination of factors that makes them more or less 'youth-friendly' have not been conducted. This protocol will scrutinise the current youth-friendliness of youth clinics in northern Sweden and identify the best combination of conditions needed in order to implement the criteria of youth-friendliness within Swedish youth clinics and elsewhere.

    Methods/design: In this study, we will use qualitative comparative analysis to analyse the conditions that are sufficient and/or necessary to implement Youth Friendly Health Services in 20 selected youth-clinics (cases). In order to conduct Qualitative Comparative Analysis, we will first identify the outcomes and the conditions to be assessed. The overall outcome - youth-friendliness - will be assessed together with specific outcomes for each of the five domains - accessible, acceptable, equitable, appropriate and effective. This will be done using a questionnaire to be applied to a sample of young people coming to the youth clinics. In terms of conditions, we will first identify what might be the key conditions, to ensure the youth friendliness of health care services, through literature review, interviews with professionals working at youth clinics, and with young people. The combination of conditions and outcomes will form the hypothesis to be further tested later on in the qualitative comparative analysis of the 20 cases. Once information on outcomes and conditions is gathered from each of the 20 clinics, it will be analysed using Qualitative Comparative Analysis.

    Discussion: The added value of this study in relation to the findings is twofold: on the one hand it will allow a thorough assessment of the youth-friendliness of northern Swedish youth clinics. On the other hand, it will extract lessons from one of the most consolidated examples of differentiated services for young people. Methodologically, this study can contribute to expanding the use of Qualitative Comparative Analysis in health systems research.

  • 23.
    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 approach2012Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, s. 18748-Artikel i tidskrift (Refereegranskat)
    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.

  • 24.
    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 Peru2017Ingår i: Global Public Health, ISSN 1744-1692, E-ISSN 1744-1706, Vol. 12, nr 8, s. 1004-1017Artikel i tidskrift (Refereegranskat)
    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.

  • 25.
    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 Sweden2018Ingår i: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, artikel-id 69Artikel i tidskrift (Refereegranskat)
    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.

  • 26.
    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 Spain2015Ingår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 29, nr 6, s. 431-436Artikel i tidskrift (Refereegranskat)
    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.

  • 27.
    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-study2015Ingår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, artikel-id 228Artikel i tidskrift (Refereegranskat)
    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.

  • 28.
    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 study2019Ingår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 33, nr 2, s. 169-176Artikel i tidskrift (Refereegranskat)
    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.

  • 29.
    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 Approaches2015Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 8, artikel-id e0135167Artikel i tidskrift (Refereegranskat)
    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.

  • 30.
    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 protocol2013Ingår i: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8, s. 36-Artikel i tidskrift (Refereegranskat)
    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.

  • 31.
    Hansson, Jonas
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lauritz, Lars-Erik
    Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    Padyab, Mojgan
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Swedish Police Officers' Job Strain, Work-Related Social Support and General Mental Health2017Ingår i: Journal of Police and Criminal Psychology, ISSN 0882-0783, E-ISSN 1936-6469, Vol. 32, nr 2, s. 128-137Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study investigated the association between psychosocial job characteristics and general mental health among police officers and the extent to which social support at work plays a role in this association. The findings are based on a cross-sectional survey. A written questionnaire was assessed by 714 police officers volunteered to participate in the study. The participants completed a series of validated instruments assessing job demand, control and social support at work (JDCS); general mental health (GHQ); and sociodemographic characteristics. High job strain was associated with low levels of work-related social support. Moreover, poor mental health was associated with low levels of work-related social support, active work and high job strain. The joint effect of high job strain and low levels of work-related social support had a significant effect on poor mental health. Work-related social support buffered job strain to some extent. Workforce health promotion policies should attempt to reduce job strain and emphasise the importance of work-related social support. Knowledge about police officers' general mental health and policymakers' support for police officers may have positive effects on the performance of the police force.

  • 32. 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 populations2019Ingår i: World Development, ISSN 0305-750X, E-ISSN 1873-5991, Vol. 113, s. 392-401Artikel i tidskrift (Refereegranskat)
    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. 

  • 33.
    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) (Övrigt vetenskapligt)
    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.

  • 34.
    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 Guatemala2012Ingår i: ISRN Nursing, ISSN 2090-5483, E-ISSN 2090-5491, Vol. 2012, s. 648769-Artikel i tidskrift (Refereegranskat)
    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.

  • 35.
    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 Guatemala2015Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, artikel-id 91Artikel i tidskrift (Refereegranskat)
    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.

  • 36.
    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 Guatemala2014Ingår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, nr 1, s. 112-Artikel i tidskrift (Refereegranskat)
    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.

  • 37.
    Hurtig, Anna Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pande, Shanta B
    Baral, Sushil C
    Newell, James
    Porter, John D H
    Bam, Dirga Sing
    Linking private and public sectors in tuberculosis treatment in Kathmandu Valley, Nepal.2002Ingår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 17, nr 1, s. 78-89Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Tuberculosis (TB) is a major public health problem and the world's foremost cause of death from a single infectious agent. Despite the increasing number of TB patients who seek help in the private sector, there are few practical examples of how to create a public/private linkage of TB services. The paper presents a pilot service-linkage project between the public and private sector in TB control in Kathmandu Valley, Nepal. The study documents and examines the process of the service-linkage project through the undertaking of a longitudinal analytical case study. A detailed description of the project from formulation to a short-term evaluation is given. The analysis relates the activities and early outcomes of the service-linkage project to the context, characteristics and interactions of the organizations involved. The study reveals that although the involved organizations initially agreed on the objective of the service-linkage project, differences in capacity, motivation, environment and needs had implications for the implementation and short-term success of the project. The public sector, despite the will, did not have the structure or resources to engage with the private sector. The private sector lacked interest in public health aspects of TB treatment and trust in the public sector. The study points to two different organizations that have the potential capacities to act as mediators between the public and private sectors: international research institutions and non-governmental organizations.