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  • 1.
    Amroussia, Nada
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Reproductive health policy in Tunisia: women's right to reproductive health and gender empowerment2016Ingår i: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 18, nr 2, s. 183-194Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia's reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country's reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government's lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia.

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  • 2.
    Amroussia, Nada
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "Is the doctor God to punish me?!": An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia2017Ingår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, artikel-id 32Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia.

    METHODS: This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes.

    RESULTS: Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care.

    CONCLUSION: Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination.

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  • 3.
    Birabwa, Catherine
    et al.
    Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Chemonges, Dennis
    Department of Programs, Population Services International Uganda, Kampala, Uganda; Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; School of Pharmacy, Waterloo University, Waterloo, ON, Canada.
    Baroudi, Mazen
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Namatovu, Fredinah
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Akuze, Joseph
    Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Makumbi, Fredrick
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Atuyambe, Lynn
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Sewe, Maquins Odhiambo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Knowledge and information exposure about family planning among women of reproductive age in informal settlements of Kira municipality, Wakiso district, Uganda2021Ingår i: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, artikel-id 650538Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda.

    Methods: Using a cross-sectional study design, we interviewed 626 women aged 15–49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance.

    Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24–1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01–2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37–4.54) were more likely to have contact with a provider to discuss FP.

    Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

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  • 4.
    Hernandez, Alison
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Jerez, Fernando
    Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala.
    Flores, Walter
    Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala.
    'History obligates us to do it': political capabilities of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala2022Ingår i: BMJ Global Health, E-ISSN 2059-7908, Vol. 7, nr 5, artikel-id e008530Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Growing interest in how marginalised citizens can leverage countervailing power to make health systems more inclusive and equitable points to the need for politicised frameworks for examining bottom-up accountability initiatives. This study explores how political capabilities are manifested in the actions and strategies of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. Qualitative data were gathered through group discussions and interviews with initiative leaders (called defenders of the right to health) and initiative collaborators in three municipalities. Analysis was oriented by three dimensions of political capabilities proposed for evaluating the longer-term value of participatory development initiatives: political learning, reshaping networks and patterns of representation. Our findings indicated that the defenders' political learning began with actionable knowledge about defending the right to health and citizen participation. The defenders used their understanding of local norms to build trust with remote Indigenous communities and influence them to participate in monitoring to attempt to hold the state accountable for the discriminatory and deficient healthcare they received. Network reshaping was focused on broadening their base of support. Their leadership strategies enabled them to work with other grassroots leaders and access resources that would expand their reach in collective action and lend them more influence representing their problems beyond the local level. Patterns of representing their interests with a range of local and regional authorities indicated they had gained confidence and credibility through their evolving capability to navigate the political landscape and seek the right authority based on the situation. Our results affirm the critical importance of sustained, long-term processes of engagement with marginalised communities and representatives of the state to enable grassroots leaders of accountability initiatives to develop the capabilities needed to mobilise collective action, shift the terms of interaction with the state and build more equitable health systems.

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  • 5.
    Hernández, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Enabling the performance of nurses in rural Guatemala: the role of relationships2014Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions.

    Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs.

    Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance.

    Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

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  • 6.
    Hernández, Alison
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Supporting the performance of rural nurses: a concept mapping study with regional health system actors in GuatemalaManuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

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

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

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

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

  • 7.
    Hernández, Alison
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala2012Ingår i: ISRN Nursing, ISSN 2090-5483, E-ISSN 2090-5491, Vol. 2012, s. 648769-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

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  • 8.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala2015Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, artikel-id 91Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

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  • 9.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala2014Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, nr 1, s. 112-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

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  • 10.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis2014Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, s. 23190-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

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  • 11.
    Mulubwa, Chama
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
    Munakampe, Margarate Nzala
    Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
    Namakula, Hilda
    Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Ssekamatte, Tonny
    Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Atuyambe, Lynn M.
    Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, College of Health Sciences New Mulago Hospital Complex, Kampala, Uganda.
    Birabwa, Catherine
    Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Chemonges, Denis
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Namatovu, Fredinah
    Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR). Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Makumbi, Fredrick
    Department of Epidemiology and Biostatistics, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda; School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.
    Framing contraceptive use motivations among adolescents and young adults living in informal settlements in Kira municipality, Wakiso district, Uganda2021Ingår i: Epidemiologic Methods, ISSN 2194-9263, E-ISSN 2161-962X, Vol. 2, artikel-id 658515Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not).

    Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda.

    Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives.

    Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

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  • 12.
    Ruano, Ana Lorena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernández, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala2012Ingår i: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 70, s. 18-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s healthissues required more than just hospital-based and physician-centered policies. The declaration called for a paradigmchange that would allow governments to provide essential care to their population in a universally acceptablemanner. The figure of the community health worker (CHW) remains a central feature of participation within thePHC approach, and being a CHW is still considered to be an important way of participation within the healthsystem.Methods: This study explores how the values and personal motivation of community health workers influencestheir experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, weused an ethnographic approach and collected data in January-March of 2009 and 2010 by using participantobservation and in-depth interviews.Results: We found that the CHWs in the municipality had a close working relationship with the mobile health teamand with the community, and that their positions allowed them to develop leadership and teamwork skills that mayprove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is akey value in Palencia, but there is a lack of infrastructure and growth opportunities.Conclusion: Attention should be paid to keeping the high levels of commitment and integration within the healthteam as well as keeping up supervision and economic funds for the program.

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    'It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala
  • 13.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. School of Pharmacy, University of Waterloo, Waterloo, ON, Canada; Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Jonsson, Frida
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Whyle, Eleanor
    School of Public Health & Family Medicine (SPHFM), University of Cape Town, Cape Town, South Africa.
    Zulu, Joseph
    School of Public Health & Family Medicine (SPHFM), University of Cape Town, Cape Town, South Africa.
    Schneider, Helen
    School of Public Health, University of the Western Cape, Cape Town, South Africa; South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Centre for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala.
    Strengthening Research and Practice in Community Health Systems: A Research Agenda and Manifesto2022Ingår i: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 11, nr 1, s. 17-23Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a 'manifesto' on strengthening research and practice in the CHS. The CHS research agenda domains were developed through a modified concept mapping process with a team of 33 experts on the CHS including policy-makers, implementers and researchers from institutions in six countries: Uganda, Guatemala, South Africa, Sweden, Tanzania and Zambia. The process began remotely with brainstorming research priorities and concluded in a one-week workshop that was held in Zambia where priorities for strengthening CHS were discussed, grouped into domains, interpreted, and drafted into a collective declaration. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies forresearching the CHS. By harnessing a set of diverse and rich experiences and perspectives on CHS through a structured process, a multifaceted research agenda and manifesto that transcend context, disciplines and time were developed. We posit this as an entry into greater debate and diversity in the field as we continue to find ways to strengthen research and practice in the CHS. 

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  • 14. Vives-Cases, Carmen
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sanz-Barbero, Belen
    Gill, Aisha K.
    Baldry, Anna Costanza
    Schroettle, Monika
    Stoeckl, Heidi
    Expert Opinions on Improving Femicide Data Collection across Europe: A Concept Mapping Study2016Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 11, nr 2, artikel-id e0148364Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Femicide, defined as the killings of females by males because they are females, is becoming recognized worldwide as an important ongoing manifestation of gender inequality. Despite its high prevalence or widespread prevalence, only a few countries have specific registries about this issue. This study aims to assemble expert opinion regarding the strategies which might feasibly be employed to promote, develop and implement an integrated and differentiated femicide data collection system in Europe at both the national and international levels. Concept mapping methodology was followed, involving 28 experts from 16 countries in generating strategies, sorting and rating them with respect to relevance and feasibility. The experts involved were all members of the EU-Cost-Action on femicide, which is a scientific network of experts on femicide and violence against women across Europe. As a result, a conceptual map emerged, consisting of 69 strategies organized in 10 clusters, which fit into two domains: "Political action" and "Technical steps". There was consensus among participants regarding the high relevance of strategies to institutionalize national databases and raise public awareness through different stakeholders, while strategies to promote media involvement were identified as the most feasible. Differences in perceived priorities according to the level of human development index of the experts' countries were also observed.

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  • 15. Vives-Cases, Carmen
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernández, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sanz-Barbero, Belen
    Davó-Blanes, MCarmen
    La Parra-Casado, Daniel
    Priorities and strategies for improving Roma women's access to primary health care services in cases on intimate partner violence: a concept mapping study2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 96Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: With an explicit focus on Roma women in Spain (Kale/Spanish Gypsies), this study aims to integrate key informants' opinions about the main actions needed to improve primary health care services' and professionals' responses to Roma women in an Intimate Partner Violence (IPV) situation. Methods: Concept mapping study. A total of 50 (brainstorming phase), 36 (sorting and rating phase) and 16 (interpretation phase) participants from Roma civil society groups, primary health care professionals and other related stakeholders (social services, academic experts and other IPV NGOs representatives) from different cities in Spain were involved in the different study phases. Results: Among the 55 action proposals generated, ten priority actions were identified through consensus as most important for improving primary health care's response to Romani women in an IPV situation, and these included primary, secondary and tertiary prevention activities. Conclusion: Results indicated that efforts to address this challenge should take an integrated approach that reinforces the primary health care response to IPV in general, while also promoting more specific actions to address barriers to access that affect all Roma women and those who experience IPV in particular.

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