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  • 1.
    Abeid, Muzdalifat
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili University of Health and Allied Sciences, Tanzania.
    Muganyizi, Projestine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili University of Health and Allied Sciences, Tanzania.
    Mpembeni, Rose
    Muhimbili University of Health and Allied Sciences, Tanzania.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian University of Science and Technology, Trondheim, Norway.
    Axemo, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    A community-based intervention for improving health-seeking behavior among sexual violence survivors: A controlled before and after design study in rural Tanzania2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 28608Article in journal (Refereed)
    Abstract [en]

    Background: Despite global recognition that sexual violence is a violation of human rights, evidence still shows it is a pervasive problem across all societies. Promising community intervention studies in the low- and middle-income countries are limited.

    Objective: This study assessed the impact of a community-based intervention, focusing on improving the community’s knowledge and reducing social acceptability of violence against women norms with the goal to prevent and respond to sexual violence.

    Design: The strategies used to create awareness included radio programs, information, education communication materials and advocacy meetings with local leaders. The intervention took place in Morogoro region in Tanzania. The evaluation used a quasi-experimental design including cross-sectional surveys at baseline (2012) and endline (2014) with men and women aged 18-49. Main outcome measures were number of reported rape cases at health facilities and the community’s knowledge and attitudes towards sexual violence.

    Results: The number of reported rape events increased by more than 50% at health facilities during the intervention. Knowledge on sexual violence increased significantly in both areas over the study period (from 57.3% to 80.6% in the intervention area and from 55.5% to 71.9% in the comparison area; p<.001), and the net effect of the intervention between the two areas was statistically significant (6.9, 95% CI 0.2–13.5, p= 0.03). There was significant improvement in most of attitude indicators in the intervention area, but not in the comparison area. However, the intervention had no significant effect in the overall scores of acceptance attitudes in the final assessment when comparing the two areas (-2.4, 95%CI: -8.4 – 3.6, p= 0.42).

    Conclusions: The intervention had an effect on some indicators on knowledge and attitudes towards sexual violence even after a short period of intervention. This finding informs the public health practitioners of the importance of combined strategies in achieving changes.

  • 2.
    Abeid, Muzdalifat
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). MUHAS, Dept Obstet Gynecol, Dar Es Salaam, Tanzania.
    Muganyizi, Projestine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). MUHAS, Dept Obstet Gynecol, Dar Es Salaam, Tanzania.
    Mpembeni, Rose
    MUHAS, Dept Epidemiol & Biostat, Dar Es Salaam, Tanzania.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian Univ Sci & Technol, Dept Publ Hlth & Gen Practice, Trondheim, Norway.
    Axemo, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Evaluation of a training program for health care workers to improve the quality of care for rape survivors: a quasi-experimental design study in Morogoro, Tanzania2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 31735Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND:

    Sexual violence against women and children in Tanzania and globally is a human rights violation and a developmental challenge.

    OBJECTIVE:

    The aim of this study was to assess the impact of training health professionals on rape management. The specific objectives were to evaluate the changes of knowledge and attitudes toward sexual violence among a selected population of health professionals at primary health care level.

    DESIGN:

    A quasi-experimental design using cross-sectional surveys was conducted to evaluate health care workers' knowledge, attitude, and clinical practice toward sexual violence before and after the training program. The study involved the Kilombero (intervention) and Ulanga (comparison) districts in Morogoro region. A total of 151 health professionals at baseline (2012) and 169 in the final assessment (2014) participated in the survey. Data were collected using the same structured questionnaire. The amount of change in key indicators from baseline to final assessment in the two areas was compared using composite scores in the pre- and post-interventions, and the net intervention effect was calculated by the difference in difference method.

    RESULTS:

    Overall, there was improved knowledge in the intervention district from 55% at baseline to 86% and a decreased knowledge from 58.5 to 36.2% in the comparison area with a net effect of 53.7% and a p-value less than 0.0001. The proportion of participants who exhibited an accepting attitude toward violence declined from 15.3 to 11.2% in the intervention area but increased from 13.2 to 20.0% in the comparison area.

    CONCLUSIONS:

    Training on the management of sexual violence is feasible and the results indicate improvement in healthcare workers' knowledge and practice but not attitudes. Lessons learned from this study for successful replication of such an intervention in similar settings require commitment from those at strategic level within the health service to ensure that adequate resources are made available.

  • 3. AbouZahr, Carla
    et al.
    Boerma, Ties
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Sch Publ Hlth, Johannesburg, South Africa ; Univ Aberdeen, Inst Appl Hlth Sci, Aberdeen, Scotland.
    Bridging the data gaps: do we have the right balance between country data and global estimates?2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1299978Article in journal (Refereed)
  • 4.
    Adams, Emma A.
    et al.
    Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, NO-7491 Trondheim, Norway;Ontario Shores Ctr Mental Hlth Sci, Strateg Initiat, Whitby, ON, Canada.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, NO-7491 Trondheim, Norway;St Olavs Univ Hosp, Dept Obstet & Gynecol, Trondheim, Norway.
    Wijewardene, Kumudu
    Univ Sri Jayewardenepura, Fac Med Sci, Dept Community Med Hlth, Nugegoda, Sri Lanka.
    Infanti, Jennifer J.
    Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, NO-7491 Trondheim, Norway.
    Perceptions on the sexual harassment of female nurses in a state hospital in Sri Lanka: a qualitative study2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1560587Article in journal (Refereed)
    Abstract [en]

    Background:

    Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings.

    Objective:

    To explore female nurses' perceptions of workplace sexual harassment in a large state hospital in Sri Lanka.

    Methods:

    This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups.

    Results:

    The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital.

    Conclusions:

    Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

  • 5.
    Adcock, Joanna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Overseas Development Institute, London, UK.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    The North-South information highway: case studies of publication access among health researchers in resource-poor countries2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1Article in journal (Refereed)
    Abstract [en]

    Background: Less than 2% of scientific publications originate in low-income countries. Transfer of information from South to North and from South to South is grossly limited and hinders understanding of global health, while Northern-generated information fails to adequately address the needs of a Southern readership.

    Methods: A survey of a new generation of health researchers from nine low-income countries was conducted using a combination of email questionnaires and face-to-face interviews. Data were gathered on personal experiences, use and aspirations regarding access and contribution to published research.

    Results: A total of 23 individuals from 9 countries responded. Preference for journal use over textbooks was apparent, however a preference for print over online formats was described among African respondents compared to respondents from other areas. Almost all respondents (96%) described ambition to publish in international journals, but cited English language as a significant barrier.

    Conclusion: The desire to contribute to and utilise contemporary scientific debate appears to be strong among study respondents. However, longstanding barriers

  • 6. Adlard, B.
    et al.
    Donaldson, S. G.
    Odland, J. O.
    Weihe, P.
    Berner, J.
    Carlsen, A.
    Bonefeld-Jorgensen, E. C.
    Dudarev, A. A.
    Gibson, J. C.
    Krümmel, E. M.
    Olafsdottir, K.
    Abass, K.
    Rautio, A.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Mulvad, G.
    Future directions for monitoring and human health research for the Arctic Monitoring and Assessment Programme2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1480084Article in journal (Refereed)
    Abstract [en]

    For the last two and a half decades, a network of human health experts under the Arctic Monitoring and Assessment Program (AMAP) has produced several human health assessment reports. These reports have provided a base of scientific knowledge regarding environmental contaminants and their impact on human health in the Arctic. These reports provide scientific information and policy-relevant recommendations to Arctic governments. They also support international agreements such as the Stockholm Convention on Persistent Organic Pollutants (POPs) and the Minamata Convention on Mercury. Key topics discussed in this paper regarding future human health research in the circumpolar Arctic are continued contaminant biomonitoring, health effects research and risk communication. The objective of this paper is to describe knowledge gaps and future priorities for these fields.

  • 7. Ahmed, Syed Masud
    et al.
    Hadi, Abdullahel
    Razzaque, Abdur
    Ashraf, Ali
    Juvekar, Sanjay
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Indonesia.
    Kanungsukkasem, Uraiwan
    Soonthornthada, Kusol
    Van Minh, Hoang
    Huu Bich, Tran
    Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, no 1, p. 68-75Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.

    OBJECTIVES: This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine

    INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries. DESIGN: Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25-64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.

    RESULTS: Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.

    CONCLUSIONS: Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.

  • 8. Ajeani, Judith
    et al.
    Ayiasi, Richard Mangwi
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Namazzi, Gertrude
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne Namusoke
    Beyeza-Kashesya, Jolly
    A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345497Article in journal (Refereed)
    Abstract [en]

    Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

    Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

    Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

    Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

    Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

  • 9.
    Akuamoah-Boateng, Henrietta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Self-reported vision health status among older people in the Kassena-Nankana District, Ghana2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Background: If current trends continue, Ghana's aged population will increase in the coming decades. Currently, there is little knowledge on the health of the aged in Ghana. Research on vision problems among this group is virtually non-existent. This research gap needs to be filled immediately in order to promote the general health among older people in Ghana.

    Objective: The objective of the study was to analyse vision health and its determinants among the older adult population in a district in one of the poorest regions in Ghana - the Kassena-Nankana district.

    Methods: Data were obtained from the WHO multi-country studies unit (SAGE). A total of 4,294 people over the age of 50 responded to the survey. Data analysis was conducted using Stata statistical package. The aim of the analysis was to identify the prevalence of self-reported vision problems and assistive device use. Age, level of education, marital status, living arrangement, socio-economic status and proportion of people aged 50 and over in a household were used as determinants of vision health.

    Results: In total, 54 and 63% (p-value, 0.00) of men and women reported having far-sightedness, while 35% of men and 40.6% of women reported having near-sightedness (p-value, 0.00). In total, 33.5% of men and 38.6% of women reported having both near-sightedness and far-sightedness (p-value, 0.00). Of those who reported having either vision problems, 2.9% reported the use of visual assistive devices. Men had a higher assistive device use of 4.5% compared to 2.1% among women (p = 0.002). Age and household socio-economic status was positively associated with reporting vision problems and assistive device use, respectively.

    Conclusions: The results from this analysis showed that despite the high reporting of vision problems, only 2.9% reported using assistive devices. This outcome shows that there is a need to prevent vision problems and increase access to assistive devices among older people in the Kassena-Nankana district in Ghana.

  • 10.
    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.

  • 11.
    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.

  • 12. Ali, Tazeen S
    et al.
    Krantz, Gunilla
    Gul, Raisa
    Asad, Nargis
    Johansson, Eva
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 7448-Article in journal (Refereed)
    Abstract [en]

    Background: Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women’s and men’s life prospects.

    Objective: The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men’s and women’s life circumstances.

    Design: Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

    Findings: Two major themes emerged during analysis: ‘Reiteration of gender roles’ and ‘Agents of change’. The first theme included perceptions of traditional gender roles and how these preserve women’s subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

    Conclusions: This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women’s empowerment.

  • 13.
    Allvin, Marie Klingberg
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Atuhairwe, S
    Cleeve, A
    Byamugisha, J K
    Larsson, Elin C.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Makenzius, M
    Oguttu, M
    Gemzell-Danielsson, K
    Co-creation to scale up provision of simplified high-quality comprehensive abortion care in East Central and Southern Africa.2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1490106Article in journal (Refereed)
    Abstract [en]

    Universal access to comprehensive abortion care (CAC) is a reproductive right and is essential to reduce preventable maternal mortality and morbidity. In East Africa, abortion rates are consistently high, and the vast majority of all abortions are unsafe, significantly contributing to unnecessary mortality and morbidity. The current debate article reflects and summarises key action points required to continue to speed the implementation of and expand access to CAC in the East, Central, and Southern African (ECSA) health community. To ensure universal access to quality CAC, a regional platform could facilitate the sharing of best practices and successful examples from the region, which would help to visualise opportunities. Such a platform could also identify innovative ways to secure women's access to quality care within legally restrictive environments and would provide information and capacity building through the sharing of recent scientific evidence, guidelines, and training programmes aimed at increasing women's access to CAC at the lowest effective level in the healthcare system. This type of infrastructure for exchanging information and developing co-creation could be crucial to advancing the Sustainable Development Goals 2030 agenda.

  • 14. Al-Murani, F.
    et al.
    Aweko, J.
    Nordin, I.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
    Delobelle, P.
    Kasujja, Fx.
    Östenson, C.-G.
    Peterson, Stefan S.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Daivadanam, Meena
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics. Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Alvesson, HM.
    Community and stakeholders' engagement in the prevention and management of Type 2 diabetes: a qualitative study in socioeconomically disadvantaged suburbs in region Stockholm2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1609313Article in journal (Refereed)
    Abstract [en]

    Background: Community-based approaches have been identified as an effective strategy to address the growing burden of noncommunicable diseases (NCDs) worldwide. However, little is known about community as a concept among people living in socioeconomically disadvantaged settings and stakeholders’ interactions and engagement in NCDs prevention and management.

    Objective: The aim of this study was to understand; (1) the meaning of community among people living in socioeconomically disadvantaged suburbs in Region Stockholm and (2) how communities interact and engage with stakeholders at local and regional levels for the prevention and management of type 2 diabetes (T2D).

    Methods: This qualitative study was conducted in three municipalities in Region Stockholm with a high proportion of migrants. Multiple data collection methods were used, including observations of community activities; interviews with community members, representatives of public authorities and NGOs; and group interviews with healthcare providers. Data were analyzed using content analysis.

    Results: Community was perceived as living in close proximity with shared beliefs, values and resources. Although they recognized its social and cultural diversity, community members focused more on the commonalities of living in their neighborhood and less on their differences in country of birth and languages spoken. Several mismatches between awareness of community needs and the available skills and resources among stakeholders for T2D prevention were identified. Stakeholders expressed awareness of T2D risk and interest in addressing it in a culturally appropriate manner.

    Conclusion: Interaction between the communities and stakeholders was limited, as was engagement in T2D prevention and management. This highlights barriers in the collaboration between community, healthcare institutions and other stakeholders which consequently affect the implementation of preventive interventions. Innovative ways to link the community to the healthcare sector and other local government institutions are needed to build the capacity of health systems for T2D prevention in socioeconomically disadvantaged communities.

  • 15. Ameh, Soter
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Klipstein-Grobusch, Kerstin
    Predictors of health care use by adults 50 years and over in a rural South African setting2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 1-11Article in journal (Refereed)
    Abstract [en]

    Background: South Africa's epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults.

    Objective: To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa.

    Design: A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables.

    Results: Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e. g. hypertension), acute conditions (27% - e. g. flu and fever), other conditions (26% - e. g. musculoskeletal pain), chronic communicable diseases (3% - e. g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR = 5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR = 2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR = 2.49, 95% CI: 1.27, 4.86) compared with those with no formal education.

    Conclusion: Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.

  • 16.
    Amroussia, Nada
    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.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Explaining mental health inequalities in Northern Sweden: a decomposition analysis2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1305814Article in journal (Refereed)
    Abstract [en]

    Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

    Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

    Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

    Results: The overall concentration index of mental health in Northern Sweden was −0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. 

    Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

  • 17.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    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.

  • 18. Arthur, Samuelina S.
    et al.
    Nyide, Bongiwe
    Soura, Abdramane Bassiahi
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weston, Mark
    Sankoh, Osman
    Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-13, article id 28298Article, review/survey (Refereed)
    Abstract [en]

    Background: Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Objective: To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs). Methods: Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords 'nutrition', 'malnutrition', 'over and under nutrition', we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight paperswere identified and reviewed, and 67 were selected for this study. Results: The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition. Conclusions: Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

  • 19.
    Arvidsson, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Vauquline, Polly
    Department of Women's Studies, Gauhati University, Guwahati, India.
    Johnsdotter, Sara
    Faculty of Health and Society, Malmö University, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Surrogate mother – praiseworthy or stigmatized: a qualitative study on perceptions of surrogacy in Assam, India2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1328890Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Surrogacy is a reproductive practice that has been strongly marketed in India as a solution for childless couples. As a result, the number of surrogacy clinics is increasing. Meanwhile, a global discourse on surrogacy, originating from a Western perspective, has characterized surrogacy as being exploitative of women in low-income settings, where poverty drives them to become surrogate mothers.

    OBJECTIVE: This study explored perspectives on surrogacy from men and women in Assam, an Indian state known to be a low-income setting. Surrogacy arrangements in Assam are still uncommon. It can be expected that the dominant global discourses on surrogacy will be unfamiliar to the general population, and the objective was also to position the results within the divergent global discourses of surrogacy.

    METHODS:  In order to explore local views on surrogacy, we conducted individual interviews and focus group discussions with people from various socioeconomic groups in Assam.

    RESULTS: Our findings reveal that people in Assam perceive surrogacy as a good option for a childless couple, as it would result in a child who is a 'blood' relation - something highly desirable for sociocultural reasons. However, the part played by the surrogate mother complicates local views on surrogacy. Most people consider payment to the surrogate mother contrary to societal norms. A surrogate mother is also often judged in a moral light, either as a 'bad mother' for selling her child, or as a 'noble woman' who has helped a childless couple and deserves payment for her services.

    CONCLUSIONS: In order to decrease the stigmatization of women, a regulatory policy is needed that will take into account the complex understandings of surrogacy and perceptions of surrogate mothers in Indian society. In policy, the possible effect of the dominant exploitation discourse needs to be modulated by local understandings of this reproduction method.

  • 20.
    Aryal, Umesh R.
    et al.
    Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal / Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Petzold, Max
    Akademistatistik - Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Bondjers, Göran
    Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Krettek, Alexandra
    Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden / Nordic School of Public Health NHV, Gothenburg, Sweden.
    Correlates of smoking susceptibility among adolescents in a peri-urban area of Nepal: a population-based cross-sectional study in the Jhaukhel-Duwakot Health Demographic Surveillance Site2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, no 1, p. 1-14, article id 24488Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Susceptibility to smoking is defined as an absence of firm commitment not to smoke in the future or when offered a cigarette by best friends. Susceptibility begins in adolescence and is the first step in the transition to becoming an established smoker. Many scholars have hypothesized and studied whether psychosocial risk factors play a crucial role in preventing adolescent susceptibility to smoking or discourage susceptible adolescents from becoming established smokers. Our study examined sociodemographic and family and childhood environmental factors associated with smoking susceptibility among adolescents in a peri-urban area of Nepal.

    DESIGN: We conducted a population-based cross-sectional study during October-November 2011 in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) located in a peri-urban area near Kathmandu, the capital city of Nepal, where tobacco products are easily available. Trained local enumerators conducted face-to-face interviews with 352 respondents aged 14-16. We used stepwise logistic regression to assess sociodemographic and family and childhood environmental factors associated with smoking susceptibility.

    RESULTS: The percentage of smoking susceptibility among respondents was 49.70% (95% CI: 44.49; 54.93). Multivariable analysis demonstrated that smoking susceptibility was associated with smoking by exposure of adolescents to pro-tobacco advertisements (AOR [adjusted odds ratio] =2.49; 95% CI: 1.46-4.24), the teacher (2.45; 1.28-4.68), adolescents attending concerts/picnics (2.14; 1.13-4.04), and smoking by other family members/relatives (1.76; 1.05-2.95).

    CONCLUSIONS: Smoking susceptible adolescents are prevalent in the JD-HDSS, a peri-urban community of Nepal. Several family and childhood environmental factors increased susceptibility to smoking among Nepalese non-smoking adolescents. Therefore, intervention efforts need to be focused on family and childhood environmental factors with emphasis on impact of role models smoking, refusal skills in social gatherings, and discussing harmful effects of smoking with family members and during gatherings with friends.

  • 21. Ashraf, Ali
    et al.
    Quaiyum, M.A.
    Ng, Nawi
    Purworejo Health and Demographic Surveillance System, Indonesia.
    Van Minh, Hoang
    Razzaque, Abdur
    Masud Ahmed, Syed
    Hadi, Abdullahel
    Juvekar, Sanjay
    Kanungsukkasem, Uraiwan
    Soonthornthada, Kusol
    Huu Bich, Tran
    Self-reported use of tobacco products in nine rural INDEPTH Health and Demographic Surveillance Systems in Asia2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 19-27Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Tobacco use is the most preventable cause of premature death and disability. Even though tobacco use is common in many Asian countries, reliable and comparable data on the burden imposed by tobacco use in this region are sparse, and surveillance systems to track trends are in their infancy.

    OBJECTIVE: To assess and compare the prevalence of tobacco use and its associated factors in nine selected rural sites in five Asian countries.

    METHODS: Tobacco use among 9,208 men and 9,221 women aged 25-64 years in nine Health and Demographic Surveillance System (HDSS) sites in five Asian countries of the INDEPTH Network were examined in 2005 as part of a broader survey of the major chronic non-communicable disease risk factors. All sites used a standardised protocol based on the WHO STEPS approach to risk factor surveillance; expanded questions of local relevance, including chewing tobacco, were also included. Multivariable logistic regression was used to assess demographic factors associated with tobacco use.

    RESULTS: Tobacco use, whether smoked or chewed, was common across all sites with some notable variations. More than 50% of men smoked daily; this applied to almost all age groups. Few women smoked daily in any of the sites. However, women were more likely to chew tobacco than men in all sites except Vadu in India. Tobacco use in men began in late adolescence in most of the sites and the number of cigarettes smoked daily ranged from three to 15. Use of both forms of tobacco, smoked and chewed, was associated with age, gender and education. Men were more likely to smoke compared to women, smoking increased with age in the four sites in Bangladesh but not in other sites and with low level of education in all the sites.

    CONCLUSION: The prevalence of tobacco use, regardless of the type of tobacco, was high among men in all of these rural populations with tobacco use started during adolescence in all HDSS sites. Innovative communication strategies for behaviour change targeting adolescents in schools and adult men and women at work or at home, may create a mass awareness about adverse health consequences of tobacco smoking or chewing tobacco. Such efforts, to be effective, however, need to be supported by strong legislation and leadership. Only four of the five countries involved in this multi-site study have ratified the Framework Convention on Tobacco Control, and even where it has been ratified, implementation is uneven.

  • 22.
    August, Furaha
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pembe, Andrea B.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kayombo, Edmund
    Mbekenga, Columba
    Axemo, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Birth preparedness and complication readiness - a qualitative study among community members in rural Tanzania2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-U12, article id 26922Article in journal (Refereed)
    Abstract [en]

    Background: Birth preparedness and complication readiness (BP/CR) strategies are aimed at reducing delays in seeking, reaching, and receiving care. Counselling on birth preparedness is provided during antenatal care visits. However, it is not clear why birth preparedness messages do not translate to utilisation of facility delivery. This study explores the perceptions, experiences, and challenges the community faces on BP/CR. Design: A qualitative study design using Focused Group Discussions was conducted. Twelve focus group discussions were held with four separate groups: young men and women and older men and women in a rural community in Tanzania. Qualitative content analysis was used to analyse the data. Results: The community members expressed a perceived need to prepare for childbirth. They were aware of the importance to attend the antenatal clinics, relied on family support for practical and financial preparations such as saving money for costs related to delivery, moving closer to the nearest hospital, and also to use traditional herbs, in favour of a positive outcome. Community recognised that pregnancy and childbirth complications are preferably treated at hospital. Facility delivery was preferred; however, certain factors including stigma on unmarried women and transportation were identified as hindering birth preparedness and hence utilisation of skilled care. Challenges were related to the consequences of poverty, though the maternal health care should be free, they perceived difficulties due to informal user fees. Conclusions: This study revealed community perceptions that were in favour of using skilled care in BP/CR. However, issues related to inability to prepare in advance hinder the realisation of the intention to use skilled care. It is important to innovate how the community reinforces BP/CR, such as using insurance schemes, using community health funds, and providing information on other birth preparedness messages via community health workers.

  • 23.
    August, Furaha
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pembe, Andrea B.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mpembeni, Rose
    Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Axemo, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Community Health workers can improve male involvement in maternal health: Evidence from rural Tanzania2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 30064Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Male involvement in maternal health is recommended as one of the interventions to improve maternal and newborn health. There have been challenges in realising this action, partly due to the position of men in society and partly due to health system challenges in accommodating men. The aim of this study was therefore to evaluate the effect of Home Based Life Saving Skills training by community health workers on improving male involvement in maternal health in terms of knowledge of danger signs, joint decision-making, birth preparedness, and escorting wives to antenatal and delivery care in a rural community in Tanzania.

    DESIGN:

    A community-based intervention consisting of educating the community in Home Based Life Saving Skills by community health workers was implemented using one district as the intervention district and another as comparison district. A pre-/post-intervention using quasi-experimental design was used to evaluate the effect of Home Based Life Saving Skills training on male involvement and place of delivery for their partners. The effect of the intervention was determined using difference in differences analysis between the intervention and comparison data at baseline and end line.

    RESULTS:

    The results show there was improvement in male involvement (39.2% vs. 80.9%) with a net intervention effect of 41.1% (confidence interval [CI]: 28.5-53.8; p <0.0001). There was improvement in the knowledge of danger signs during pregnancy, childbirth, and postpartum periods. The proportion of men accompanying their wives to antenatal and delivery also improved. Shared decision-making for place of delivery improved markedly (46.8% vs. 86.7%), showing a net effect of 38.5% (CI: 28.0-49.1; p <0.0001). Although facility delivery for spouses of the participants improved in the intervention district, this did not show statistical significance when compared to the comparison district with a net intervention effect of 12.2% (95% CI: -2.8-27.1: p=0.103).

    CONCLUSION:

    This community-based intervention employing community health workers to educate the community in the Home Based Life Saving Skills programme is both feasible and effective in improving male involvement in maternal healthcare.

  • 24. Barkman, Catharina
    et al.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Policymakers and mHealth: roles and expectations, with observations from Ethiopia, Ghana and Sweden2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1337356Article in journal (Refereed)
    Abstract [en]

    The rapid increase in mobile phone use and other telecommunication technologies in health care during the past decade has paved the way for optimism. mHealth (mobile health) initiatives need to be integrated into national health systems and priorities and fit into the system that the country has already invested in. Partnership between government, regional governments, health care systems, Community Health Workers, the private sector and universities is considered as a precondition for success. In turn, this requires strategic and integrative policy decisions on the national/regional level to be defined in the action plans as concrete steps. Decision makers are calling for scale-up plans to be in place even in the pilot phases. Hope is expressed that the initial joy and curiosity that new technology generates in the implementation phase will be transferred to routine work. Standards and a common technical architecture that enables interoperability and upscaling are key issues. Based on publications on policy and national strategies, this paper highlights some key areas for decision makers' role and expectations with regard to mHealth. The paper will also report some mHealth experiences from Ethiopia, Ghana and Sweden.

  • 25.
    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.

  • 26. Batura, Neha
    et al.
    Pulkki-Brännström, Anni-Maria
    Institute for Global Health, University College London, London, UK.
    Agrawal, Priya
    Bagra, Archana
    Haghparast-Bidgoli, Hassan
    Bozzani, Fiammetta
    Colbourn, Tim
    Greco, Giulia
    Hossain, Tanvir
    Sinha, Rajesh
    Thapa, Bidur
    Skordis-Worrall, Jolene
    Collecting and analysing cost data for complex public health trials: reflections on practice2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 23257-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.

    OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.

    DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.

    RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.

    CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.

  • 27.
    Biermann, Olivia
    et al.
    Karolinska Institute, Sweden.
    Eckhardt, Martin
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Emergency Medicine. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine.
    Carlfjord, Siw
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Falk, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Forsberg, Birger C.
    Karolinska Institute, Sweden.
    Collaboration between non-governmental organizations and public services in health - a qualitative case study from rural Ecuador2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 32237Article in journal (Refereed)
    Abstract [en]

    Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations.

  • 28.
    Binder-Finnema, Pauline
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Lien, Pham T. L.
    Hoa, Dinh T. P.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Determinants of marginalization and inequitable maternal health care in North-Central Vietnam: a framework analysis2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 27554Article in journal (Refereed)
    Abstract [en]

    Background: Vietnam has achieved great improvements in maternal healthcare outcomes, but there is evidence of increasing inequity. Disadvantaged groups, predominantly ethnic minorities and people living in remote mountainous areas, do not gain access to maternal health improvements despite targeted efforts from policymakers. Objective: This study identifies underlying structural barriers to equitable maternal health care in Nghe An province, Vietnam. Experiences of social inequity and limited access among child-bearing ethnic and minority women are explored in relation to barriers of care provision experienced by maternal health professionals to gain deeper understanding on health outcomes. Design: In 2012, 11 focus group discussions with women and medical care professionals at local community health centers and district hospitals were conducted using a hermeneutic-dialectic method and analyzed for interpretation using framework analysis. Results: The social determinants 'limited negotiation power' and 'limited autonomy' orchestrate cyclical effects of shared marginalization for both women and care professionals within the provincial health system's infrastructure. Under-staffed and poorly equipped community health facilities referwomen and create overload at receiving health centers. Limited resources appear diverted away from local community centers as compensation to the district for overloaded facilities. Poor reputation for low care quality exists, and professionals are held in low repute for causing overload and resulting adverse outcomes. Country-wide reforms force women to bear responsibility for limited treatment adherence and health insight, but overlook providers' limited professional development. Ethnic minority women are hindered by relatives from accessing care choices and costs, despite having advanced insight about government reforms to alleviate poverty. Communication challenges are worsened by non-existent interpretation systems. Conclusions: For maternal health policy outcomes to become effective, it is important to understand that limited negotiation power and limited autonomy simultaneously confront childbearing women and health professionals. These two determinants underlie the inequitable economic, social, and political forces in Vietnam's disadvantaged communities, and result in marginalized status shared by both in the poorest sectors.

  • 29.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    What about healthy participants?: the improvement and deterioration of self-reported health at a 10-year follow-up of the Västerbotten Intervention Programme2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5435-Article in journal (Refereed)
    Abstract [en]

    AIM: The Västerbotten Intervention Programme (VIP) addresses cardiovascular disease and diabetes in the middle-aged population of Västerbotten County, Sweden. Self-reported health (SRH) is one of the risk factors for both conditions. The aim of this study was to analyse the development patterns of SRH among the VIP participants.

    METHODS: Cross-sectional data from 1990 to 2007 were used to analyse the prevalence of poor SRH among 101,396 VIP participants aged 40-60 years. Panel data were used to study the change in SRH among 25,695 persons aged 30-60 years, who participated in the VIP twice within a 10-year interval.

    RESULTS: Prevalence of poor SRH fluctuated between 1990 and 2007 in Västerbotten County. There was a temporary decline around 2000, with SRH continuously improving thereafter. The majority of panel participants remained in good SRH; over half of those with poor or fair SRH at baseline reported better SRH at follow-up. SRH declined in 19% of the panel participants, mostly among those who had good SRH at the baseline. The decline was common among both women and men, in all educational, age and marital status groups.

    CONCLUSIONS: The SRH improvement among those with poor and fair SRH at baseline suggests that VIP has been successful in addressing its target population. However, the deterioration of SRH among 21% of the individuals with good SRH at baseline is of concern. From a public health perspective, it is important for health interventions to address not only the risk group but also those with a healthy profile to prevent the negative development among the seemingly healthy participants.

  • 30.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Souares, Aurelia
    Niamba, Louis
    Sie, Ali
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Measuring self-reported health in low-income countries: piloting three instruments in semi-rural Burkina Faso2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, p. 8488-Article in journal (Refereed)
    Abstract [en]

    Background: National surveys in low-income countries increasingly rely on self-reported measures of health. The ease, speed, and economy of collecting self-reports of health make such collection attractive for rapid appraisals. However, the interpretation of these measures is complicated since different cultures understand and respond to the same question in different ways. Objective: The aim of this pilot study was to develop a culturally sensitive tool to study the self-reported health (SRH) of the local adult population in Burkina Faso. Design: The study was carried out in the 2009 rainy season. The sample included 27 men and 25 women aged 18 or older who live in semi-urban Nouna, Burkina Faso. Three culturally adapted instruments were tested: a SRH question, a wooden visual analogue scale (VAS), and a drawn VAS. Respondents were asked to explain their answers to each instrument. The narratives were analyzed with the content analysis technique, and the prevalence of poor SRH was estimated from the quantitative data by stratification for respondent background variables (sex, age, literacy, education, marital status, ethnicity, chronic diseases). The correlation between the instruments was tested with Spearman's correlation test. Results: The SRH question showed a 38.5% prevalence of poor SRH and 44.2% prevalence with both VAS. The correlation between the VAS was 0.89, whereas the correlation between the VAS and the SRH question was 0.60-0.64. Nevertheless, the question used as the basis of each instrument was culturally sensitive and clear to all respondents. Analysis of the narratives shows that respondents clearly differentiated between the various health statuses. Conclusion: In this pilot, we developed and tested a new version of the SRH question that may be more culturally sensitive than its non-adapted equivalents. Additional insight into this population's understanding and reporting of health was also obtained. A larger sample is needed to further study the validity and reliability of the SRH question and the VAS and understand which instrument is best suited to study SRH in the low-income setting of semi-rural Burkina Faso.

  • 31. Bocquier, Philippe
    et al.
    Sankoh, Osman
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Are health and demographic surveillance system estimates sufficiently generalisable?2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, p. 1-3, article id 1356621Article in journal (Refereed)
    Abstract [en]

    Sampling rules do not apply in a Health and Demographic Surveillance System (HDSS) that covers exhaustively a district-level population and is not meant to be representative of a national population. We highlight the advantages of HDSS data for causal analysis and identify in the literature the principles of conditional generalisation that best apply to HDSS. A probabilistic view on HDSS data is still justified by the need to model complex causal inference. Accounting for contextual knowledge, reducing omitted-variable bias, detailing order of events, and high statistical power brings credence to HDSS data. Generalisation of causal mechanisms identified in HDSS data is consolidated through systematic comparison and triangulation with national or international data.

  • 32.
    Boman, Magnus
    et al.
    KTH, School of Information and Communication Technology (ICT), Software and Computer systems, SCS. RISE SICS AB, Sweden.
    Kruse, E.
    Supporting global health goals with information and communications technology2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1321904Article in journal (Refereed)
    Abstract [en]

    The objective of this study is to critically assess the possible roles of information and communications technology (ICT) in supporting global health goals. This is done by considering privilege and connectibility. In short, ICT can contribute by providing health information via four different kinds of access, each with its own history and prospective future. All four are analyzed here, in two perspectives: business-as-usual and disruptive. Health data analytics is difficult since the digital representation of past, current, and future health information is lacking. The flow of analytics that may prove beneficial to the individual and not just meet abstract population-level goals or ambitions is analyzed in detail. Sensemaking is also needed, to meet the minimum requirement of making prospective future services understandable to policymakers. Drivers as well as barriers for areas in which policy decisions have the potential to drive positive developments for meeting the Sustainable Development Goals are identified.

  • 33.
    Boman, Magnus
    et al.
    RISE - Research Institutes of Sweden, ICT, SICS. KTH Royal Institute of Technology, Sweden.
    Kruse, Erik
    Ericsson, Sweden.
    Supporting global health goals with information and communications technology2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1321904Article in journal (Refereed)
    Abstract [en]

    The objective of this study is to critically assess the possible roles of information and communications technology (ICT) in supporting global health goals. This is done by considering privilege and connectibility. In short, ICT can contribute by providing health information via four different kinds of access, each with its own history and prospective future. All four are analyzed here, in two perspectives: business-as-usual and disruptive. Health data analytics is difficult since the digital representation of past, current, and future health information is lacking. The flow of analytics that may prove beneficial to the individual and not just meet abstract population-level goals or ambitions is analyzed in detail. Sensemaking is also needed, to meet the minimum requirement of making prospective future services understandable to policymakers. Drivers as well as barriers for areas in which policy decisions have the potential to drive positive developments for meeting the Sustainable Development Goals are identified. © 2017 The Author(s).

  • 34.
    Bonita, Ruth
    et al.
    School of Population Health, University of Auckland, Auckland, New Zealand;.
    Brändström, Anders
    Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Malmberg, Gunnar
    Umeå University, Faculty of Social Sciences, Department of Social and Economic Geography. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Linnaeus: Alive and well2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5760-2Article in journal (Refereed)
  • 35.
    Borg, Johan
    et al.
    Lunds universitet.
    Bergman, Anna-Karin
    Ostergren, Per-Olof
    Is ‘legal empowerment of the poor’ relevant to people with disabilities in developing countries?: An empirical and normative review2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, p. 1-15Article in journal (Refereed)
    Abstract [en]

    Background: Legal empowerment of the poor is highly relevant to public health as it aims to relieve income poverty, a main determinant of health. The Commission on Legal Empowerment of the Poor (CLEP) has proposed legal empowerment measures in the following four domains: access to justice and the rule of law, property, labor, and business rights. Despite being overrepresented among the poor, CLEP has not explicitly considered the situation of people with disabilities. Objectives: To examine the empirical evidence for the relevance of the CLEP legal empowerment measures to people with disabilities in low-and lower middle-income countries, and to evaluate the extent to which the Convention on the Rights of Persons with Disabilities (CRPD) addresses those measures. Methods: Critical literature review of empirical studies and a checklist assessment of the CRPD. Results: Fourteen included articles confirm that people with disabilities experience problems in the domains of access to justice and the rule of law, labor rights, and business rights. No texts on property rights were found. Evidence for the effectiveness of the proposed measures is insufficient. Overall, the CRPD fully or partially supports two-thirds of the proposed measures (seven out of nine measures for access to justice and the rule of law, none of the five measures for property rights, all seven measures for labor rights, and six out of nine measures for business rights). Conclusions: Although most of the domains of the CLEP legal empowerment measures are relevant to people with disabilities from both empirical and normative perspectives, it is uncertain whether the devised measures are of immediate relevance to them. Further research is warranted in this regard.

  • 36.
    Bremnes, Hanna Stromholt
    et al.
    Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, Singsakerbakken 22A, Trondheim, Norway.
    Wiig, Asil Kjol
    Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, Singsakerbakken 22A, Trondheim, Norway.
    Abeid, Muzdalifat
    Temeke Reg Referral Hosp, Dept Obstet & Gynecol, Dar Es Salaam, Tanzania.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian Univ Sci & Technol, NTNU, Dept Publ Hlth & Nursing, Trondheim, Norway; St Olavs Hosp, Dept Obstet & Gynecol, Trondheim, Norway..
    Challenges in day-to-day midwifery practice: a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1453333Article in journal (Refereed)
    Abstract [en]

    Background: Maternal and infant mortality rates in Tanzania have decreased over the past decades, but remain high. One of the challenges the country faces, is the lack of skilled health care workers. High fertility rates make midwives and their patients particularly susceptible to stress as a result of understaffing.

    Objective: This paper explores the challenges midwives face in their day-to-day practice at a regional referral hospital in Tanzania, and investigates which measures the midwives themselves find necessary to implement to improve their situation.

    Methods: A qualitative study design with focus group discussions (FGDs) was employed to explore which challenges the midwives experienced. Each focus group consisted of five to six midwives. A FGD topic guide covering challenges, consequences, motivation, ideal situation and possible solutions was used. These data were analyzed using Systematic Text Condensation.

    Results: A total of 28 Midwives, six men and 22 women, participated in five FGDs. Four categories emerged from the collected material: Feelings of demoralization, shortage of resources, societal challenges and personal struggles. A feeling of demoralization was especially prevalent and was caused by a lack of support from the leaders and little appreciation from the patients. Shortage of resources, and shortage of personnel in particular, was also highlighted as it led to an excessive workload resulting in difficulties with providing adequate care. These difficulties were intensified by lack of equipment, facilities and a non-optimal organization of the healthcare system.

    Conclusion: The challenges revealed during the FGDs prevent the midwives from providing sufficient midwifery care. To improve the situation, measures such as supportive leadership, reduction of workload, increasing availability of equipment and increasing knowledge of reproductive health in society, should be taken.

  • 37.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Climate change and population health in Africa: where are the scientists?2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 173-176Article in journal (Refereed)
    Abstract [en]

    Despite a growing awareness of Africans' vulnerability to climate change, there is relatively little empirical evidence published about the effects of climate on population health in Africa. This review brings together some of the generalised predictions about the potential continent-wide effects of climate change with examples of the relatively few locally documented population studies in which climate change and health interact. Although ecologically determined diseases such as malaria are obvious candidates for susceptibility to climate change, wider health effects also need to be considered, particularly among populations where adequacy of food and water supplies may already be marginal.

  • 38.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Epidemiology without borders: an anational view of global health2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Most analyses of global health use country as a unit of observation, not least because countries are intrinsic to health services and to many international organisations. However, this can mask geographical influences on population health, which do not respect political boundaries.

    METHODS: A global anational database was constructed with one degree cells of latitude and longitude, and used to calculate densities for population and key health indicators. These data were aggregated into 240 15 degrees ansectors, 171 of which were populated. Differences in ansector rank orders between population density and health outcomes (infant, maternal and HIV-related deaths and income) were calculated and mapped as quintiles.

    FINDINGS: Individual ansectors contained parts of 1-21 countries. Mapping by ansector showed that the four outcomes analysed were strongly geographically correlated. Sub-Saharan Africa was consistently disadvantaged in terms of health outcomes, while the Indian sub-continent was at an advantage in terms of HIV mortality, despite poverty.

    INTERPRETATION: Although in most cases it makes sense to analyse health on a national basis, these findings highlight the often unquestioned assumptions involved in doing so. Even if global patterns of health do not turn out so differently when analysed anationally, some major effects on health, such as climate change, are not nationally based, and should not necessarily be nationally analysed. Progress towards Millennium Development Goals must be evaluated on a population basis, rather than by counting countries achieving targets. Data files are available in Excel format and attached as separate files to this paper (see Supplementary files under Reading Tools online).

  • 39.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Is global health really global?2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-3Article in journal (Refereed)
    Abstract [en]

    This editorial is based on a keynote address given at the International Conference on Global Public Health, Colombo, Sri Lanka, in December 2012. It accompanies a set of papers which were also presented at the conference. So far, these papers describe a range of global health issues, from the health status of the United Arab Emirates through to social determinants of health in India. Two papers from Rwanda and India consider specific aspects of oral public health, which was a major sub-theme of the conference.

  • 40.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Towards a global agenda on ageing2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1Article in journal (Other academic)
  • 41.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Calvert, Clara
    Miiro-Nakiyingi, Jessica
    Lutalo, Tom
    Michael, Denna
    Crampin, Amelia
    Gregson, Simon
    Takaruza, Albert
    Robertson, Laura
    Herbst, Kobus
    Todd, Jim
    Zaba, Basia
    InterVA-4 as a public health tool for measuring HIV/AIDS mortality: a validation study from five African countries2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, article id 22448Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reliable population-based data on HIV infection and AIDS mortality in sub-Saharan Africa are scanty, even though that is the region where most of the world's AIDS deaths occur. There is therefore a great need for reliable and valid public health tools for assessing AIDS mortality.

    OBJECTIVE: The aim of this article is to validate the InterVA-4 verbal autopsy (VA) interpretative model within African populations where HIV sero-status is recorded on a prospective basis, and examine the distribution of cause-specific mortality among HIV-positive and HIV-negative people.

    DESIGN: Data from six sites of the Alpha Network, including HIV sero-status and VA interviews, were pooled. VA data according to the 2012 WHO format were extracted, and processed using the InterVA-4 model into likely causes of death. The model was blinded to the sero-status data. Cases with known pre-mortem HIV infection status were used to determine the specificity with which InterVA-4 could attribute HIV/AIDS as a cause of death. Cause-specific mortality fractions by HIV infection status were calculated, and a person-time model was built to analyse adjusted cause-specific mortality rate ratios.

    RESULTS: The InterVA-4 model identified HIV/AIDS-related deaths with a specificity of 90.1% (95% CI 88.7-91.4%). Overall sensitivity could not be calculated, because HIV-positive people die from a range of causes. In a person-time model including 1,739 deaths in 1,161,688 HIV-negative person-years observed and 2,890 deaths in 75,110 HIV-positive person-years observed, the mortality ratio HIV-positive:negative was 29.0 (95% CI 27.1-31.0), after adjustment for age, sex, and study site. Cause-specific HIV-positive:negative mortality ratios for acute respiratory infections, HIV/AIDS-related deaths, meningitis, tuberculosis, and malnutrition were higher than the all-cause ratio; all causes had HIV-positive:negative mortality ratios significantly higher than unity.

    CONCLUSIONS: These results were generally consistent with relatively small post-mortem and hospital-based diagnosis studies in the literature. The high specificity in cause of death attribution achieved in relation to HIV status, and large differences between specific causes by HIV status, show that InterVA-4 is an effective and valid tool for assessing HIV-related mortality.

  • 42.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chandramohan, Daniel
    Clark, Samuel J.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Herbst, Abraham J.
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krishnan, Anand
    Leitao, Jordana
    Odhiambo, Frank
    Sankoh, Osman A.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.

  • 43.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    de Savigny, Don
    Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland and University of Basel, Basel, Switzerland.
    Lopez, Alan D
    Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia.
    Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 158-168Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way.

    PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers.

    CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.

  • 44.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fantahun, Mesganaw
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Molla, Mitike
    Berhane, Yemane
    Spatio-temporal clustering of mortality in Butajira HDSS, Ethiopia, from 1987 to 20082010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 26-31Article in journal (Refereed)
    Abstract [en]

    Background: Mortality in a population may be clustered in space and time for a variety of reasons, including geography, socio-economics, environment and demographics. Analysing mortality clusters can therefore reveal important insights into patterns and risks of mortality in a particular setting. Objective and design: To investigate the extent of spatio-temporal clustering of mortality in the Butajira District, Ethiopia, from 1987 to 2008. The Health and Demographic Surveillance System (HDSS) dataset recorded 10,696 deaths among 951,842 person-years of observation, with each death located by household, in which population time at risk was also recorded. The surveyed population increased from 28,614 in 1987 to 62,322 in 2008, in an area approximately 25 km in diameter. Spatio-temporal clustering analyses were conducted for overall mortality and by specific age groups, grouping the population into a 0.01° latitude-longitude grid. Results: A number of significantly high- and low-mortality clusters were identified at various times and places. Butajira town was characterised by significantly low mortality throughout the period. A previously documented major mortality crisis in 1998-1999, largely resulting from malaria and diarrhoea, dominated the clustering analysis. Other local high-mortality clusters, appreciably attributable to meningitis, malaria and diarrhoea, occurred in the earlier part of the period. In the later years, a more homogeneous distribution of mortality at lower rates was observed. Conclusions: Mortality was by no means randomly distributed in this community during the period of observation. The clustering analyses revealed a clear epidemiological transition, away from localised infectious epidemics, over a generation.

  • 45.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Friberg, Peter
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Beyond 2015: time to reposition Scandinavia in global health?2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6Article in journal (Refereed)
    Abstract [en]

    Global health currently finds itself in an exciting, almost bewildering, state of flux. A plethora of initiatives, statements, high-level meetings, and other activities are generating a continuous flow of new ideas, with the impetus at least partly driven by the advent of the 2015 target date set for the Millennium Development Goals that were adopted in 2000. Whatever shape the post-2015 global health landscape may eventually take, it is already clear that there will be new targets of some kind as the world tries to make further progress on some of the less tractable health issues.

  • 46.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nurturing Global Health Action through its first decade2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1569847Article in journal (Refereed)
  • 47.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Twine, Wayne
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kjellström, Tord
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing a population's exposure to heat and humidity: an empirical approach2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5421-Article in journal (Refereed)
    Abstract [en]

    Background: It is widely accepted that assessing the impact of heat on populations is an important aspect of climate change research. However, this raises questions about how best to measure people’s exposure to heat under everyday living conditions in more detail than is possible by relying on nearby sources of meteorological data. Objective: This study aimed to investigate practical and viable approaches to measuring air temperature and humidity within a population, making comparisons with contemporaneous external data sources. This was done in a rural South African population during the subtropical summer season. Results: Air temperature and humidity were measured indoors and outdoors at three locations over 10 days and the datalogger technology proved reliable and easy to use. There was little variation in measurements over distances of 10 km. Conclusions: Small battery-powered automatic dataloggers proved to be a feasible option for collecting weather data among a rural South African population. These data were consistent with external sources but offered more local detail. Detailed local contemporary data may also allow post hoc modelling of previously unmeasured local weather data in conjunction with global gridded climate models.

  • 48.
    Cameron, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ubels, Jasper
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1447828Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system.

    OBJECTIVES: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data.

    METHODS: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations.

    RESULTS: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made.

    CONCLUSIONS: Most national C/E thresholds identified in our review fall within the WHO's recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

  • 49. Chaturvedi, Sarika
    et al.
    Ali, Sayyed
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sabde, Yogesh
    Diwan, Vishal
    De Costa, Ayesha
    Availability and distribution of safe abortion services in rural areas: a facility assessment study in Madhya Pradesh, India2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-7, article id 26346Article in journal (Refereed)
    Abstract [en]

    Background: Unsafe abortion contributes to a significant portion of maternal mortality in India. Access to safe abortion care is known to reduce maternal mortality. Availability and distribution of abortion care facilities can influence women's access to these services, especially in rural areas. Objectives: To assess the availability and distribution of abortion care at facilities providing childbirth care in three districts of Madhya Pradesh (MP) province of India. Design: Three socio demographically heterogeneous districts of MP were selected for this study. Facilities conducting at least 10 deliveries a month were surveyed to assess availability and provision of abortion services using UN signal functions for emergency obstetric care. Geographical Information System was used for visualisation of the distribution of facilities. Results: The three districts had 99 facilities that conducted > 10 deliveries a month: 74 in public and 25 in private sector. Overall, 48% of facilities reported an ability to provide safe surgical abortion service. Of public centres, 32% reported the ability compared to 100% among private centres while 18% of public centres and 77% of private centres had performed an abortion in the last 3 months. The availability of abortion services was higher at higher facility levels with better equipped and skilled personnel availability, in urban areas and in private sector facilities. Conclusions: Findings showed that availability of safe abortion care is limited especially in rural areas. More emphasis on providing safe abortion services, particularly at primary care level, is important to more significantly dent maternal mortality in India.

  • 50.
    Choulagai, Bishnu P.
    et al.
    Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal / Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Aryal, Umesh Raj
    Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal.
    Shrestha, Binjwala
    Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal / Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Vaidya, Abhinav
    Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal.
    Onta, Sharad
    Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
    Petzold, Max
    Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden / School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Krettek, Alexandra
    University of Skövde, School of Health and Education. University of Skövde, Health and Education. Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden / Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
    Jhaukhel-Duwakot Health Demographic Surveillance Site, Nepal: 2012 follow-up survey and use of skilled birth attendants2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 29396Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Estimates of disease burden in Nepal are based on cross-sectional studies that provide inadequate epidemiological information to support public health decisions. This study compares the health and demographic indicators at the end of 2012 in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) with the baseline conducted at the end of 2010. We also report on the use of skilled birth attendants (SBAs) and associated factors in the JD-HDSS at the follow-up point.

    DESIGN: We used a structured questionnaire to survey 3,505 households in the JD-HDSS, Bhaktapur, Nepal. To investigate the use of SBAs, we interviewed 434 women who had delivered a baby within the prior 2 years. We compared demographic and health indicators at baseline and follow-up and assessed the association of SBA services with background variables.

    RESULTS: Due to rising in-migration, the total population and number of households in the JD-HDSS increased (13,669 and 2,712 in 2010 vs. 16,918 and 3,505 in 2012). Self-reported morbidity decreased (11.1% vs. 7.1%, respectively), whereas accidents and injuries increased (2.9% vs. 6.5% of overall morbidity, respectively). At follow-up, the proportion of institutional delivery (93.1%) exceeded the national average (36%). Women who accessed antenatal care and used transport (e.g. bus, taxi, motorcycle) to reach a health facility were more likely to access institutional delivery.

    CONCLUSIONS: High in-migration increased the total population and number of households in the JD-HDSS, a peri-urban area where most health indicators exceed the national average. Major morbidity conditions (respiratory diseases, fever, gastrointestinal problems, and bone and joint problems) remain unchanged. Further investigation of reasons for increased proportion of accidents and injuries are recommended for their timely prevention. More than 90% of our respondents received adequate antenatal care and used institutional delivery, but only 13.2% accessed adequate postnatal care. Availability of transport and use of antenatal care was associated positively with institutional delivery.

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