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Women, migrants and those in manual occupations face barriers in the labor market and are more vulnerable to unemployment, which in turn may impact mental health and contributes to inequalities. Previous research has not considered the intertwinement of multiple inequalities. This study examined intersectional inequalities (intersecting gender, social class, and migration status) in poor mental health and the mediation role of unemployment in the Spanish adult population, using the 2012 and 2017 cross-sectional Spanish National Health Surveys (n = 22,383, 18–64 years, response rates: 89.6 % and 74.0 %). Mental health was measured using the GHQ-12 and classified into good and poor. Unemployment was classified as employed or unemployed. Gender (men or women), social class (manual or non-manual) and migration status (born in Spain or migrant) were cross-classified in eight intersectional strata. Intersectional mediation analysis showed that, compared to non-manual native men, poorer mental health was found in women, migrants and manual occupations (total effect). Unemployment completely mediates mental health inequalities in strata of men with manual occupations but partially in strata of women. Moreover, mental health inequality was explained by both higher unemployment prevalence (pure indirect effect) and by greater vulnerability to unemployment (mediated interaction effect) among native men and women in manual occupations and immigrant women in non-manual occupations compared to non-manual native men. In conclusion, complex mental health inequalities seem to be underpinned by the dual processes of higher risks and worse consequences of unemployment. Health policies should target strata of manual occupations since they were more likely to be unemployed.

This study assessed the prevalence, reasons, and factors associated with refraining from seeking needed health care among the Sámi population in Sweden. Using data from a 2021 health survey, 3,658 individuals participated. Descriptive and regression analyses were applied to summarize the data and determine the magnitude of associations between independent variables and refraining from health care. Results showed 19.9% of participants refrained from seeking needed health care. Common reasons included lack of time (25%), problem resolution (16%), long wait times (16%), and uncertainty about where to seek care (13%). Factors associated with the higher prevalence of refraining included being a woman, being under 65, having lower income, experiencing economic stress, belonging to a forest reindeer herding community, and residing outside Sámi homelands. Interventions should be designed to address healthcare access inequities among vulnerable Sámi subgroups. Further research is needed to understand these disparities and reasons for refraining from care in non-pandemic contexts.

Este informe analiza la evolución del cáncer en las provincias amazónicas de Sucumbíos y Orellana durante el período 1990–2019, una región históricamente afectada por la explotación petrolera. El estudio se basa en los datos del Registro Nacional de Tumores (RNT) de Quito, ya que en la región amazónica no existe un registro local. Se incluyeron 2.773 casos de cáncer diagnosticados a residentes de estas provincias en el periodo mencionado, mostrando un incremento sostenido del 360% en los casos reportados.

Las tasas de cáncer fueron sistemáticamente más altas en mujeres, destacando el cáncer de cuello uterino como el más prevalente, seguido por mama y tiroides. En hombres, los tipos más frecuentes fueron próstata, estómago y piel. Las tasas estandarizadas para la edad se incrementaron especialmente a partir del año 2005, alcanzando en el último quinquenio (2015-2019) tasas ajustadas para la edad de 45,4 por 100.000 en hombres y 90,2 por 100.000 en mujeres.

A nivel territorial, los cantones de Lago Agrio, Orellana y Sucumbíos mostraron las tasas más elevadas. Se observó una clara asociación entre la exposición prolongada a actividades petroleras y una mayor incidencia de cáncer. Los cantones con más de 20 años de explotación petrolera presentaron tasas hasta seis veces mayores que los no expuestos, especialmente en mujeres. Esta diferencia se observó a lo largo de los distintos periodos, salvo en el periodo 2010-2014 para mujeres.

El informe destaca la debilidad de la infraestructura sanitaria local: ausencia de servicios oncológicos, falta de programas de prevención y diagnóstico temprano, y dependencia de Quito para tratamiento, lo que genera importantes inequidades.

Entre las recomendaciones se incluyen la creación de un registro regional de cáncer, fortalecimiento de la prevención (vacunación, tamizaje), expansión de servicios de diagnóstico y tratamiento en la Amazonía, y mayor investigación sobre la relación entre cáncer y contaminación petrolera. También se sugiere capacitación continua del personal de salud en oncología y salud ambiental con enfoque intercultural.

El informe concluye que existe una situación alarmante de salud pública en Sucumbíos y Orellana, agravada por la exposición ambiental, la falta de servicios adecuados y la ausencia de medidas preventivas eficaces.

Bakgrund: Sveriges regering har nyligen antagit en nationell strategi för psykisk hälsa och suicidprevention, där samiska perspektiv för första gången inkluderats. I rapporter om ungas psykiska hälsa, och samisk folkhälsa, saknas dock unga samers perspektiv. Den här rapporten fyller den kunskapsluckan, genom att undersöka och belysa unga samers hälsa och välbefinnande i Sverige,med särskilt fokus på psykisk hälsa.

Metoder: Rapporten har tagits fram i nära samverkan med den samiska ungdomsorganisationen Sáminuorra och bygger på kvalitativa data insamlade 2024 och kvantitativa data insamlade 2021. Totalt deltog 15 unga samer i intervjuer(15–30 år), 16 i webbenkäter (15–30 år), och 364i en befolkningsbaserad folkhälsoenkät (18–29 år). Kvalitativa data har analyserats med tematisk analys. Kvantitativa data har analyserats med deskriptiv statistik och skillnader mellan grupper har undersökts genom bivariat regressionsanalys.

Kvalitativa resultat: Genom analysen identifierades ett huvudtema och fyra underteman. Huvudtemat ”Det är hemskt och magiskt samtidigt” handlar om hur den samiska identiteten innebär både positiva och negativa sidor i de ungas liv. Detta återkommer i alla underteman. Undertemat ”Livsbalans” belyser hur unga samer (liksom andra unga) upplever stress och försöker få goda levnadsvanor och relationer att fungera för bättre välmående. Deltagarna beskriver stolthet i undertemat ”Samisk identitet”, men också utmaningar kopplade till att ta den samiska kampen – att försvara och förklara sin kultur för andra. Detta återkommer i ”Samhällets spelregler”, som också speglar hur bristande stöd och förståelse från majoritetssamhället försvårar livssituationen, samt hur rasism, diskrimineringoch kränkningar underminerar välmående. Slutligen visar analysen i ”Vårdens villkor” att deltagarna upplever att den svenska hälso- och sjukvården behöver stärka sin kunskap och tillgänglighet för att unga samer ska kunna få likvärdig vård och stöd.

Kvantitativa resultat: Analysen av kvantitativa data redovisas beskrivande som andelar (procent) av unga samer och jämnåriga i Sverige, fördelat på kön och totalt samt om skillnader mellan grupper var statistiskt säkerställda. En kort sammanställning visar att:

• Ungefär tre av fyra unga samer rapporterade gott psykiskt välbefinnande (76,7 procent) och bra allmän hälsa (74,4 procent). De totala andelarna skilde sig inte mellan unga samer och andra unga i Sverige.
• Unga samiska kvinnor rapporterade mindre ofta bra allmän hälsa (68,6 procent respektive76,6 procent), mer ofta att de fått en depressionsdiagnos av läkare (29,9 procent respektive22,4 procent) samt hade mer ofta försökt ta sina liv (18,4 procent respektive 9,9 procent), jämfört med andra unga kvinnor i Sverige.
• Unga samer var mindre ofta stillasittande merän 10 timmar dagligen (24,6 procent respektive 35,2 procent) jämfört med andra unga i Sverige, men hade annars mindre sunda levnadsvanor (åt mindre ofta grönsaker/rotfrukter och snusade mer) samt var mer ofta överviktiga.
• De allra flesta unga samer har någon att anförtro sig åt (84,4 procent) eller be om hjälp från om de behöver detta (95,8 procent). Dessa andelar skiljer sig inte från andra unga i Sverige.
• Unga samer har oftare än andra unga i Sverige svårigheter att klara sina löpande utgifter(23,7 procent respektive 17,8 procent).
• Sex av tio unga samer har upplevt diskriminering eller rasism för att de är samer och var fjärde har upplevt detta under det senaste året. Det är mycket vanligare att unga samer än andra unga i Sverige upplevt att de blivit behandlade på ett sådant sätt att de känt sig kränkta på grund av den egna etniciteten under de tre senaste månaderna(25,7 procent respektive 3,4 procent).
• Endast 11 procent av de unga samerna upplevde att vårdpersonalen vid deras senaste besök hade tillräcklig kunskap om samisk kultur och livsvillkor för att kunna ge bra vård, och var tionde ung same har avstått från att berätta om sin samiska identitet i ett vårdmöte, trots att de själva upplevt att det haft betydelse för att bedömningen ska bli rätt.

Slutsatser: Rapporten visar att de flesta unga samer har god hälsa och ofta tillgång till särskilda resurser som stärker deras hälsa – det vill säga den ”magiska” sidan av unga samers liv. Detta är till exempel den stolthet, trygghet och det sociala nätverk som har sin grund i den samiska identiteten. Samtidigt visar rapporten också på ”hemska” sidor såsom unga samers större ekonomiska sårbarhet, samt stora utsatthet för rasism, diskriminering och kränkningar mot dem för att de är just samer. Det finns också en del hälsoområden där unga samer har sämre hälsa än andra, och mest allvarligt är att de unga samiska kvinnorna oftare saknar bra allmän hälsa, oftare rapporterar att de fått depressionsdiagnoser och oftare gjort självmordsförsök, jämfört med andra unga kvinnor i Sverige. Detta är områden där samhället måste göra mer för att förverkliga unga samers lika rätt till god hälsa och välbefinnande.

Rapporten fyller kunskapsluckor och skapar bättre förutsättningar för att det samiska och svenska samhället ska kunna stötta och stärka unga samers hälsa och välbefinnande, samt prioritera insatserna där de behövs bäst. Deltagarna har själva lämnat många goda förslag som kan förväntas stärka unga samers hälsa, inklusive genom att skapa fler trygga samiska mötesplatser och öka möjligheterna att få lära sig och tala samiska. Det omgivande samhället bör också öka sin kunskap om det samiska och motverka rasism mot samer, så unga samer slipper utsättas och försvara sig. Unga samer behöver också en lättillgänglig hälso- och sjukvård där personalen har den kompetens som krävs för att de ska bli förstådda på lika villkor som andra.

Background: The Swedish government has recently adopted a national strategy for mental health and suicide prevention, which for the first time includes Sámi perspectives. However, reports on young people's mental health and Sámi public health lack the perspectives of young Sámi. This report fills that knowledge gap by examining and highlighting the health and well-being of young Sámi in Sweden, with a particular focus on mental health.

Methods: The report was developed in close collaboration with the Sámi youth organisation Sáminuorra and is based on qualitative data collected in 2024 and quantitative data collected in 2021. A total of 15 youang Sámi participated in interviews (ages 15–30), 16 in online surveys (ages 15–30), and 364 in a population-based public health survey (ages 18–29). Qualitative data were analysed using thematic analysis. Quantitative data were analysed using descriptive statistics, and differences between groups were examined using bivariate regression analysis.

Qualitative results: The analysis identified one main theme and four sub-themes. The main theme, "It is terrible and magical at the same time," describes how Sámi identity involves both positive and negative aspects in young people's lives. This is reflected in all sub-themes. The sub-theme "Life balance" highlights how young Sámi (like other young people) experience stress and strive to maintain good living habits and relationships for better well-being. Participants expressed pride in the sub-theme "Sámi identity," but also challenges related to defending and explaining their culture to others. This is echoed in "Society's rules," which also reflects how lack of support and understanding from the majority society complicates life situations, and how racism, discrimination, and harassment undermine well-being. Finally, the analysis in "Conditions of care" shows that participants feel that the Swedish healthcare system needs to strengthen its knowledge and accessibility to provide equitable care and support for young Sámi.

Quantitative results: The analysis of quantitative data is presented descriptively as proportions (percentages) of young Sámi and peers in Sweden, divided by gender and total, and whether differences between groups were statistically significant. A brief summary shows that:

• About three out of four young Sámi reported good mental well-being (76.7%) and good general health (74.4%). The total proportions did not differ between young Sámi and other young people in Sweden.
• Young Sámi women reported good general health less often (68.6% vs. 76.6%), that they had received a depression diagnosis from a doctor more often (29.9% vs. 22.4%), and more often had attempted suicide (18.4% vs. 9.9%) compared to other young women in Sweden.
• Young Sámi were less often sedentary for more than 10 hours daily (24.6% vs. 35.2%) compared to other young people in Sweden, but otherwise had less healthy living habits (ate vegetables/root vegetables less often and used ‘snus’ more), and were more often overweight.
• Most young Sámi have someone to confide in (84.4%) or ask for help if needed (95.8%). These proportions do not differ from other young people in Sweden.Young Sámi more often than other young people in Sweden have difficulty managing their ongoing expenses (23.7% vs. 17.8%).
• Six out of ten young Sámi have experienced discrimination or racism because they are Sámi, and one in four has experienced this in the past year. It is much more common for young Sámi than other young people in Sweden to have felt insulted because of their ethnicity in the past three months (25.7% vs. 3.4%).
• Only 11% of young Sámi felt that the healthcare staff at their last visit had sufficient knowledge of Sámi culture and living conditions to provide good care, and one in ten young Sámi has refrained from disclosing their Sámi identity in a healthcare encounter, despite feeling that it was relevant for an accurate assessment.

Conclusions: The report shows that most young Sámi have good health and often access to specific resources that strengthen their health – the "magical" side of young Sámi's lives. This includes the pride, security, and social network rooted in Sámi identity. At the same time, the report also highlights "terrible" aspects such as young Sámi's greater economic vulnerability and significant exposure to racism, discrimination, and harassment because they are Sámi. There are also some health topics where young Sámi have poorer health than others, and most seriously, young Sámi women more often lack good general health, more often report receiving depression diagnoses, and more often have attempted suicide compared to other young women in Sweden. These are areas where society must do more to realise young Sámi's equal right to good health and well-being.

The report fills knowledge gaps and creates better conditions for the Sámi and Swedish societies to support and strengthen young Sámi's health and well-being and prioritise interventions where they are most needed. Participants themselves have provided many good suggestions that can be expected to strengthen young Sámi's health, including creating safer Sámi meeting places and increasing opportunities to learn and speak Sámi. The surrounding society should also increase its knowledge of the Sámi and counteract racism against Sámi so that young Sámi do not have to be exposed and defend themselves. Young Sámi also need accessible healthcare where staff have the competence required to understand them on equal terms as others.

OBJECTIVES: Latin American countries have long struggled with socioeconomic inequalities and health equity. In 2007, Ecuador implemented a health reform to address these issues by making public health services free, coordinating finances between subsystems and increasing the state's health budget. This study evaluates whether Ecuador's health system reform (2007-2017) reduced out-of-pocket (OOP) health spending, catastrophic health spending (CHS) and socioeconomic inequalities in CHS.

DESIGN: Cross-sectional study.

SETTING: Secondary data available of households from the 2006 and 2014 National Living Standards Measurement surveys.

METHODS: Descriptive statistics (means and medians) and log-binomial regression were applied to assess prevalence of OOP and socioeconomic inequalities (residence, region, health insurance status and wealth) in catastrophic health expenditure (CHE) for each period and over time.

RESULTS: Overall, there was a significant reduction of 14% points in the proportion of households with OOP healthcare expenditure. The prevalence of CHE decreased from 17% to 10% and within each socioeconomic group over time. Significant reductions in relative risk were observed in all socioeconomic variables. The inequality in CHE decreased significantly in households placed in rural areas (relative difference (RD): 0.88; 95% CI: 0.79 to 0.97) and poorest (RD: 0.82; 95% CI: 0.69 to 0.97); however, it increased within regions (RD: 0.58; 95% CI: 0.44 to 0.76) and for uninsured households (RD: 1.39; 95% CI: 0.95 to 2.04).

CONCLUSIONS: This study suggests that recent health reform effectively reduced OOP healthcare expenditure, CHE and some socioeconomic inequalities. Future reforms should further invest in key areas, expand health insurance for the most disadvantaged and monitor progress towards universal health coverage to address persistent inequalities.

Introduction: Depression is a leading cause of disability globally, with disparities evident across gender and ethnicity. Indigenous populations, including the Sámi people in Sweden, face compounded disadvantages due to intersecting social inequalities. This study aimed to estimate the differences in depression prevalence across different intersectional groups defined by Indigenous status and gender in Sweden.

Methods: Data on participants (N = 19,839) aged 18–84 years were obtained from two cross-sectional surveys conducted in 2021: the SámiHET study and the Health on Equal Terms (HET) survey. Depression prevalence was assessed using self-reported doctor-diagnosed depression. Four intersectional categories were created representing Sámi women, Sámi men, non-Sámi women, and non-Sámi men. Intersectional disparities (joint, referent, and excess) were estimated to examine the combined effects of Indigenous status and gender on depression prevalence.

Results: Sámi women reported the highest prevalence of depression (26%), while Sámi men had the lowest (12%). The joint disparity in depression prevalence was 10 percentage points (pp) (95% CI: 8.4 to 12, adjusted), reflecting a higher prevalence of depression among Sámi women compared with non-Sámi men. Most of the joint disparity was explained by the referent disparities for Indigenous status (-2.6 pp, 95% CI: -4.7 to -0.49) and gender (9.7 pp, 95% CI: 8.5 to 11). The excess intersectional disparity, reflecting the compounded effects of being Indigenous and gender, accounted for a third of the joint disparity (3.3 pp, 95% CI: 0.48 to 6.1, adjusted).

Conclusion: Sámi women experienced a disproportionate burden of depression due to intersectional disadvantages. These findings highlight the importance of culturally sensitive mental health strategies and the need for further qualitative research to explore their lived experiences.

Introduction: Accountability is crucial for improved functionality of health systems and can be ensured through community participation in health governance. To engage the community in the governance of the local health system, health facility governing committees (HFGCs) have been implemented in several low-income and middle-income countries including Tanzania. However, the effect of HFGCs on health system performance is not well studied. The aim of this study was to investigate the relationship between the functionality of the HFGCs and health system performance in 180 districts of mainland Tanzania, and to assess whether this relationship varies between dispensaries, health centres and hospitals.

Methods: We conducted an ecological study in which the studied outcome was health system performance. The main independent variable was functionality of HFGCs, that is, to what extent these committees reflect the concerns of and connect back to the community. Other explanatory variables included staff availability, location of the facility, gender of the manager of the facility and ownership of the facility. Data on all of the variables were retrieved from the Star Rating Assessment of 2017/2018, measured as mean proportions of all facilities in the districts. The analyses included linear regression for all facility levels combined, as well as for the levels of facility separated (dispensaries, health centres and hospitals).

Results: We found a positive relationship between the functionality of the HFGCs and health system performance (β=0.53; 95% CI=0.47 to 0.60). The relationship was stronger for dispensaries (β=0.56; 95% CI=0.50 to 0.63) compared to health centres (β=0.39; 95% CI=0.33 to 0.44) and hospitals (β=0.23; 95% CI=0.15 to 0.31).

Conclusions: Districts that have functional HFGCs tend to have better health system performance than others. This relationship is stronger in dispensaries compared to health centres and hospitals. Therefore, we believe the district authorities should allocate resources to strengthen the HFGCs.

Background: Mental health problems are the leading cause of disease burden among young people in India. While evidence shows that youth mental health and resilience can be improved with group interventions in school settings, such an intervention has not been robustly evaluated in informal urban settings.

Objective: This study aimed to evaluate whether the Nae Disha 3 group intervention could improve youth resilience, mental health and gender equal attitudes among disadvantaged young people from low-income urban communities in India.

Methods: This cluster randomised controlled trial used an analytic sample of 476 adolescents and young adults aged 11–25 years from randomised clusters in urban Dehradun, India. The 251 intervention group participants were 112 boys and 139 girls, and the 225 young people in the wait-control group were 101 boys and 124 girls. Five validated tools measuring resilience gender equity and mental health were filled by participants at three different points in time.

Results: Difference in difference (DiD) analysis at T2 showed that scores improved among girls in intervention group, for adjusted model, resilience (DiD = 4.12; 95% CI: 2.14, 6.09) and among boys, for resilience (DiD = 5.82; 95% CI: 1.57, 9.74).

Conclusions: The Nae Disha 3 intervention among disadvantaged urban youth moderately improved resilience for both young men and women, though it did not significantly impact mental health, self-efficacy, or gender-equal attitudes. We establish potential merit for this approach to youth mental health but recommend further research to examine active ingredients and the ideal duration of such group interventions.

Background: Health system managers and policymakers played a crucial role in shaping response strategies, allocating resources, and guiding healthcare delivery during the COVID-19 pandemic. However, few studies have explored their perspectives on the health system response. This study aimed to examine the health system response to the COVID-19 pandemic in Cochabamba, Bolivia, from their viewpoint.

Methods: We conducted a qualitative study using semi-structured interviews with 10 health system managers and policymakers responsible for the pandemic response. Reflexive thematic analysis guided the identification, organization, and interpretation of themes within the data.

Results: The COVID-19 pandemic exposed and intensified pre-existing vulnerabilities within the health system sectors. Political instability and centralized decision-making delayed the response, increased public unrest, and hindered resource mobilization. Fragmented governance structures and inadequate coordination between the public, private, and social security sectors further weakened the capacity of the system. Health services, already strained before the pandemic, faced critical shortages in personnel, equipment, and infrastructure. Stay-at-home regulations, short-term staffing policies, and financial barriers exacerbated these challenges. However, innovations such as telemedicine and non-conventional care delivery helped mitigate gaps in service provision.

Conclusions: Our findings highlight how governance weaknesses, human resource limitations, and structural service delivery fragmentation constrain the health system ability to respond effectively to emergencies. Addressing these challenges requires strengthening intersectoral coordination, improving workforce sustainability, and investing in future public health emergency preparation. Prioritizing flexible governance, equitable human resource allocation, and integrated service delivery to enhance system resilience.

BACKGROUND: During the COVID-19 pandemic, health system managers and policymakers were vital in shaping response strategies, allocating resources, and overseeing healthcare delivery. Despite this, limited research has examined their perspectives on the health system response to the crisis, especially in the Latin American context. This study addresses that gap by exploring the health system's response to this pandemic in Cochabamba, Bolivia, through the lens of these key stakeholders.

METHODS: We conducted a qualitative study using semi-structured interviews with 10 health system managers and policymakers responsible for the pandemic response. Reflexive thematic analysis guided the development and interpretation of the themes.

RESULTS: Our findings shed light on how the pandemic revealed and intensified pre-existing vulnerabilities within the health system sectors. Political instability and centralized decision-making delayed the response, increased public unrest, and hindered resource mobilization. Fragmented governance structures and inadequate coordination between the public and social security sectors further weakened the health system's capacity. Health services, already strained before the pandemic, faced critical shortages in personnel, equipment, and infrastructure. Stay-at-home regulations, short-term staffing policies, and financial barriers exacerbated staff attrition. However, innovations such as telemedicine and non-conventional healthcare strategies helped mitigate gaps in service delivery.

CONCLUSIONS: Our findings highlight governance weaknesses, human resource limitations, and structural fragmentation of service delivery, which constrained the Bolivian health system's ability to respond effectively to the pandemic. Addressing these challenges requires strengthening intersectoral coordination and communication, improving workforce sustainability, and investing in better future public health emergency preparation. Improving governance mechanisms, allocating resources equitably, and integrating service delivery could enhance the health system's resilience capacity.