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  • 1.
    Alemu, Andinet Worku
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, article id 5398Article in journal (Refereed)
    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.

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  • 2.
    Alfredsson, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    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, Cambodia2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1331579Article in journal (Refereed)
    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.

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  • 3.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Kiwara, Angwara Denis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 1140Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

    METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data.

    RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

    CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

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  • 4.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 459Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

    METHODS: An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

    RESULTS: Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

    CONCLUSION: While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

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  • 5.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    The experience of providing the health insurance benefits to elderly in rural Tanzania: Providers’ perspectivesManuscript (preprint) (Other (popular science, discussion, etc.))
  • 6.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    Tungu, Malale
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study2020In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, no 1, article id 179Article in journal (Refereed)
    Abstract [en]

    Background: Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population.

    Methods: A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors.

    Results: A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (− 1; 95% CI: − 1.45, − 0.45) and inpatient (− 2; 95% CI: − 2.69, − 1.30) care.

    Conclusion: The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

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  • 7.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundh, Thomas
    Alegre, Yuri
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lead exposure in indigenous communities of the Amazon basin, Peru2011In: International journal of hygiene and environmental health (Print), ISSN 1438-4639, E-ISSN 1618-131X, Vol. 215, no 1, p. 59-63Article in journal (Refereed)
    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.

  • 8.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lead exposure among children from native communities of the Peruvian Amazon basin2012In: Revista panamericana de salud pùblica, ISSN 1020-4989, E-ISSN 1680-5348, Vol. 31, no 4, p. 296-302Article in journal (Refereed)
    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.

  • 9.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sources and risk factors for lead exposure in indigenous children of the Peruvian Amazon, disentangling connections with oil activity2012In: International journal of occupational and environmental health, ISSN 1077-3525, E-ISSN 2049-3967, Vol. 18, no 4, p. 268-277Article in journal (Refereed)
    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.

  • 10.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Bergdahl, Ingvar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Easier said than done: applying the Ecohealth principles to a study of heavy metals exposure among indigenous communities of the Peruvian Amazon2013In: BMC Public Health, E-ISSN 1471-2458, Vol. 13, article id 437Article in journal (Refereed)
    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.

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  • 11.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Anemia and malnutrition in indigenous children and adolescents of the Peruvian Amazon in a context of lead exposure: a cross-sectional study2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7Article in journal (Refereed)
    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.

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  • 12.
    Anyatonwu, Obinna Princewill
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Rural-urban disparities in postpartum contraceptive use among women in Nigeria: a Blinder-Oaxaca decomposition analysis2022In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 21, no 1, article id 71Article in journal (Refereed)
    Abstract [en]

    Background: Unintended pregnancies are a global public health concern that could be prevented with appropriate access to contraceptive methods. Evidence from research has indicated that avoidance of closely space birth/pregnancy within the first year of postpartum, mitigates the risk of adverse health outcomes such as preterm birth, low birth-weight, etc. Postpartum family planning helps women to minimize closely spaced and unplanned pregnancies within the first 12 months after delivery. Less contraceptive use is often present in more socially disadvantaged groups. Studies from Nigeria have shown a persistent disparity on contraceptive use between rural and urban residents. To identify the factors explaining these inequalities is important to implement targeted interventions. This study aimed to identify the factors contributing to the rural-urban disparity in postpartum contraceptive use among women in Nigeria. Methods: This is a cross-sectional study using the Nigerian Demographic Health Survey. In total, 28,041 postpartum Nigerian women were included. Self-reported contraceptive use was the outcome, while the selected explanatory variables were grouped according to three theoretical perspectives: materialistic, behavioural/cultural, and psychosocial variables. Descriptive statistics and Blinder-Oaxaca decomposition were used to summarize and identify the factors contributing to the rural-urban disparity in postpartum contraceptive use. Results: In this study, 27% of women reported to have used contraceptives during the postpartum period. The rural-urban disparity in postpartum contraceptive use accounted for 18.2 percentage points. The findings further showed that the disparities in postpartum contraceptive use between rural-urban residence were mostly explained by materialistic variables (82%), followed by the behavioural/cultural variables and age (included as covariate) accounting for 15.6 and 3.0%, respectively. Household wealth (37%) and educational attainment (38%) had the most significant contribution to the differences in postpartum contraceptive use. Only 15% of the difference in postpartum contraceptive use remained unexplained. Conclusion: This study has shown important inequalities in postpartum contraceptive use between rural and urban residents in Nigeria. These differences were mainly explained by materialistic factors. These findings highlight crucial areas for the government to target in order to close the existing gap between rural and urban settings in contraceptive use in the country.

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  • 13.
    Arias Fuentes, Fara Faith
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Arteaga, Erika
    Health Sciences College, University of San Francisco de Quito, Quito, Ecuador.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Social inequalities in women exposed to obstetric and gyneco-obstetric violence in Ecuador: a cross-sectional study2022In: BMC Women's Health, E-ISSN 1472-6874, Vol. 22, no 1, article id 419Article in journal (Refereed)
    Abstract [en]

    Background: Obstetric and gyneco-obstetric violence (OV, GOV) is a concerning public health problem, particularly in Latin America. This study aimed to determine the prevalence of OV and GOV and to assess its socio-geographical distribution in Ecuador.

    Methods: This cross-sectional study used data from a national survey conducted in 2019 (n = 17,211) among women aged 15 years and over. Independent variables included age, marital status, education, ethnicity, place of residence and region. The chosen outcomes were lifetime experience of OV and GOV. Frequency tables were calculated and crude and adjusted regression models estimating prevalence ratios and their 95% confidence intervals were computed.

    Results: Nearly one-third (32.8%) of the participants had experienced OV and two-fifths (41.86%) GOV at least once in their lifetime. Prevalence of OV were particularly common in women 26–35 and 46–55 years old, with primary or middle education and in urban regions. In comparison, GOV had a higher prevalence in women aged > 65 years and with no formal education. Both subtypes of violence were more common among women with current or earlier partners compared with the single ones. Also the two outcomes were more prevalent in the non-white population, OV among the populations of colour (POC), while GOV both, in the POC and Indigenous group. Additionally, women from the Highlands and Amazon reported higher OV and GOV than the Coastal group.

    Conclusion: Our study showed that OV and GOV are common in Ecuador and identified an unequal distribution of their prevalence across different socio-geographical groups. Further studies including more social factors and a continuous monitoring of OV and GOV are recommended. Current policies, laws to protect women and guidelines regarding the treatment of women, particularly in health care settings, need to be constantly advocated for and effectively implemented in the country.

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  • 14.
    Aweesha, Huzeifa
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. World Health Organization Sudan Country Office, Sudan.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Sudan's health sector partnership: from confined progression to openness and hope to uncertain demise2024In: Development Policy Review, ISSN 0950-6764, E-ISSN 1467-7679, Vol. 42, no 2, article id e12757Article in journal (Refereed)
    Abstract [en]

    Motivation: Despite signature of the 2005 Paris Declaration on Aid Effectiveness and subsequent adoption of the effective development cooperation (EDC) principles for better health cooperation, there is a gap in documenting the challenges to implement these commitments at country level. Sudan represents an interesting case study: the country adopted a local health compact in 2014, but for much of the time since the regime was under sanction. Sudan witnessed a revolution in 2018, followed by a counter-coup in 2021.

    Purpose: We aim to explore the evolution of Sudan health sector partners’ relationships, perspectives, and adherence to EDC principles of ownership, alignment, and harmonization, while accounting for underlying processes and context changes between 2015 and 2022.

    Methods and approach: We collected data through two rounds of interviews, in 2015 (16) and 2022 (8), with stakeholders within the Sudan Health Sector Partnership. We used the framework method for data analysis where responses are coded then sorted into themes.

    Findings: Prior to the 2019 revolution cooperation was progressive but restricted, with civil society marginalized and a dominating government. The principles, especially ownership, were misused and misaligned with national priorities driven by donors’ interests and conditions.

    The transitional (post-revolution) period witnessed partners’ openness and influx, but unstable leadership and subsequent changes in priorities led to wasted opportunities.

    Following the coup, donors adopted a no-contact policy towards the de facto government. Instead, the expectation was that civil society organizations would replace the government as the main implementers. Overall, limited coordination capacity and no sustainability measures were present throughout.

    Policy implications: Much of what was observed was down to the often complicated and difficult context of the governance of Sudan. That said, general issues arose including the government's ability to coordinate policy and implementation; the need for stable, legitimate arrangements; and the need to define the role of civil society and to empower civil society organizations. Within a complex and volatile context, revisiting partners’ commitments through joint compact reviews and transparent EDC progress monitoring is crucial.

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  • 15.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Social factors associated with trust in the health system in northern Sweden: a cross-sectional study2022In: BMC Public Health, E-ISSN 1471-2458, Vol. 22, no 1, article id 881Article in journal (Refereed)
    Abstract [en]

    Background: Despite the importance of having trust in the health system, there is a paucity of research in this feldin Sweden. The aim of this study was to estimate the level of trust in the health system and to assess the factors asso‑ciated with it in northern Sweden.

    Methods: A cross-sectional survey was conducted in 2014 in the four northern regions of Sweden. A total of 24 795 participants (48% response rate) aged 18 to 84 years were involved in the study. A log-binomial regression was usedto measure the association between sociodemographic factors and trust in the health system.

    Results: Two thirds of the participants (68.5%) reported high trust in the health system i.e. had very much or quitea lot confdence in the health system. Women had lower prevalence of trust compared to men (PR=0.96; 95%CI=0.94–0.98) while older participants had a higher trust compared to youth (PR=1.11; 95% CI=1.06–1.16). Participants with lower level of education, those who experienced economic stress, those who were born outside Swedenand those living in small municipalities also had lower prevalence of trust in the health system. Conversely, lowerincome was associated with higher trust (PR=1.08; 95% CI=1.04–1.12). Finally, a strong relationship between highersocial capital (having emotional and instrumental support, horizontal trust, and higher social participation) and trustin the health system was also found.

    Conclusions: Trust in the health system was moderately high in northern Sweden and strongly associated withsociodemographic and social capital factors. Trust is a complex phenomenon and a deeper exploration of the relationbetween trust in the health system and sociodemographic factors is needed.

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  • 16.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Jonzon, Robert
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. The Public Health Agency of Sweden, Solna, Sweden.
    Nkulu Kalengayi, Faustine
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Young migrants' sexual rights in Sweden: a cross-sectional study2021In: BMC Public Health, E-ISSN 1471-2458, Vol. 21, no 1, article id 1618Article in journal (Refereed)
    Abstract [en]

    In national public health surveys including those assessing sexual and reproductive health, migrants generally tend to be underrepresented due to cultural, linguistic, structural and legal barriers, minimising the possibility to measure sexual rights' fulfilment in this group. This study aims to describe to what extent sexual rights of young migrants in Sweden are being fulfilled. A self-administered questionnaire was used to collect data from 1773 young (16 - 29 years) migrants by post, online, and at language schools and other venues. Sexual rights were operationalised and categorised into five domains adapted from the Guttmacher-Lancet Commission's definition. These domains included the right to: 1) access sexual and reproductive healthcare, 2) access information and education about sexuality and sexual and reproductive health and rights, 3) have bodily integrity, 4) make free informed decisions about sexuality and sexual relations and 5) have a satisfying and safe sexual life. Descriptive analysis was used to assess the extent of fulfilment for each right. There were wide variations in the fulfilment of sexual rights between subgroups and among the five domains. Most respondents rated their sexual health as good/fair, however, 6.3% rated their sexual health as bad/very bad. While most of those who visited related services were satisfied, 17.4% of respondents refrained from visiting the services despite their needs. Around four in ten respondents did not know where to get information about sexuality and sexual health. One-fourth of respondents reported sexual violence. Another 12.7% were limited by family members or fellow countrymen regarding with whom they can have an intimate relationship. Most respondents were satisfied with their sexual life, except for 11.9%. Men, non-binary respondents, lesbians, gays, bisexuals, asexuals, those who were awaiting a decision regarding residence permit and those born in South Asia reported poor sexual health to a greater extent and fulfilment of their sexual rights to a lesser extent than other groups. Timely and culturally adapted information about sexual rights, gender equalities, laws and available services in Sweden should be provided in appropriate languages and formats in order to raise awareness about sexual rights and improve access to available services. Tailored attention should be paid to specific vulnerable subgroups.

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  • 17.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nkulu Kalengayi, Faustine
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Jonzon, Robert
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. The Public Health Agency of Sweden, Solna, Sweden.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Access of Migrant Youths in Sweden to Sexual and Reproductive Healthcare: A Cross-sectional Survey2022In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 11, no 3, p. 287-298Article in journal (Refereed)
    Abstract [en]

    Background: This study aims to assess migrant youths’ access to sexual and reproductive healthcare (SRHC) in Sweden, to examine the socioeconomic differences in their access, and to explore the reasons behind not seeking SRHC. 

    Methods: A cross-sectional survey was conducted for 1739 migrant youths 16 to 29 years-old during 2018. The survey was self-administered through: ordinary post, web survey and visits to schools and other venues. We measured access as a 4-stage process including: healthcare needs, perception of needs, utilisation of services and met needs. 

    Results: Migrant youths faced difficulties in accessing SRHC services. Around 30% of the participants needed SRHC last year, but only one-third of them fulfilled their needs. Men and women had the same need (27.4% of men [95% CI: 24.2, 30.7] vs. 32.7% of women [95% CI: 28.2, 37.1]), but men faced more difficulties in access. Those who did not categorise themselves as men or women (50.9% [95% CI: 34.0, 67.9]), born in South Asia (SA) (39% [95% CI: 31.7, 46.4]), were waiting for residence permit (45.1% [95% CI: 36.2, 54.0]) or experienced economic stress (34.5% [95% CI: 30.7, 38.3]) had a greater need and found more difficulties in access. The main difficulties were in the step between the perception of needs and utilisation of services. The most commonly reported reasons for refraining from seeking SRHC were the lack of knowledge about the Swedish health system and available SRHC services (23%), long waiting times (7.8%), language difficulties (7.4%) and unable to afford the costs (6.4%). 

    Conclusion: There is an urgent need to improve migrant youths’ access to SRHC in Sweden. Interventions could include: increasing migrant youths’ knowledge about their rights and the available SRHC services; improving the acceptability and cultural responsiveness of available services, especially youth clinics; and improving the quality of language assistance services.

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  • 18.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    The perception of youth health centres' friendliness: does it differ between immigrant and Swedish-Scandinavian youths?2020In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 30, no 4, p. 780-785Article in journal (Refereed)
    Abstract [en]

    Background: Ensuring a good quality service and equal access according to need for all young people is a key objective of the Swedish health system. The aim of this study was to explore youths’ perception of youth health centres’ (YHCs’) friendliness and to assess the differences in perception between immigrant and Swedish-Scandinavian youths.

    Methods: All YHCs in the four northern counties in Sweden were invited (22 centres), and 20 agreed to participate. Overall, 1089 youths aged 16–25 years answered the youth-friendly health services-Sweden questionnaire between September 2016 and February 2017. Thirteen sub-domains of friendliness were identified and their scores were calculated. Multilevel analysis was used to examine the differences in perception between immigrant and Swedish-Scandinavian youths.

    Results: Our sample consisted of 971 Swedish-Scandinavian youths (89.2%) and 118 immigrants (10.8%). Generally, both groups perceived the services to be very friendly. All 13 sub-domains were rated more than three in a four-point scale except for fear of exposure and parental support of psychosocial services. However, immigrant youths perceived YHCs less friendly than their counterparts, particularly regarding the domains of equity, respect, quality and parental support.

    Conclusions: Our study suggests that even though youths perceived YHCs as highly friendly, there is a space for improvement regarding access to health care. Our findings highlight the importance of an open and culturally sensitive attitude of the staff and the need to engage parents and community as a key to improve immigrant youths’ accessibility to health care.

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  • 19.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe; a new questionnaire to assess youth friendliness2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 343-Article in journal (Other academic)
    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.
  • 20.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe: a questionnaire to assess youth-friendliness in differentiated health services2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1380399Article in journal (Refereed)
    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.

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  • 21.
    Beck, Simon
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Basic income – healthy outcome? Effects on health of an Indian basic income pilot project: a cluster randomised trial2015In: Journal of Development Effectiveness, ISSN 1943-9342, E-ISSN 1943-9407, Vol. 7, no 1, p. 111-126Article in journal (Refereed)
    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.

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  • 22.
    Blåhed, Hanna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Arts, Várdduo – Centre for Sámi Research.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Arts, Várdduo – Centre for Sámi Research.
    "Det är ju faktiskt framtiden som tas ifrån en": en hälsokonsekvensbedömning med anledning av den potentiella gruvetableringen i Gállok/Kallak, svenska Sápmi2020Report (Other academic)
    Abstract [sv]

    Inledning: Denna rapport avser den potentiella gruvetableringen i Gállok/Kallak, ett område 4 mil utanför Jokkmokk, svenska Sápmi. Markerna kring Gállok/Kallak används till renskötsel året om av samebyn Jåhkågasska tjiellde. En gruvetablering skulle påverka renarnas migrationsrutt avsevärt, och försvåra hållbar renhållning för samebyn. Det skulle också medföra högre utfordrings– och transportkostnader för renskötarna, potentiellt öka konflikterna mellan samebyarna, och för många skulle det innebära slutet på ett traditionellt leverne. Även om miljökonsekvensbeskrivningar (MKB) genomförs enligt lag vid alla typer av utvecklingsprojekt, så bedöms hälsa oftast vagt och ytligt i dessa, och potentiella hälsoeffekter på lokalbefolkningen bedöms sällan. Syftet med denna hälsokonsekvensbedömning (HKB) var således att utröna hälsoeffekter bland medlemmar i Jåhkågasska tjiellde sameby, med anledning av det planerade gruvverksamheten i Gállok/Kallak.

    Metod: Metoden som användes kallas HKB och är ett femstegsverktyg, rekommenderat av bland annat Folkhälsomyndigheten. Stegen inkluderar i) screening ii) tillämpningsområde iii) bedömning iv) presentation av resultat och rekommendationer och v) övervakning och utvärdering, varav alla förutom det sista steget har genomförts. Steg i) –ii) undersökte förutsättningarna för en HKB. Steg iii) bestod av en litteraturöversikt, följt av en kvalitativ studie. Steg iv) bestod i rapportskrivning med rekommendationer. Gällande den kvalitativa delen genomfördes djupintervjuer med sex deltagare från Jåhkågasska tjiellde, för att fånga nuvarande och potentiella framtida hälsoupplevelser med anledning av den tilltänkta gruvan. Tematisk analys användes för att tolka data.

    Resultat: Resultatet av litteraturöversikten visade att få studier har undersökt hälsorisker i förhållande till lokalbefolkningar. Trots att gruvetableringar ofta planeras på mark som har kopplingar till urfolk så finns få hälsobedömningar i relation till urfolk. Ur intervjuerna framkom fem teman, uppdelade i två avsnitt: “Nuvarande hälsoeffekter och dess bakomliggande orsaker” och “Potentiella framtida hälsoeffekter och dess bakomliggande orsaker”. Under nuvarande effekter diskuterades maktobalansen mellan de olika aktörerna under temat “Det är som Davids kamp mot Goliat”. I detta avsnitt presenterades även de specifika hälsoeffekterna som uppkommit som ett resultat av den långa gruvprocessen, under temat “Det är en långsam process som tar mycket kraft och energi”. Det sista temat i det första avsnittet “Det är som ett försvar (…) som för att skydda sig själv” avslöjade de olika strategier som deltagarna utvecklat för att hantera situationen. Två temat uppstod under potentiella framtida effekter: “Om renen dör, dör allt” och “Man skulle känna att man inte har någon makt, [man skulle känna sig] åsidosatt, bortryckt, inte omtyckt”. Det förstnämnda temat skildrade den negativa påverkan av en potentiell gruva på renskötseln, medan den senare presenterade konkreta hälsokonsekvenser utav densamma.

    Slutsats: Resultaten av studien visade att planerna på en gruva i Gállok/Kallak redan har gett upphov till negativa psykosociala hälsoeffekter i Jåhkågasska tjiellde. Detta var oväntat, då HKB betraktas som ett framtidsorienterat verktyg. Nuvarande hälsoeffekter inkluderade ångest, stress och oro, medan potentiella framtida effekter pekade på försämrad psykisk hälsa. Osäkerheten kring beslut, den långa väntan och rädslan för att förlora ens försörjning – inklusive den framtida generationens försörjning – medverkade till nuvarande, och potentiellt försämrad, psykisk hälsa. 5 Fyra rekommendationer presenteras i denna rapport: i) HKB bör regleras i lag och bli praxis i alla utvecklingsprojekt; ii) HKB bör undersöka och övervaka både nuvarande och framtida hälsoeffekter; iii) HKB bör genomföras på ett systematiskt, deltagande och öppet sätt, och ges samma vikt i beslutsfattande som MKB; v) stöd för att förhindra psykisk ohälsa bör erbjudas i början av varje utvecklingsprojekt.

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  • 23.
    Blåhed, Hanna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Arts, Várdduo – Centre for Sámi Research.
    “If the reindeer die, everything dies”: The mental health of a Sámi community exposed to a mining project in Swedish Sápmi2021In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 80, no 1, article id 1935132Article in journal (Refereed)
    Abstract [en]

    In 2006, a British mining company started the process of extracting ore from Gállok/Kallak, in Swedish Sápmi. These grounds are used all year round for reindeer herding by the Sámi community Jåhkågasska tjiellde. While environmental impact assessments should be conducted by law in any development project in Sweden, the health component included is usually vague. The aim of this study was to understand the experiences and perceptions of the Sámi community regarding the current and potential health effects of the proposed mine.A qualitative study, including six in-depth interviews with members of the community, was conducted in 2020. Interviews were analysed using thematic analysis. Five themes were identified and organised in current and future impacts. Current impacts included “It’s like David’s battle against Goliath”, “It’s a slow process that takes a lot of power and energy”, “It’s a defense … like, to protect oneself”; with future impacts including: “If the reindeer die, everything dies”, “You would feel that you do not possess any power, [you would feel] overridden, pushed away, not liked”.The fear of losing current and future generations’ livelihoods appeared to be the main mediators of the current and potential worsened mental health experienced by the community.

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  • 24.
    Blåhed, Hanna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Arts, Várdduo – Centre for Sámi Research.
    Health impact assessment of a mining project in Swedish Sápmi: lessons learned2022In: Impact Assessment and Project Appraisal, ISSN 1461-5517, E-ISSN 1471-5465, Vol. 40, no 1, p. 38-45Article in journal (Refereed)
    Abstract [en]

    Whereas assessing health is a mandatory feature of environmental impact assessments (EIAs) in Sweden, health impacts are often vaguely described, making their health preventive role meaningless. In 2006, a mine was planned in the reindeer grazing lands of a Sámi community in northern Sweden. While an EIA was conducted in 2013, health was superficially addressed. The aim of this study was to describe and reflect on the health impact assessment (HIA) process that assessed the potential health risks and/or benefits that the mine establishment could bring to the Sámi community.The classic five steps of an HIA are presented. The literature review showed a scarcity of studies regarding HIA on mining in indigenous territories. Participants in the study were currently experiencing negative psychosocial health effects and described potential adverse social and health effects originating from the loss of their traditional way of life.Despite certain challenges, this study proved that it is possible to conduct a comprehensive HIA in the context of Sámi health research. Given that mining in Sweden occurs mostly in Sámi territory and the adverse health effects found in this study, the lack of comprehensive HIAs on mining projects in Sweden raises serious concerns.

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  • 25.
    Boldis, Beáta Vivien
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Unsafe and unequal: a decomposition analysis of income inequalities in fear of crime in northern Sweden2018In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, article id 110Article in journal (Refereed)
    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.

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  • 26.
    Bozorgmehr, Kayvan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Trade liberalization and tuberculosis incidence: a longitudinal multi-level analysis in 22 high burden countries between 1990 and 20102014In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 29, no 3, p. 328-351Article in journal (Refereed)
    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.

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  • 27. Bozorgmehr, Kayvan
    et al.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    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 2008-20102015In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, article id 28Article in journal (Refereed)
    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.

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  • 28.
    Brandén, Jennie
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nilsson, Lena Maria
    Umeå University, Arctic Research Centre at Umeå University. Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Burman, Monica
    Umeå University, Faculty of Social Sciences, Unit of Police Work.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Stoor, Jon Petter
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Våld mot samiska kvinnor2024Report (Other academic)
    Abstract [sv]

    I den här rapporten presenterar vi resultat från forskningsprojektet ”Våld mot samiska kvinnor” som 2021-2024 genomförts av forskargruppen Lávvuo vid Umeå Universitet, på uppdrag av Sámediggi (Sametinget i Sverige).

    Rapporten består av en kvantitativ och en kvalitativ del, samt fem åtgärdsförslag riktade till Sveriges regering.

    De kvantitativa resultaten i korthet

    Den kvantitativa delen av rapporten baseras på enkätundersökningen Samisk hälsa på lika villkor som genomfördes 2021. Resultaten har jämförts med Sveriges befolkning genom den nationella enkäten Sexuell och reproduktiv hälsa genomförd 2017. 

    Det övergripande mönstret är att kvinnor är betydligt mer utsatta för våld än män, samt att samiska kvinnor 2021 uppger en högre våldsutsatthet än kvinnor i Sverige 2017, för de flesta typer av våld.

    • Över hälften av de samiska kvinnorna har utsatts för sexuellt våld (55,5 procent), sju av tio har utsatts för psykiskt våld (68,5 procent) och nästan var tredje för fysiskt våld (27,9 procent).
    • En större andel samiska kvinnor än kvinnor i Sverige i stort uppger utsatthet för de grövsta formerna av sexuellt våld, såsom våldtäktsförsök (14,1 jämfört med 10,6 procent) och våldtäkt (10,3 jämfört med 7,0 procent).
    • En större andel samiska kvinnor än kvinnor i Sverige i stort uppger utsatthet för psykiskt våld, både sammantaget (68,5 jämfört med 50,9 procent) och vad gäller alla de former av psykiskt våld som undersöktes.
    • Även när det gällde fysiskt våld rapporterade samiska kvinnor (27,9 procent) en högre utsatthet jämfört med kvinnor i Sverige (22,0 procent).
    • Samiska kvinnors utsatthet för våld varierar med både ålder och geografi. Överlag var utsattheten högst bland kvinnor yngre än 45 år. Geografiskt var utsattheten för sexuellt och fysiskt våld högre bland samiska kvinnor i mellersta och södra Sverige, med undantag av Stockholmsområdet. För psykiskt våld hade samiska kvinnor i Jämtland Härjedalen en högre utsatthet.
    • Det finns flera starka samband mellan olika typer av våldsutsatthet och psykisk och fysisk ohälsa. Upprepad våldsutsatthet (fler än en gång) är förenat med ännu högre risk för ohälsa, särskilt psykisk ohälsa. Starkast är detta samband när det gäller stress och självmordstankar.
    • När det gäller diskriminering och rasism uppger en betydande andel av samer i Sverige att de utsatts någon gång i livet. Liksom för andra former av våld i denna undersökning visar analysen att en högre andel samiska kvinnor (44,5 procent) utsatts jämfört med samiska män (37,0 procent).
    • HBTQ-samer är mer våldsutsatta än andra samer. Detta gäller sexuellt våld (64,6 jämfört med 30,9 procent), psykiskt våld (81,7 jämfört med 58,4 procent) och fysiskt våld (43,8 jämfört med 25,5 procent).

    De kvalitativa resultaten i korthet

    Den kvalitativa delen baseras på intervjuer med professionella som arbetar inom samhällets stödstrukturer för våldsutsatta i olika delar av den svenska delen av Sápmi.

    • Intervjustudien visar att våld mot samiska kvinnor är en fråga som behöver förstås i relation till den bredare politiska och historiska, koloniala, och könade kontext som våldet utspelar sig i.
    • Frågan om våld mot samiska kvinnor osynliggörs och beskrivs som svår att adressera – både i det samiska samhället och i majoritetssamhället.
    • Kunskapen om det samiska samhället är låg inom samhällets stödstrukturer. Deltagare beskrev att samiska perspektiv saknas i styrdokument kring mäns våld mot kvinnor och i befintlig terminologi. Detta gör att förhållanden i det samiska samhället som kan påverka den våldsutsattas situation negligeras i mötet med samiska klienter, patienter och brukare som utsätts för våld.
    • Frågan om våld mot samiska kvinnor beskrevs som ”känslig” och ”laddad”. Sammantaget framträder ett stigma kring frågan och en oro för att ”göra fel” eller bidra till fördomar och rasism mot samer, både i det samiska samhället och majoritetssamhället.
    • Problemet med våld mot samiska kvinnor beskrevs som svår att adressera inom en redan marginaliserad samisk kontext, där värnandet av samiska kollektiva rättigheter har prioriterats.
    • Det finns en rad särskilda förhållanden knutna till det samiska samhället som är viktiga att ha kunskap om och vara lyhörd för i mötet med våldsutsatta samiska personer och i arbetet för att motverka våld mot samiska kvinnor.
    • Närheten och lokalkännedomen i mindre samhällen beskrevs som styrkor, men samtidigt lyftes utmaningar såsom bristande anonymitet, resurser, kompetens och insatser. Svårigheten att vara anonym och långa geografiska avstånd till samhällets stöd beskrevs som extra påtagligt i det samiska samhället. Stark samhörighet i det samiska samhället beskrevs som positivt men också potentiellt problematiskt när det gäller den utsattas situation.
    • Bristande tillit till myndigheter bland samer är en potentiell barriär för att nå och stötta våldsutsatta samiska kvinnor. Den bristande tilliten relaterades till både historiska och samtida erfarenheter av okunskap, förtryck, rasism och diskriminering.
    • Deltagare beskrev ojämställdhet och tystnad kring våld mot kvinnor i det samiska samhället, och att våld mot kvinnor ofta hanteras internt. Tystnaden knöts till en lojalitet med samiska män, ett ideal att samiska kvinnor ska vara starka och klara sig själva, samt en vilja att skydda familjen och det samiska kollektivet.
    • Ett centralt hinder för utsatta kvinnor att lämna en våldsam relation beskrevs vara rädslan för att uppbrottet skulle innebära förlust av deras samiska sammanhang. Ens samiska identitet beskrevs till exempel som nära knuten till platsen och markerna och därmed som svår att upprätthålla vid flytt till en annan ort för att söka skydd.

    Åtgärdsförslag till Sveriges regering

    Baserat på de utvecklingsbehov som identifierats genom detta forskningsprojekt utmynnar rapporten i fem åtgärdsförslag riktade till den svenska regeringen.

    1. Uppdra åt Sametinget att följa upp och samordna arbetet för att motverka våld mot samiska kvinnor.
    2. Utforma en nationell policy för att motverka våld mot samiska kvinnor.
    3. Utveckla stödstrukturer för våldsutsatta samiska kvinnor och flickor.
    4. Genomför kortsiktiga utbildningsinsatser.
    5. Säkra långsiktig kunskapsproduktion och kompetenshöjning.
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  • 29.
    Brattlöf, Frida
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Prevalence and change in social inequalities in physical activity before and during the COVID-19 pandemic in Sweden2023In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 22, no 1, article id 21Article in journal (Refereed)
    Abstract [en]

    Background: Physical activity is crucial for our wellbeing. Since the COVID-19 pandemic emerged, physical activity behaviour has changed globally, and social inequalities that already exist in physical activity have increased. However, there is limited knowledge of how these inequalities have evolved in Sweden. Thus, the aim of this study was to assess the prevalence of physical activity, and the socioeconomic inequalities in physical activity before and during the COVID-19 pandemic.

    Methods: This study analysed data from the national ‘Health on Equal Terms’ survey which was conducted on participants between 16 and 84, through a repeated cross-sectional design in 2018 (pre-pandemic) and 2021 (during the pandemic). The socioeconomic variables included gender, age, education, occupation, income, and place of birth. For both years, the prevalence of low physical activity, the absolute risk differences, the slope index of inequality, and the slope index difference for each of the variables were calculated.

    Results: The level of physical activity increased for the total population studied. However, the social inequalities that existed in 2018 increased over time and across age, education, occupation, income, and place of birth, but not with regard to gender.

    Conclusions: Even though the Swedish population increased their levels of physical activity during the COVID-19 pandemic, the social inequalities that already existed in physical activity increased. Interventions to increase the level of physical activity among the young, people with low socioeconomic status, and those born outside Sweden are needed to reduce these social inequalities, and to improve the Swedish population’s wellbeing.

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  • 30.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighbourhood unemployment and functional somatic symptoms2017In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 43, p. 113-120Article in journal (Refereed)
    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.

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  • 31.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Does contextual unemployment matter for health status across the life course?2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no Suppl 1, p. 142-142Article in journal (Refereed)
    Abstract [en]

    Background: Individual health is affected by one’s individual life conditionsand by the context in which individuals live, interact anddevelop. Research shows that living in a neighbourhood withhigh levels of unemployment might affect residents’ health, atleast partially independent of own labour market status.However, how such contextual-individual transactions playout across the life course is unknown. The present study aims:(i) to examine whether neighbourhood unemployment isrelated to health status across the life course independently ofthe individual employment from adolescence to middle age(age 16 to 42); and (ii) to analyse whether this relationship isobservable at four specific life course periods from adolescenceto middle age (age 16, 21, 30 and 42).

    Methods: A 26-year prospective Swedish cohort (n = 1010), linked toregister data on neighbourhood unemployment. Individualemployment and functional somatic symptoms were measuredby self-reported questionnaire data. Two models of hierarchallinear regressions were built: a longitudinal analysis, and a setof age-specific cross-sectional analyses at each age.

    Results: The longitudinal analysis showed an independent contributionof neighbourhood unemployment and individual employmenton FSS across the life course. The cross-sectional analysisshowed an association at age 30, when accounting forindividual employment, but no association was found at age21 and 42.

    Conclusions: Neighbourhood unemployment has a significant relationshipwith functional somatic symptoms across the life course. Thereseems to be an age-specific pattern where neighbourhoodunemployment may have stronger implications in earlyadulthood than in other phases of the life course

    Key messages:

    • High neighbourhood unemployment predicts higher levelsof individual FSS across the life course, independently ofown labour market position, socioeconomic status andeducation
    • These findings stress the importance of neighbourhoodunemployment for current health status as well as development of health status across the life course, particular duringearly adulthood
  • 32.
    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 University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health2018In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, no 59, article id 59Article in journal (Refereed)
    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.

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  • 33.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The impact of economic recession on the association between youth unemployment and functional somatic symptoms in adulthood: a difference-in-difference analysis from Sweden2016In: BMC Public Health, E-ISSN 1471-2458, Vol. 16, article id 230Article in journal (Refereed)
    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.

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  • 34. Buitron, Diego
    et al.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    [Nutritional status of Naporuna children under five in the Amazon region of Ecuador]2004In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 15, no 3, p. 151-9Article in journal (Other academic)
  • 35.
    Coe, Anna-Britt
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Understanding how young people do activism: Youth strategies on sexual health in Ecuador and Peru2015In: Youth & society, ISSN 0044-118X, E-ISSN 1552-8499, Vol. 47, no 1, p. 3-28Article in journal (Refereed)
    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.

  • 36.
    Cordoba-Dona, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 1Delegación Territorial de Igualdad, Salud y Políticas Sociales de Andalucía.
    Escolar-Pujolar, Antonio
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    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 unemployment2016In: BMC Public Health, E-ISSN 1471-2458, Vol. 16, article id 267Article in journal (Refereed)
    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.

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  • 37.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Delegación Territorial de la Consejería de Salud de la Junta de Andalucía, Cádiz, Spain.
    Escolar-Pujolar, Antonio
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain2018In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 3, article id e0195293Article in journal (Refereed)
    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.

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  • 38.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    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 University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain2014In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, article id 55Article in journal (Refereed)
    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.

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  • 39.
    Daca, Chanvo S. L.
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Directorate of Planning and Cooperation, Ministry of Health, Maputo, Mozambique; Centre for African Studies, Universidade Eduardo Mondlane, Maputo, Mozambique.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Arnaldo, Carlos
    Centre for African Studies, Universidade Eduardo Mondlane, Maputo, Mozambique.
    Schumann, Barbara
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden.
    Namatovu, Fredinah
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 1007Article in journal (Refereed)
    Abstract [en]

    Background: Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed.

    Objective: The present study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique.

    Methods: The study was based on repeated cross-sectional surveys from nationally representative samples: the Survey of Indicators on Immunisation, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015 and the 2018 Malaria Indicator survey. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage of three indicators: insecticide-treated net use, fever treatment of children, and use of Fansidar malaria prophylaxis for pregnant women. Absolute risk differences and the slope index of inequality (SII) were calculated for the 2015 survey period and the 2018 survey period, respectively. An interaction term between the socioeconomic and geographical variables and the period was included to assess inequality changes between 2015 and 2018.

    Results: The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. Significant reductions in the inequality related to insecticide-treated net use were observed for all socioeconomic variables. Concerning fever treatment, some reductions in socioeconomic inequalities were observed, though not statistically significant. For malaria prophylaxis, the SII was significant for education, wealth, and residence in both periods, but no significant inequality reductions were observed in any of these variables over time.

    Conclusions: We observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. Decision-makers should target underserved populations, specifically the non-educated, poor, and rural women, to address inequalities in health care coverage.

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  • 40.
    Daca, Chanvo
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Ministry of Health, Directorate of Planning and Cooperation, Maputo, Mozambique.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Arnaldo, Carlos
    Universidade Eduardo Mondlane, Maputo, Mozambique.
    Schumann, Barbara
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Socio-economic and demographic factors associated with reproductive and child health preventive care in Mozambique: a cross-sectional study2020In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, no 1, article id 200Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reproductive and child health interventions are essential to improving population health in Africa. In Mozambique, although some progress on reproductive and child health has been made, knowledge of social inequalities in health and health care is lacking.

    OBJECTIVE: To investigate socio-economic and demographic inequalities in reproductive and child preventive health care as a way to monitor progress towards universal health coverage.

    METHODS: A cross-sectional study was conducted, using data collected from the 2015 Immunization, AIDS and Malaria Indicators Survey (IMASIDA) in Mozambique. The sample included 6946 women aged 15 to 49 years. Outcomes variables were the use of insecticide treated nets (ITN) for children under 5 years, full child immunization and modern contraception use, while independent variables included age, marital status, place of residence, region, education, occupation, and household wealth index. Prevalence ratios (PR) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship between the socio-economic and demographic characteristics and the three outcomes of interest.

    RESULTS: The percentage of mothers with at least one child under 5 years that did not use ITN was 51.01, 46.25% of women had children aged 1 to 4 years who were not fully immunized, and 74.28% of women were not using modern contraceptives. Non-educated mothers (PR = 1.33; 95% CI: 1.16-1.51) and those living in the Southern region (PR = 1.36; 95% CI: 1.17-1.59) had higher risk of not using ITN, while the poorest quintile (PR = 1.34; 95% CI: 1.04-1.71) was more likely to have children who were not fully immunized. Similarly, non-educated women (PR = 1.17; 95% CI: 1.10-1.25), non-working women (PR = 1.09; 95% CI: 1.04-1.16), and those in the poorest quintile (PR = 1.13; 95% CI: 1.04-1.24) had a higher risk of not using modern contraceptives.

    CONCLUSION: Our study showed a low rate of ITN utilization, immunization coverage of children, and modern contraceptive use among women of reproductive age. Several socio-economic and demographics factors (region, education, occupation, and wealth) were associated with these preventive measures. We recommend an equity-oriented resource allocation across regions, knowledge dissemination on the importance of ITN and contraceptives use, and an expansion of immunization services to reach socio-economically disadvantaged families in order to achieve universal health coverage in Mozambique.

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  • 41.
    Daca, Chanvo
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Cooperation, Ministry of Health, Directorate of Planning and Cooperation, Maputo, Mozambique.
    Schumann, Barbara
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Arnaldo, Carlos
    Universidade Eduardo Mondlane, Maputo, Mozambique.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Wealth inequalities in reproductive and child health preventive care in Mozambique: a decomposition analysis2022In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 15, no 1, article id 2040150Article in journal (Refereed)
    Abstract [en]

    Background: Assessing the gap between rich and poor is important to monitor inequalities in health. Identifying the contribution to that gap can help policymakers to develop interventions towards decreasing that difference.

    Objective: To quantify the wealth inequalities in health preventive measures (bed net use, vaccination, and contraceptive use) to determine the demographic and socioeconomic contribution factors to that inequality using a decomposition analysis.

    Methods: Data from the 2015 Immunisation, Malaria and AIDs Indicators Survey were used. The total sample included 6946 women aged 15–49 years. Outcomes were use of insecticide-treated nets (ITN), child vaccination, and modern contraception use. Wealth Index was the exposure variable and age, marital status, place of residence, region, education, occupation, and household wealth index were the explanatory variables. Wealth inequalities were assessed using concentration indexes (Cindex). Wagstaff-decomposition analysis was conducted to assess the determinants of the wealth inequality.

    Results: The Cindex was −0.081 for non-ITN, −0.189 for lack of vaccination coverage and −0.284 for non-contraceptive use, indicating a pro-poor inequality. The results revealed that 88.41% of wealth gap for ITN was explained by socioeconomic factors, with education and wealth playing the largest roles. Lack of full vaccination, socioeconomic factors made the largest contribution, through the wealth variable, whereas geographic factors came next. Finally, the lack of contraceptive use, socioeconomic factors were the main explanatory factors, but to a lesser degree than the other two outcomes, with wealth and education contributing most to explaining the gap.

    Conclusion: There was a pro-poor inequality in reproductive and child preventive measures in Mozambique. The greater part of this inequality could be attributed to wealth, education, and residence in rural areas. Resources should be channeled into poor and non-educated rural communities to tackle these persistent inequities in preventive care.

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  • 42.
    Degerlund Maldi, Kinza
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Jonsson, Frida
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Widespread and widely widening?: Examining absolute socioeconomic health inequalities in northern Sweden across twelve health indicators2019In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, article id 197Article in journal (Refereed)
    Abstract [en]

    Background: Socioeconomic inequalities in health is a widely studied topic. However, epidemiological research tends to focus on one or a few outcomes conditioned on one indicator, overlooking the fact that health inequalities can vary depending on the outcome studied and the indicator used. To bridge this gap, this study aims to provide a comprehensive picture of the patterns of socioeconomic health inequalities in Northern Sweden over time, across a range of health outcomes, using an 'outcome-wide' epidemiological approach.

    Method: Cross-sectional data from three waves of the 'Health on Equal Terms' survey, distributed in 2006, 2010 and 2014 were used. Firstly, socioeconomic inequalities by income and education for twelve outcomes (self-rated health, self-rated dental health, overweight, hypertension, diabetes, long-term illness, stress, depression, psychological distress, smoking, risky alcohol consumption, and physical inactivity) were examined by calculating the Slope Index of Inequality. Secondly, time trends for each outcome and socioeconomic indicator were estimated.

    Results: Income inequalities increased for psychological distress and physical inactivity in men as well as for selfrated health, overweight, hypertension, long-term illness, and smoking among women. Educational inequalities increased for hypertension, long-term illness, and stress (the latter favouring lower education) in women. The only instance of decreasing income inequalities was seen for long-term illness in men, while education inequalities decreased for long-term illness in men and poor self-rated health, poor self-rated dental health, and smoking in women.

    Conclusion: Patterns of absolute socioeconomic inequalities in health vary by health and socioeconomic indicator, as well as between men and women. Overall, trends appear more stagnant in men while they fluctuate in women. Income inequalities seem to be generally greater than educational inequalities when looking across several different health indicators, a message that can only be derived from this type of outcome-wide study. These disparate findings suggest that generalised and universal statements about the development of health inequalities can be too simplistic and potentially misleading. Nonetheless, despite inequalities being complex, they do exist and tend to increase. Thus, an outcome-wide approach is a valuable method which should be utilised to generate evidence for prioritisations of policy decisions

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  • 43. Dei, Vincent
    et al.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Is healthcare really equal for all?: Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians2018In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, article id 86Article in journal (Refereed)
    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.

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  • 44.
    Dresse, Menayit Tamrat
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Stoor, Jon Petter A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Centre for Sámi Health Research, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nilsson, Lena Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Arctic Research Centre at Umeå University. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Umeå University, Faculty of Arts, Várdduo – Centre for Sámi Research.
    Prevalence and factors associated with healthcare avoidance during the COVID-19 pandemic among the Sámi in Sweden: the SámiHET study2023In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 82, no 1, article id 2213909Article in journal (Refereed)
    Abstract [en]

    The aim of this population-based cross-sectional study was to assess the prevalence of healthcare avoidance during the COVID-19 pandemic and its associated factors among the Sámi population in Sweden. Data from the “Sámi Health on Equal Terms” (SámiHET) survey conducted in 2021 were used. Overall, 3,658 individuals constituted the analytical sample. Analysis was framed using the social determinants of health framework. The association between healthcare avoidance and several sociodemographic, material, and cultural factors was explored through log-binomial regression analyses. Sampling weights were applied in all analyses. Thirty percent of the Sámi in Sweden avoided healthcare during the COVID-19 pandemic. Sámi women (PR: 1.52, 95% CI: 1.36–1.70), young adults (PR: 1.22, 95% CI:1.05–1.47), Sámi living outside Sápmi (PR: 1.17, 95% CI: 1.03–1.34), and those having low income (PR: 1.42, 95% CI:1.19–1.68) and experiencing economic stress (PR: 1.48, 95% CI: 1.31–1.67) had a higher prevalence of healthcare avoidance. The pattern shown in this study can be useful for planning future pandemic responses, which should address healthcare avoidance, particularly among the identified vulnerable groups, including the active participation of the Sámi themselves.

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  • 45.
    Edeby, Agnes
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Prevalence and sociogeographical inequalities of violence against women in Ecuador: a cross-sectional study2021In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 20, no 1, article id 130Article in journal (Refereed)
    Abstract [en]

    Background: Violence against women (VAW) is a vast public health problem in Latin America. The aim of this study was to determine the prevalence of violence against women and to assess its sociogeographical inequalities in Ecuador during 2019.

    Methods: This cross-sectional study used data from a national survey conducted in 2019 (n = 17,211) among women aged 15 years and over. Independent variables included age, marital status, education, ethnicity, place of residence and region. The chosen outcomes were lifetime experience of total violence, sexual violence, physical violence, psychological violence and economic violence. Frequency tables were first calculated, and then crude and adjusted regression models estimating risk differences and their 95% confidence intervals were computed.

    Results: Nearly two-thirds (64.86%) of the participating women had experienced some form of violence during their lifetime, mainly psychological violence (56.92%). The second most prevalent type of violence was physical (35.44%) closely followed by sexual (32.67%). Almost one-fifth (16.38%) stated to have experienced some form of economic violence. Physical and psychological violence were more common among women aged 26–35 and less among older women. All forms of violence were more often reported among women with no education except for sexual violence, which was more frequent among those with higher education. Physical, psychological and economic violence were more often reported by those living with a partner, being married or divorced/separated. Sexual violence was associated with those belonging to a non-indigenous ethnic group, while all types of violence were more common among those living in an urban setting (except physical violence), in the Highlands or in the Amazon region.

    Conclusions: Our study showed that VAW is a common event in Ecuador and identified several sociogeographical inequalities that varied depending on the type of violence. VAW was more common among the younger age groups, those with low education, those living with a partner or being divorced/separated, or residing in an urban setting, in the Highlands or in the Amazon. Further studies including more social factors and a continuous monitoring of VAW are recommended. Current policies and laws to protect women need to be expanded and effectively implemented to reduce VAW in the Ecuador.

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  • 46.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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 University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Illanes, Daniel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessment of a Leishmaniasis Reporting System in Tropical Bolivia Using the Capture-Recapture Method2018In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 98, no 1, p. 134-138Article in journal (Refereed)
    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.

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  • 47.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Biomedical Research, Faculty of Medicine, San Simon University, Aniceto Arce Avenue 371, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Rojas, Ernesto
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Illanes, Daniel
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Risk factors for cutaneous leishmaniasis in the rainforest of Bolivia: a cross-sectional study2018In: Tropical Medicine and Health, ISSN 1348-8945, E-ISSN 1349-4147, Vol. 46, article id 9Article in journal (Refereed)
    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.

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  • 48.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach2019In: BMC International Health and Human Rights, E-ISSN 1472-698X, Vol. 19, no 1, article id 12Article in journal (Refereed)
    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.

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  • 49.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    "Cheaper and better": an economic analysis of changing first line treatment for cutaneous leishmaniasis in BoliviaManuscript (preprint) (Other academic)
    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.

  • 50.
    Eid Rodríguez, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    "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 Bolivia2019In: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 13, no 11, article id e0007788Article in journal (Refereed)
    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.

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