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  • 1.
    Alemu, Andinet Worku
    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.
    Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia2010Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, artikel-id 5398Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.

    Methods: All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan-Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.

    Results: The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/mu L with a median CD4 count of 103 cells/mu L. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.

    Conclusion: The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality - but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

  • 2.
    Alfredsson, Maria
    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.
    Jeghannathan, Bhoomikumar
    Attitudes towards mental health and the integration of mental health services into primary health care: a cross-sectional survey among health-care workers in Lvea Em District, Cambodia2017Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikel-id 1331579Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Cambodia is a country where the resources for treating mental health disorders are far from sufficient. One strategy to narrow the treatment gap is to integrate mental health into primary health care (PHC). Understanding the knowledge and attitudes towards mental health integration that health-care workers have is important for assessing the challenges and opportunities when planning a potential integration project. Objective: The aim of this study was to assess these basic conditions in Lvea Em District, Cambodia. Design: A structured self-reporting questionnaire regarding attitudes and knowledge about mental health and its integration into PHC was collected from 75 health-care workers in Lvea Em District, Cambodia in October 2015. Firstly, descriptive analyses were carried out, and secondly, linear regression analyses to assess the relationship between attitudes and socio-demographic variables were conducted. Results: There was clear support towards integrating mental health services into PHC among these participants as 81.3% were interested in personally delivering mental health care at their units. Respondents who reported having received some kind of mental health-care training tended to have a more positive attitude towards mentally ill people (p = 0.005) and those who thought there was a high need for mental health care had a more favourable attitude towards the integration of mental health services (p = 0.007). Conclusions: The most important finding from this survey was the willingness and the acceptance of the need for integration of mental health care. This enhances the feasibility of integrating mental health services at the PHC level. Improving the competence of mental health care in these settings will likely help to reduce the treatment gap for mental, neurological and substance use disorders in Cambodia.

  • 3.
    Anticona, Cynthia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bergdahl, Ingvar A
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Lundh, Thomas
    Alegre, Yuri
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lead exposure in indigenous communities of the Amazon basin, Peru2011Ingår i: International journal of hygiene and environmental health (Print), ISSN 1438-4639, E-ISSN 1618-131X, Vol. 215, nr 1, s. 59-63Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Since 2006, three studies have reported elevated levels of lead (Pb) among the indigenous population of the Corrientes river, in the Amazon basin of Peru. Due to the large evidence of environmental pollution related to oil exploitation in the area, this activity has been suggested as the source of exposure. This study aimed to evaluate Pb levels in the population and environment of two communities exposed and one community non-exposed to the oil exploitation activity. Blood lead levels (BLL) were determined by the instrument Leadcare. A comparison with the graphite furnace atomic absorption technique was performed in order to validate the Leadcare results. Environmental samples were analyzed by inductively coupled plasma atomic emission spectroscopy. Among 361 capillary samples, the mean BLL was 9.4μg/dl. Mean BLL of the communities exposed (n=171, x¯=9.5μg/dl) and non-exposed (n=190, x¯=9.2μg/dl) to the oil activity were not significantly different. Pb levels in environmental samples were below the maximum permissible levels. The sources of exposure could not be identified. Elevated levels of Pb in the oil-non-exposed community pointed out at other sources not yet clarified.

  • 4.
    Anticona, Cynthia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bergdahl, Ingvar A
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lead exposure among children from native communities of the Peruvian Amazon basin2012Ingår i: Revista panamericana de salud pùblica, ISSN 1020-4989, E-ISSN 1680-5348, Vol. 31, nr 4, s. 296-302Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective. To assess potential risk factors associated with elevated blood lead levels (BLLs) among children in two communities from the Corrientes River basin in the Peruvian Amazon.

    Methods. Children aged 0-17 years were screened for BLLs, hemoglobin levels, and anthropometric measures. Dwelling, family, and child data were collected through a parental questionnaire. Statistical analysis included descriptive and bivariate analysis. Multiple linear and logistic regressions using generalized estimating equations were also conducted to determine associated risk factors. A map of each community was drawn to examine the spatial distribution of BLLs.

    Results. Of 208 children (88 from 23 households of the Peruanito community and 120 from 28 households of Santa Isabel), 27.4% had BLLs >= 10 mu g/dL. The geometric mean (+/- standard deviation) BLL was 8.7 +/- 4.0 mu g/dL (range 3.0-26.8 mu g/dL). In the total population, linear regression analysis indicated that age was positively associated with BLLs (P < 0.05). Logistic regression analysis showed that boys had 2.12 times greater odds of having BLLs >= 10 mu g/dL than girls (P < 0.05). Among the children 0-3 years, those whose mothers had BLLs >= 10 mu g/dL had 45.0% higher odds of presenting BLLs >= 10 mu g/dL than children whose mothers had BLLs < 10 mu g/dL (P < 0.05).

    Conclusions. Older age, male gender, and mothers' BLL >= 10 mu g/dL were the main risk factors for elevated BLLs. The higher risk in boys 7-17 years suggests that exposure could be related to specific activities in this group, such as fishing and hunting. Continuous monitoring of BLLs in the Corrientes River population is recommended.

  • 5.
    Anticona, Cynthia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bergdahl, Ingvar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sources and risk factors for lead exposure in indigenous children of the Peruvian Amazon, disentangling connections with oil activity2012Ingår i: International journal of occupational and environmental health, ISSN 1077-3525, E-ISSN 2049-3967, Vol. 18, nr 4, s. 268-277Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: In the Corrientes river basin, Peruvian Amazon, lead exposure among indigenous communities was first reported in 2006. To address controversy regarding the main source of exposure, this study aimed to identify the sources and risk factors for lead exposure among children from the communities in question, and to clarify the potential relationship with oil activity.Methods: This cross-sectional study was conducted in six communities. Participants were children aged 0–17 years and their mothers. Data collection included blood lead levels (BLLs) and hemoglobin determination, a questionnaire on risk factors and environmental sampling. We used age-stratified multivariate regression models, with generalized estimating equation to account for correlation within households.Results: Twenty-seven percent of the children had BLLs ≧10 μg/dl. Mother's BLLs ≧10 μg/dl, playing and chewing lead scraps, fishing ≧three times/week, and living in highly oil-exposed communities increased the risk of having BLLs ≧10 μg/dl. Lead concentrations in sediment, soil, dust, and fish samples were below reference values.Conclusions: Mother's BLLs ≧10 μg/dl, playing and chewing lead scraps to manufacture fishing sinkers were the most important risk factors for children’s BLLs ≧10 μg/dl. The connection with oil activity appears to be through access to metal lead from the industry's wastes.

  • 6.
    Anticona, Cynthia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Bergdahl, Ingvar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Easier said than done: applying the Ecohealth principles to a study of heavy metals exposure among indigenous communities of the Peruvian Amazon2013Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, artikel-id 437Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background The renewed interest in community participation in health research is linked to its potential for bridging gaps between research and practice. Its main attributes are the generation of knowledge that can lead to socially robust, long-lasting solutions and the creation of a colearner relationship between researchers and research users. Following this philosophy, Ecohealth has evolved into a specialized framework for participatory research on the impact of pollution on ecosystems and human health. However, its principles pose considerable challenges. Its outcomes are strongly influenced by contextual factors that are impossible to control for ahead of time.

    This paper describes how the Ecohealth principles were applied to an epidemiological study of heavy metals exposure among indigenous communities of the Peruvian Amazon. It illustrates how knowledge generated from participatory research does not necessarily imply solving a public health problem. This study aimed to contribute to the understanding of the benefits and barriers of following the basic principles of the Ecohealth approach, and assist researchers working in similar contexts.

    Research process Based upon their personal experience as participant observers, the authors describe the research process; then, they discuss the most important challenges faced, their implications, and the attempted strategies for resolution.

    Challenges Challenges were grouped into four themes: (1) building trust; (2) one partnership, many stakeholders, multiple agendas; (3) being a researcher; and (4) communicating complex and unexpected findings.

    Conclusions Integrating the principles of transdisciplinarity and participation posed a series of challenges to the research process that were difficult, and sometimes impossible to overcome. However, positive outcomes from this experience were the lessons learned by the different actors. Despite the lack of immediate action, it is expected that useful interventions to prevent and control lead exposure in the Corrientes population will be implemented in the medium term.

  • 7.
    Anticona, Cynthia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Anemia and malnutrition in indigenous children and adolescents of the Peruvian Amazon in a context of lead exposure: a cross-sectional study2014Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Indigenous children and adolescents of the Peruvian Amazon live in precarious conditions that could increase the risk of malnutrition. A particular problem in the Corrientes river communities is the high exposure to lead among children and adolescents. Objective: This study aimed to determine the nutritional status of children and adolescents in indigenous communities in the Corrientes river basin and examine risk factors for anemia, stunting, underweight, and wasting. Design: This was a cross-sectional assessment in children and adolescents aged 0-17 years from six communities (n = 330). Data collection included measurement of hemoglobin levels, anthropometrics, blood lead levels (BLLs); a parental questionnaire including demographic and dwelling information; parents' occupation; and the child's duration of breastfeeding and food consumption. Analysis included univariate, bivariate, and logistic regression. Results: Overall, anemia prevalence was 51.0%, stunting (proxy for chronic malnutrition) 50.0%, and underweight 20.0%. Bivariate analysis showed that anemia and underweight prevalence was higher in the 0-4 years group (p<0.05). No association was found between anemia, stunting, or underweight with gender, community exposure to oil activity, or consumption of river water. Stunting prevalence was higher in the group whose BLLs were >5 mu g/dL (p<0.05). In the logistic regression analysis, no variable was associated with anemia or underweight. The group 5-11 years and >12 years had 1.9 and 3.1 times higher risk of stunting than the group under five years, respectively. Children and adolescents with BLLs >5 mu g/dL had twice the risk of stunting compared to those with lower BLLs. Conclusions: Half of the study population was found with anemia and stunting. Anemia was more prevalent in the 0- to 5-year age group and stunting in the 12- to 17-year group. The association between stunting and BLLs might be attributed to a direct effect of lead on human growth. Also, poor nutrition and other socioeconomic-related factors may contribute to the simultaneous existence of stunting and elevated BLLs.

  • 8.
    Baroudi, Mazen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waenerlund, 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.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the dimensionality of YFHS-Swe; a new questionnaire to assess youth friendliness2017Ingår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, nr suppl_3, s. 343-Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Background: Ensuring the youth friendliness of health services can increase the utilization of these services and contribute to improve youth’s health. Few validated instruments to assess youth-friendliness exist worldwide and none in Sweden. To assess the youth-friendliness of Swedish youth clinics (differentiated services for youth that exist since the 70s), an adapted version of YFHS WHO+ questionnaire called (YFHS-Swe) was developed. YFHS-Swe proved to have good internal homogeneity and consistency over time. The aim of our study was to perform a psychometric analysis to assure the quality and reliability of the questionnaire, and to assess the dimensionality of YFHS-Swe to identify possible subdomains that might be of importance for policy making.

    Methods: YFHS-Swe was answered by 1,110 youths aged 16 to 25 years visiting 20 youth clinics in Northern Sweden between September 2016 and February 2017. YFHS-Swe was assessed using exploratory and confirmatory factor analysis.

    Results: Thirteen factors could be identified; ability to get contact; access to sexual and reproductive health (SRH) service; access to psychosocial health services; parental support of SRH services; parental support of psychosocial health services; equity with diverse concerns; equity with legal concerns; fear of exposure; respect; privacy and confidentiality; no judgement; quality of consultation and quality of facility. Except for “quality of facility”, all other twelve factors recorded good α reliability ranging from 0.76 to 0.97, good ρ reliability ranging from 0.77 to 0.97 and acceptable measure of fit (SRMR<0.08).

    Conclusions: The YFHS-Swe proved to be credible and suitable for assessing youths-friendliness of the Swedish youth clinics. The identified factors might be of an importance to capture different dimensions of youth friendliness. With some cultural and linguistic adaptations, this instrument can be used in other differentiated youth health services internationally.

    Key messages:

    • YFHS-Swe is credible and suitable instrument in the Swedish context and it can be used as a basis for validating other instruments to assess youth-friendliness in other contexts.
    • The dimensions identified of this novel instrument might be of importance in assessing distinct aspects of friendliness in differentiated health services and might be of importance for policy making.
  • 9.
    Baroudi, Mazen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waenerlund, 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.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the dimensionality of YFHS-Swe: a questionnaire to assess youth-friendliness in differentiated health services2017Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, nr 1, artikel-id 1380399Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The aim of this study was to assess the dimensionality of YFHS-Swe and identify possible unique factors in the evaluation of youth-friendliness. YFHS-Swe was answered by 1110 youths aged 16 to 25 years visiting youth clinics in Northern Sweden. Thirteen factors were identified by exploratory factor analysis and except for one factor they all proved to fit well and have good reliability when assessed by the confirmatory factor analysis. The YFHS-Swe proved to be credible and suitable for assessing youth-friendliness of differentiated health services in Sweden. With cultural and linguistic adaptations, it can be used in similar settings internationally.

  • 10.
    Beck, Simon
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    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.
    Basic income – healthy outcome? Effects on health of an Indian basic income pilot project: a cluster randomised trial2015Ingår i: Journal of Development Effectiveness, ISSN 1943-9342, E-ISSN 1943-9407, Vol. 7, nr 1, s. 111-126Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This article evaluates the effects on health of a basic income (BI) pilot project in Madhya Pradesh, India, between 2011 and 2012. BI can be defined as a non-contributory, universal and unconditional cash transfer paid out on an individual basis. The project was conducted as a cluster randomised trial involving 2034 households. Three health outcomes were examined: minor illnesses and injuries, illness and injuries requiring hospitalisation, and child vaccination coverage. The data were analysed with multiple imputation, propensity score matching and weighted logistic regression. BI was seen to significantly reduce the odds of minor illnesses and injuries by 46 per cent. No effect was seen on more serious illnesses and injuries, at least not in the time scale given, nor on child vaccination coverage which was already exceptionally high. Policymakers are encouraged to consider BI as an equitable policy of social protection, though further research on its impact on health is desirable.

  • 11.
    Boldis, Beáta Vivien
    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.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Unsafe and unequal: a decomposition analysis of income inequalities in fear of crime in northern Sweden2018Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, artikel-id 110Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Fear of crime is not solely an individual concern, but as a social determinant of health structured by gender it also poses a threat to public health. Social inequalities are thought to represent a breeding ground for fear of crime, which subsequently may contribute to social inequalities in health. However, little research has focused on social inequalities in fear of crime, particularly in Sweden where the level of fear of crime and income and gender inequalities are comparatively low. With a conceptual model as a point of departure, the present study aimed to estimate and decompose income-related inequalities and explore gender differences in fear of crime in northern Sweden.

    METHODS: Participants (N = 22,140; 10,220 men and 11,920 women aged 16 to 84 years) came from the Health on Equal Terms cross-sectional survey with linked register data, carried out in the four northernmost counties of Sweden in 2014. Disposable income was used as the socio-economic indicator, fear of crime as the binary outcome variable, and sociodemographic characteristics, residential context, socio-economic and material conditions and psychosocial conditions as explanatory factors. Concentration curve and concentration index were used to estimate the income inequality in fear of crime, and decomposition analysis to identify the key determinants of the inequalities, in collapsed and gender-stratified analyses.

    RESULTS: Substantial gender differences were found in the prevalence of fear of crime (20.8% in women and 3.5% and men) and among the contributing factors to fear of crime. Additionally, the analyses revealed considerable income inequalities in fear of crime in the northern Swedish context (C = - 0.219). Gender, socio-economic and material, and psychosocial conditions explained the most in income inequalities of fear of crime in the total population.

    CONCLUSIONS: The existing gender and socio-economic inequities need to be approached as a greater structural problem to mitigate inequalities in fear of crime. Further research is needed to reveal more aspects of income inequalities in fear of crime and to develop efforts to create safe environments for all.

  • 12.
    Bozorgmehr, Kayvan
    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.
    Trade liberalization and tuberculosis incidence: a longitudinal multi-level analysis in 22 high burden countries between 1990 and 20102014Ingår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 29, nr 3, s. 328-351Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND Trade liberalization is promoted by the World Trade Organization (WTO) through a complex architecture of binding trade agreements. This type of trade, however, has the potential to modify the upstream and proximate determinants of tuberculosis (TB) infection. We aimed to analyse the association between trade liberalization and TB incidence in 22 high-burden TB countries between 1990 and 2010. METHODS and findings A longitudinal multi-level linear regression analysis was performed using five different measures of trade liberalization as exposure [WTO membership, duration of membership, trade as % of gross domestic product, and components of both the Economic Freedom of the World Index (EFI4) and the KOF Index of Globalization (KOF1)]. We adjusted for a wide range of factors, including differences in human development index (HDI), income inequality, debts, polity patterns, conflict, overcrowding, population stage transition, health system financing, case detection rates and HIV prevalence.None of the five trade indicators was significantly associated with TB incidence in the crude analysis. Any positive effect of EFI4 on (Log-) TB incidence over time was confounded by differences in socio-economic development (HDI), HIV prevalence and health financing indicators. The adjusted TB incidence rate ratio of WTO member countries was significantly higher [RR: 1.60; 95% confidence interval (CI): 1.12-2.29] when compared with non-member countries. CONCLUSION We found no association between specific aggregate indicators of trade liberalization and TB incidence. Our analyses provide evidence of a significant association between WTO membership and higher TB incidence, which suggests a possible conflict between the architecture of WTO agreements and TB-related Millennium Development Goals. Further research is needed, particularly on the relation between the aggregate trade indices used in this study and the hypothesized mediators and also on sector-specific indices, specific trade agreements and other (non-TB) health outcomes.

  • 13. Bozorgmehr, Kayvan
    et al.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Brenner, Hermann
    Razum, Oliver
    Maier, Werner
    Saum, Kai-Uwe
    Holleczek, Bernd
    Miksch, Antje
    Szecsenyi, Joachim
    Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-20102015Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, artikel-id 28Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Disease Management Programmes (DMPs) have been introduced in Germany ten years ago with the aim to improve effectiveness and equity of care, but little is known about the degree to which enrolment in the programme meets the principles of equity in health care. We aimed to analyse horizontal equity in DMP enrolment among patients with coronary heart disease (CHD). Methods: Cross-sectional analysis of horizontal inequities in physician-reported enrolment in the DMP for CHD in a large population-based cohort-study in Germany (2008-2010). We calculated horizontal inequity indices (HII) and their 95% confidence intervals [95% CI] for predicted need-standardised DMP enrolment across two measures of socio-economic status (SES) (educational attainment, regional deprivation) stratified by sex. Need-standardised DMP enrolment was predicted in multi-level logistic regression models. Results: Among N = 1,280 individuals aged 55-84 years and diagnosed with CHD, DMP enrolment rates were 22.2% (women) and 35.0% (men). Education-related inequities in need-standardised DMP enrolment favoured groups with lower education, but HII estimates were not significant. Deprivation-related inequities among women significantly favoured groups with higher SES (HII = 0.086 [0.007; 0.165]. No such deprivation-related inequities were seen among men (HII = 0.014 [-0.048; 0.077]). Deprivation-related inequities across the whole population favoured groups with higher SES (HII estimates not significant). Conclusion: Need-standardised DMP enrolment was fairly equitable across educational levels. Deprivation-related inequities in DMP enrolment favoured women living in less deprived areas relative to those living in areas with higher deprivation. Further research is needed to gain a better understanding of the mechanisms that contribute to deprivation-related horizontal inequities in DMP enrolment among women.

  • 14.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighbourhood unemployment and functional somatic symptoms2017Ingår i: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 43, s. 113-120Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study examines whether neighbourhood unemployment is related to functional somatic symptoms, independently of the individual employment, across the life course and at four specific life course periods (age 16, 21, 30 and 42). Self-reported questioner data was used from a 26-year prospective Swedish cohort (n=1010) with complementary neighbourhood register data. A longitudinal and a set of age-specific cross-sectional hierarchal linear regressions was carried out. The results suggest that living in a neighbourhood with high unemployment has implications for residents' level of functional somatic symptoms, regardless of their own unemployment across time, particularly at age 30.

  • 15.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Does contextual unemployment matter for health status across the life course?2016Konferensbidrag (Refereegranskat)
  • 16.
    Brydsten, Anna
    et al.
    Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Public Health Unit, Uppsala University, Uppsala, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health2018Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, nr 59, artikel-id 59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Even though population health is strongly influenced by employment and working conditions, public health research has to a lesser extent explored the social determinants of health inequalities between people in different positions on the labour market, and whether these social determinants vary across the life course. This study analyses mental health inequalities between unemployed and employed in three age groups (youth, adulthood and mid-life), and identifies the extent to which social determinants explain the mental health gap between employed and unemployed in northern Sweden.

    Methods: The Health on Equal Terms survey of 2014 was used, with self-reported employment (unemployed or employed) as exposure and the General Health Questionnaire (GHQ-12) as mental health outcome. The social determinants of health inequalities were grouped into four dimensions: socioeconomic status, economic resources, social network and trust in institutional systems. The non-linear Oaxaca decomposition analysis was applied, stratified by gender and age groups.

    Results: Mental health inequality was found in all age groups among women and men (difference in GHQ varying between 0.12 and 0.20). The decomposition analysis showed 43–51% of the total inequality among youths, 42–98% among adults and 60–65% among middle-aged. The main contributing factors were shown to vary between age groups: cash margin (among youths and middle-aged men), financial strain (among adults and middle-aged women), income (among men in adulthood), along with trust in others (all age groups), practical support (young women) and social support (middle-aged men); stressing how the social determinants of health inequalities vary across the life course.

    Conclusions: The health gap between employments was explained by the difference in access to economic and social resources, and to a smaller extent in the trust in the institutional systems. Findings from this study corroborate that much of the mental health inequality in the Swedish labour market is socially and politically produced and potentially avoidable. Greater attention from researchers, policy makers on unemployment and public health should be devoted to the social and economic deprivation of unemployment from a life course perspective to prevent mental health inequality.

  • 17.
    Brydsten, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The impact of economic recession on the association between youth unemployment and functional somatic symptoms in adulthood: a difference-in-difference analysis from Sweden2016Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, artikel-id 230Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The impact of macroeconomic conditions on health has been extensively explored, as well as the relationship between individual unemployment and health. There are, however, few studies taking both aspects into account and even fewer studies looking at the relationship in a life course perspective. In this study the aim was to assess the role of macroeconomic conditions, such as national unemployment level, for the long-term relationship between individual unemployment and functional somatic symptoms (FSS), by analysing data from two longitudinal cohorts representing different periods of unemployment level in Sweden.

    Methods: A difference-in-difference (DiD) analysis was applied, looking at the difference over time between recession and pre-recession periods for unemployed youths (age 21 to 25) on FSS in adulthood. FSS was constructed as an index of ten self-reported items of somatic ill-health. Covariates for socioeconomics, previous health status and social environment were included.

    Results: An association was found in the difference of adult FSS between unemployed and employed youths in the pre-recession and recession periods, remaining in the adjusted model for the pre-recession period. The DiD analysis between unemployed youths showed that men had significantly lower adult FSS during the recession compared to men in the pre-recession time.

    Conclusions: Adulthood FSS showed to be significantly lower among unemployed youths, in particular among men, during recession compared to pre-recession times. Since this is a fairly unexplored research field, more research is needed to explore the role of macroeconomic conditions for various health outcomes, long-term implications and gender differences.

  • 18. 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)
  • 19.
    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.

  • 20.
    Cordoba-Dona, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. 1Delegación Territorial de Igualdad, Salud y Políticas Sociales de Andalucía.
    Escolar-Pujolar, Antonio
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    How are the employed and unemployed affected by the economic crisis in Spain?: Educational inequalities, life conditions and mental health in a context of high unemployment2016Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, artikel-id 267Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Despite an increasing number of studies on the factors mediating the impact of the economic recession on mental health, research beyond the individual employment status is scarce. Our objectives were to investigate in which ways the mental health of employed and unemployed populations is differently affected by the current economic recession along the educational scale and to examine whether financial strain and social support explain these effects of the crisis. Methods: A repeated cross-sectional study, using two waves of the Andalusian Health Survey in 2007 (pre-crisis) and 2011-2012 (crisis). A population aged between 19 and 64 years was selected. The dependent variable was the Mental Component Summary of the SF-12 questionnaire. We performed Poisson regression models stratified by working status, with period, educational level, financial strain and social support as independent variables. We examined interactions between period and educational level. Age, sex, main earner, cohabitation and partner's working status were considered as covariates. Results: The study included 3210 individuals (1185 women) in 2007 and 3633 individuals (1486 women) in 2011-2012. In working individuals the prevalence of poor mental health increased for secondary and complete primary studies groups during crisis compared to the pre-crisis period, while it decreased significantly in the university study group (PR = 0.76, 95 % CI: 0.58-0.99). However, in unemployed individuals prevalence ratios for poor mental health increased significantly only in the secondary studies group (PR = 1.73, 95 % CI: 1.06-2.83). Financial strain and social support yielded consistent associations with mental health in all subgroups. Only financial strain could partly explain the crisis effect on mental health among the unemployed. Conclusions: Our study supports the finding that current economic recession is associated with poorer mental health differentially according to labour market status and educational level. Those with secondary studies may be at risk in times of economic recession. In connection with this, emerging educational inequalities in mental health among the employed population were observed. Our research also suggests a partial mediating role of financial strain for the effects of crisis on poor mental health among the unemployed. Good social support appears to buffer poor mental health in all subgroups but not specifically during crisis period.

  • 21.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de la Consejería de Salud de la Junta de Andalucía, Cádiz, Spain.
    Escolar-Pujolar, Antonio
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain2018Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, nr 3, artikel-id e0195293Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Scant research is available on the impact of the current economic crisis and austerity policies on inequality in health services utilisation in Europe. This study aimed to describe the trends in horizontal inequity in the use of health services in Andalusia, Spain, during the early years of the Great Recession, and the contribution of demographic, economic and social factors. Consultation with a general practitioner (GP) and specialist, hospitalisation and emergency care were studied through the Andalusian Health Survey 2007 (pre-crisis) and 2011-2012 (crisis), using a composite income index as socioeconomic status (SES) indicator. Horizontal inequity indices (HII) were calculated to take differential healthcare needs into account, and a decomposition analysis of change in inequality between periods was performed. Results showed that before the crisis, the HII was positive (greater access for people with higher SES) for specialist visits but negative (greater access for people with lower SES) in the other three utilisation models. During the crisis no change was observed in inequalities in GP visits, but a pro-poor development was seen for the other types of utilisation, with hospital and emergency care showing significant inequality in favour of low income groups. Overall, the main contributors to pro-poor changes in utilisation were socioeconomic variables and poor mental health, due to changes in their elasticities. Our findings show that inequalities in healthcare utilisation largely remained in favour of the less well-off, despite the cuts in welfare benefits and health services provision during the early years of the recession in Andalusia. Further research is needed to monitor the potential impact of such measures in subsequent years.

  • 22.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Escolar-Pujolar, Antonio
    Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    Martínez-Faure, Jesús Enrique
    Empresa Pública de Emergencias Sanitarias, Cádiz, Spain.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain2014Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, artikel-id 55Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Although suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.

    METHODS: The study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003-2007) and five years after its onset (2008-2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.

    RESULTS: A sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.

    CONCLUSIONS: This study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.

  • 23. Dei, Vincent
    et al.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Is healthcare really equal for all?: Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians2018Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, artikel-id 86Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: There is a lack of focused research on the older population in Ghana and about issues pertaining to their access to healthcare services. Furthermore, information is lacking regarding the fairness in the access to these services. This study aimed to ascertain whether horizontal and vertical equity requirements were being met in the healthcare utilisation among older adults aged 50 years and above. Methods: This study was based on a secondary cross-sectional data from the World Health Organization's Study on global AGEing (SAGE) and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Bivariate and multivariable analyses were carried out to analyse the association between outpatient/inpatient utilisation and (1) socioeconomic status (SES), controlling for need variables (horizontal equity) and (2) need variables, controlling for SES (vertical equity). Odds ratios with 95% confidence intervals were calculated to analyse the association between relevant variables. Results: Horizontal and vertical inequities were found in the utilisation of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Conclusion: Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The study reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access. It provides the basis for further research in bridging the healthcare access inequity gap among older adults in Ghana.

  • 24.
    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.

  • 25.
    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.

  • 26.
    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.

  • 27.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för 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 epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    "Cheaper and better": an economic analysis of changing first line treatment for cutaneous leishmaniasis in BoliviaManuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

    Introduction: Cutaneous leishmaniasis (CL) is endemic in Bolivia, mostly affecting poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages, a lack of conditions to deliver treatment safely, treatment interruption are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in an endemic area of Bolivia.

    Methods: The cost per patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N=12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization using previous estimates of the extent of underreporting. Costs were reported in 2016 international dollars (1 INT$ = 3.10 BOB).

    Results: Treating CL using ILPA was associated with a cost saving of $248 per patient treated from the MoH perspective, and $688 per patient treated from the societal perspective. ILPA was cost-saving even under a hypothetical increase of 80% in the number of cases treated. Switching first-line treatment would allow two-and-a-half times the current number of patients to be treated, while maintaining the current budget.

    Conclusions: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.

  • 28.
    Eid Rodríguez, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för 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 epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    "Cheaper and better": Societal cost savings and budget impact of changing from systemic to intralesional pentavalent antimonials as the first-line treatment for cutaneous leishmaniasis in Bolivia2019Ingår i: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 13, nr 11, artikel-id e0007788Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Cutaneous leishmaniasis (CL), endemic in Bolivia, mostly affects poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages and a lack of safe conditions to deliver treatment are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in a Bolivian endemic area.

    METHODS: The cost-per-patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N = 12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization. Costs were reported in 2017 international dollars (1 INT$ = 3.10 BOB).

    RESULTS: Treating CL using ILPA was associated with a cost-saving of $248 per-patient-treated from the MoH perspective, and $688 per-patient-treated from the societal perspective. Switching first-line treatment to ILPA while maintaining the current budget would allow two-and-a-half times the current number of patients to be treated. ILPA remained cost-saving compared to SPA in the sensitivity analysis.

    CONCLUSIONS: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.

  • 29. Escolar Pujolar, Antonio
    et al.
    Bacigalupe, Amaia
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Looking beyond the veil of the European crisis: the need to uncover the structural causes of health inequalities2016Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 15, artikel-id 39Artikel i tidskrift (Refereegranskat)
  • 30.
    Escolar-Pujolar, Antonio
    et al.
    Delegación Territorial de Igualdad, Salud y Políticas Sociales, Junta de Andalucía, Cádiz, Spain.
    Bacigalupe, Amaia
    Department of Sociology, University of the Basque Country (UPV/EHU), Leioa, Spain.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    European economic crisis and health inequities: research challenges in an uncertain scenario2014Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, s. 59-Artikel i tidskrift (Övrigt vetenskapligt)
  • 31. Estalella, Itziar
    et al.
    San Millán, Jaione
    Trincado, María José
    Maquibar, Amaia
    Martínez-Indart, Lorea
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay2019Ingår i: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Late-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm.

    OBJECTIVE: The aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain.

    METHODS: The intervention was designed to promote parents' education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n=212) and an intervention group (n=161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups.

    RESULTS: Infants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p=0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p=0.009).

    CONCLUSION: The intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.

  • 32. 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)
  • 33.
    Forouzan, Ameneh S
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Rafiey, Hassan
    Padyab, Mojgan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Ghazinour, Seyedmehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Dejman, Masoumeh
    San Sebastian Chasco, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Reliability and validity of a Mental Health System Responsiveness Questionnaire in Iran2014Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, s. 1-10Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background:

    The Health System Responsiveness Questionnaire is an instrument designed by the World Health Organization (WHO) in 2000 to assess the experience of patients when interacting with the health care system. This investigation aimed to adapt a Mental Health System Responsiveness Questionnaire (MHSRQ) based on the WHO concept and evaluate its validity and reliability to the mental health care system in Iran.

    Design: In accordance with the WHO health system responsiveness questionnaire and the findings of a qualitative study, a Farsi version of the MHSRQ was tailored to suit the mental health system in Iran. This version was tested in a cross-sectional study at nine public mental health clinics in Tehran. A sample of 500 mental health services patients was recruited and subsequently completed the questionnaire. Item missing rate was used to check the feasibility while the reliability of the scale was determined by assessing the Cronbach's alpha and item total correlations. The factor structure of the questionnaire was investigated by performing confirmatory factor analysis (CFA).

    Results: The results showed a satisfactory feasibility since the item missing value was lower than 5.2%. With the exception of access domain, reliability of different domains of the questionnaire was within a desirable range. The factor loading showed an acceptable unidimentionality of the scale despite the fact that three items related to access did not perform well. The CFA also indicated good fit indices for the model (CFI = 0.99, GFI = 0.97, IFI = 0.99, AGFI = 0.97).

    Conclusions: In general, the findings suggest that the Farsi version of the MHSRQ is a feasible, reliable, and valid measure of the mental health system responsiveness in Iran. Changes to the questions related to the access domain should be considered in order to improve the psychometric properties of the measure.

  • 34.
    Forouzan, Ameneh Setareh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Univ Social Welf & Rehabil Sci, Social Determinants Hlth Res Ctr, Tehran, Iran.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Dejman, Masoumeh
    Rafeiey, Hassan
    Eftekhari, Monir Baradaran
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Service Users and Providers Expectations of Mental Health Care in Iran: A Qualitative Study2013Ingår i: Iranian Journal of Public Health, ISSN 2251-6085, Vol. 42, nr 10, s. 1106-1116Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Mental disorders are known to be an important cause of disabilities worldwide. Despite their importance, about two thirds of mentally ill people do not seek treatment, probably because of the mental health system's inability to decrease the negative side effects of the interaction with the mental health services. The World Health Organization has suggested the concept of responsiveness as a way to better understand the active interaction between the health system and the population. This study aimed to explore the expectations of mental health service users and providers. Methods: Six focus group discussions were carried in Tehran, the capital of Iran. In total, seventy-four participants comprising twenty-one health providers and fifty-three users of mental health system were interviewed. Interviews were analyzed through content analysis. The coding was synchronized between the researchers through two discussion sessions to ensure the credibility of the findings. The results were then discussed with two senior researchers to strengthen plausibility. Results: Five common domains among all groups were identified: accessibility, quality of interpersonal relationships, adequate infrastructure, participation in decisions, and continuity of care. The importance of cultural appropriateness of care was only raised by service users as an expectation of an ideal mental health service. Conclusions: Both users and providers identified the most relevant expectations from the mental health care system in Iran. More flexible community mental health services which are responsive to users? experiences may contribute to improving the process of care for mental health patients.

  • 35.
    Forouzan, Ameneh Setareh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Dejman, Masoumeh
    Rafeiey, Hassan
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Testing the WHO responsiveness concept in the Iranian mental healthcare system: a qualitative study of service users2011Ingår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, nr 1, artikel-id 325Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Individuals' experience of interacting with the healthcare system has significant impact on their overall health and well-being. To relate patients' experiences to a common set of standards, the World Health Organization (WHO) developed the concept of health system responsiveness. This study aimed to assess if the WHO responsiveness concept reflected the non-medical expectations of mental healthcare users in Teheran.

    Methods In this qualitative study, four mixed focus group discussions were formed, comprising 53 mental health service users in Tehran, Iran, in 2010. Content analysis was performed for data analysis. Responses were examined in relation to the eight domains of the WHO's responsiveness model.

    Results There were many commonalities between the findings of this study and the eight domains of the WHO responsiveness model, although some variations were found. Effective care was a new domain generated from our findings. In addition, the domain of prompt attention was included in two new labelled domains: attention and access to care. Participants could not differentiate autonomy from choice of healthcare provider, believing that free choice is part of autonomy. Therefore these domains were unified under the name of autonomy. The domains of quality of basic amenities, access to social support, dignity and confidentiality were considered to be important for the responsiveness concept. Some differences regarding how these domains should be defined were observed, however.

    Conclusions The results showed that the concept of responsiveness developed by the WHO is applicable to mental health services in Iran. These findings might help policy-makers' better understanding of what is useful for the improvement of mental health services.

  • 36.
    Forouzan, Setareh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Padyab, Mojgan
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR).
    Rafiey, Hassan
    Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Iran.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Dejman, Masoumeh
    Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Measuring the mental health care system responsiveness: results of an outpatient survey in Tehran2016Ingår i: Frontiers In Public Health, ISSN 2296-2565, Vol. 3, artikel-id 285Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    As explained by the World Health Organization (WHO) in 2000, the concept of health system responsiveness is one of the core goals of health systems. Since 2000, further efforts have been made to measure health system responsiveness and the factors affecting responsiveness, yet few studies have applied responsiveness concepts to the evaluation of mental health systems. The present study aims to measure responsiveness and its related domains in the mental health-care system of Tehran. Utilizing the same method used by the WHO for its responsiveness survey, responsiveness for outpatient mental health care was evaluated using a validated Farsi questionnaire. A sample of 500 public mental health service users in Tehran participated and subsequently completed the questionnaire. On average, 47% of participants reported experiencing poor responsiveness. Among responsiveness domains, confidentiality and dignity were the best performing factors while autonomy, access to care, and quality of basic amenities were the worst performing. Respondents who reported their social status as low were more likely to experience poor responsiveness overall. Attention and access to care were responsiveness dimensions that performed poorly but were considered to be highly important by study participants. In summary, the study suggests that measuring responsiveness could provide guidance for further development of mental health-care systems to become more patient orientated and provide patients with more respect.

  • 37.
    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.

  • 38.
    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.

  • 39.
    Gangane, Nitin
    et al.
    Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.