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

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

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

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

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

  • 2.
    Alfredsson, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jeghannathan, Bhoomikumar
    Attitudes towards mental health and the integration of mental health services into primary health care: a cross-sectional survey among health-care workers in Lvea Em District, Cambodia2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1331579Article in journal (Refereed)
    Abstract [en]

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

  • 3.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundh, Thomas
    Alegre, Yuri
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lead exposure in indigenous communities of the Amazon basin, Peru2011In: International journal of hygiene and environmental health (Print), ISSN 1438-4639, E-ISSN 1618-131X, Vol. 215, no 1, p. 59-63Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

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

  • 5.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sources and risk factors for lead exposure in indigenous children of the Peruvian Amazon, disentangling connections with oil activity2012In: International journal of occupational and environmental health, ISSN 1077-3525, E-ISSN 2049-3967, Vol. 18, no 4, p. 268-277Article in journal (Refereed)
    Abstract [en]

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

  • 6.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Bergdahl, Ingvar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Easier said than done: applying the Ecohealth principles to a study of heavy metals exposure among indigenous communities of the Peruvian Amazon2013In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, article id 437Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 7.
    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.

  • 8.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe; a new questionnaire to assess youth friendliness2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 343-Article in journal (Other academic)
    Abstract [en]

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

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

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

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

    Key messages:

    • YFHS-Swe is credible and suitable instrument in the Swedish context and it can be used as a basis for validating other instruments to assess youth-friendliness in other contexts.
    • The dimensions identified of this novel instrument might be of importance in assessing distinct aspects of friendliness in differentiated health services and might be of importance for policy making.
  • 9.
    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.

  • 10.
    Beck, Simon
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Basic income – healthy outcome? Effects on health of an Indian basic income pilot project: a cluster randomised trial2015In: Journal of Development Effectiveness, ISSN 1943-9342, E-ISSN 1943-9407, Vol. 7, no 1, p. 111-126Article in journal (Refereed)
    Abstract [en]

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

  • 11.
    Boldis, Beáta Vivien
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Unsafe and unequal: a decomposition analysis of income inequalities in fear of crime in northern Sweden2018In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 110Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 12.
    Bozorgmehr, Kayvan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Trade liberalization and tuberculosis incidence: a longitudinal multi-level analysis in 22 high burden countries between 1990 and 20102014In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 29, no 3, p. 328-351Article in journal (Refereed)
    Abstract [en]

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

  • 13. Bozorgmehr, Kayvan
    et al.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Brenner, Hermann
    Razum, Oliver
    Maier, Werner
    Saum, Kai-Uwe
    Holleczek, Bernd
    Miksch, Antje
    Szecsenyi, Joachim
    Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-20102015In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, article id 28Article in journal (Refereed)
    Abstract [en]

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

  • 14.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Does contextual unemployment matter for health status across the life course? A longitudinal multilevel study exploring the link between neighbourhood unemployment and functional somatic symptoms2017In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 43, p. 113-120Article in journal (Refereed)
    Abstract [en]

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

  • 15.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Does contextual unemployment matter for health status across the life course?2016Conference paper (Refereed)
  • 16.
    Brydsten, Anna
    et al.
    Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Public Health Unit, Uppsala University, Uppsala, Sweden.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health2018In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, no 59, article id 59Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 17.
    Brydsten, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The impact of economic recession on the association between youth unemployment and functional somatic symptoms in adulthood: a difference-in-difference analysis from Sweden2016In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, article id 230Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 18. Buitron, Diego
    et al.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    [Nutritional status of Naporuna children under five in the Amazon region of Ecuador]2004In: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 15, no 3, p. 151-9Article in journal (Other academic)
  • 19.
    Coe, Anna-Britt
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Understanding how young people do activism: Youth strategies on sexual health in Ecuador and Peru2015In: Youth & society, ISSN 0044-118X, E-ISSN 1552-8499, Vol. 47, no 1, p. 3-28Article in journal (Refereed)
    Abstract [en]

    While social movement research employs “tactical repertoire” to emphasize protest tactics directed at the state, literature on youth activism globally indicates that young people do politics outside the realm of formal political spheres. Youth activism on body politics in Latin America offers evidence that enhances conceptual tools intended for understanding how young people make claims and towards whom they make them. This paper takes young activists’ strategies as its point of departure through a study that explored how young people perceived their activism to advance sexual health in Ecuador and Peru. Young activists employed a range of interconnected strategies that went beyond protests directed at the state, including responding to adult allies, carrying out social advocacy among youth, building organizations, carrying out political advocacy and developing themselves as activists. Strategies were shaped by the degree to which young activists negotiated alternative notions of ‘youth’ with different actors.

  • 20.
    Cordoba-Dona, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 1Delegación Territorial de Igualdad, Salud y Políticas Sociales de Andalucía.
    Escolar-Pujolar, Antonio
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    How are the employed and unemployed affected by the economic crisis in Spain?: Educational inequalities, life conditions and mental health in a context of high unemployment2016In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, article id 267Article in journal (Refereed)
    Abstract [en]

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

  • 21.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Delegación Territorial de la Consejería de Salud de la Junta de Andalucía, Cádiz, Spain.
    Escolar-Pujolar, Antonio
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 3, article id e0195293Article in journal (Refereed)
    Abstract [en]

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

  • 22.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Escolar-Pujolar, Antonio
    Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    Martínez-Faure, Jesús Enrique
    Empresa Pública de Emergencias Sanitarias, Cádiz, Spain.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain2014In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, article id 55Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

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

  • 24.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Rojas, Ernesto
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Illanes, Daniel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessment of a Leishmaniasis Reporting System in Tropical Bolivia Using the Capture-Recapture Method2018In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 98, no 1, p. 134-138Article in journal (Refereed)
    Abstract [en]

    This study evaluates the level of underreporting of the National Program of Leishmaniasis Control (NPLC) in two communities of Cochabamba, Bolivia during the period 2013-2014. Montenegro skin test-confirmed cases of cutaneous leishmaniasis (CL) were identified through active surveillance during medical campaigns. These cases were compared with those registered in the NPLC by passive surveillance. After matching and cleaning data from the two sources, the total number of cases and the level of underreporting of the National Program were calculated using the capture-recapture analysis. This estimated that 86 cases of CL (95% confidence interval [CI]: 62.1-110.8) occurred in the study period in both communities. The level of underreporting of the NPLC in these communities was very high: 73.4% (95% CI: 62.1-110.8). These results can be explained by the inaccessibility of health services and centralization of the NPLC activities. This information is important to establish priorities among policy-makers and funding organizations as well as implementing adequate intervention plans.

  • 25.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Biomedical Research, Faculty of Medicine, San Simon University, Aniceto Arce Avenue 371, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Rojas, Ernesto
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Illanes, Daniel
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Risk factors for cutaneous leishmaniasis in the rainforest of Bolivia: a cross-sectional study2018In: Tropical Medicine and Health, ISSN 1348-8945, E-ISSN 1349-4147, Vol. 46, article id 9Article in journal (Refereed)
    Abstract [en]

    Background: Cutaneous leishmaniasis (CL) is an endemic disease in Bolivia, particularly in the rainforest of Cochabamba, in the municipality of Villa Tunari. The precarious, dispersed, and poorly accessible settlements in these farming communities make it difficult to study them, and there are no epidemiological studies in the area. The aim of the present study was to identify the risk factors associated with cutaneous leishmaniasis.

    Methods: A cross-sectional study was conducted in August 2015 and August 2016 in two communities of Villa Tunari, Cochabamba. The cases were diagnosed through clinical examinations, identification of the parasite by microscopic examination, and the Montenegro skin test. Risk factors were identified through logistic regression.

    Results: A total of 274 participants (40.9% female and 59.1% male) were surveyed, of which 43% were CL positive. Sex was the only factor associated with CL with three times more risk for men than for women; this finding suggests a sylvatic mechanism of transmission in the area.

    Conclusions: It is advisable to focus on education and prevention policies at an early age for activities related to either leisure or work. Further research is needed to assess the influence of gender-associated behavior for the risk of cutaneous leishmaniasis.

  • 26.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach2019In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 19, no 1, article id 12Article in journal (Refereed)
    Abstract [en]

    Background: Leishmaniasis is a neglected tropical disease endemic in Bolivia that disproportionately affects people with little social and political capital. Although the treatment is provided free of charge by the Bolivian government, there is an under-utilization of treatments in relation to the estimated affected population. This study explores the experiences of patients with leishmaniasis and the challenges faced when searching for diagnosis and treatment in Bolivia using a human rights approach.

    Methods: We conducted open-ended interviews with 14 participants diagnosed with leishmaniasis. The qualitative data were analysed using thematic analysis and were interpreted under a human rights approach to health care.

    Results: Four themes emerged during data analysis: (1) the decision for seeking a cure takes time; (2) the severity of symptoms and disruption of functioning drives the search for Western medicine; (3) the therapeutic journey between Western and traditional medicine; and (4) accessibility barriers to receive adequate medical treatment. This study showed that access to health care limitations were the most important factors that prevented patients from receiving timely diagnosis and treatment. Cultural factors played a secondary role in their decision to seek medical care.

    Conclusions: Accessibility barriers resulted in a large pilgrimage between public health care and traditional medicinal treatments for patients with leishmaniasis. This pilgrimage and the related costs are important factors that determine the decision to seek health care. This study contributes to the understanding of the under-utilisation problems of medical services in leishmaniasis and other similar diseases in remote and poor populations.

  • 27.
    Eid, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    "Cheaper and better": an economic analysis of changing first line treatment for cutaneous leishmaniasis in BoliviaManuscript (preprint) (Other academic)
    Abstract [en]

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

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

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

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

  • 28. Escolar Pujolar, Antonio
    et al.
    Bacigalupe, Amaia
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Looking beyond the veil of the European crisis: the need to uncover the structural causes of health inequalities2016In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 15, article id 39Article in journal (Refereed)
  • 29.
    Escolar-Pujolar, Antonio
    et al.
    Delegación Territorial de Igualdad, Salud y Políticas Sociales, Junta de Andalucía, Cádiz, Spain.
    Bacigalupe, Amaia
    Department of Sociology, University of the Basque Country (UPV/EHU), Leioa, Spain.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    European economic crisis and health inequities: research challenges in an uncertain scenario2014In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, p. 59-Article in journal (Other academic)
  • 30. Estalella, Itziar
    et al.
    San Millán, Jaione
    Trincado, María José
    Maquibar, Amaia
    Martínez-Indart, Lorea
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay2019In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 31. Feder, Gene
    et al.
    Rohde, Jon E
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Jimba, Masamine
    Materia, Enrico
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Goldin, Stephen
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Stafford, Tom
    Edvardsson, Berit
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hilt, Bjorn
    Parkinson, Stuart
    Birch, Marion
    Jones, Anna
    Archibald, Kathy
    Pastore, John O
    Reed Elsevier and the international arms trade.2005In: Lancet, ISSN 1474-547X, Vol. 366, no 9489, p. 889; discussion 889-90Article in journal (Refereed)
  • 32.
    Forouzan, Ameneh S
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Rafiey, Hassan
    Padyab, Mojgan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Social Sciences, Department of Social Work.
    Ghazinour, Seyedmehdi
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dejman, Masoumeh
    San Sebastian Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Reliability and validity of a Mental Health System Responsiveness Questionnaire in Iran2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 1-10Article in journal (Refereed)
    Abstract [en]

    Background:

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

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

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

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

  • 33.
    Forouzan, Ameneh Setareh
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Social Welf & Rehabil Sci, Social Determinants Hlth Res Ctr, Tehran, Iran.
    Ghazinour, Mehdi
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dejman, Masoumeh
    Rafeiey, Hassan
    Eftekhari, Monir Baradaran
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Service Users and Providers Expectations of Mental Health Care in Iran: A Qualitative Study2013In: Iranian Journal of Public Health, ISSN 2251-6085, Vol. 42, no 10, p. 1106-1116Article in journal (Refereed)
    Abstract [en]

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

  • 34.
    Forouzan, Ameneh Setareh
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Ghazinour, Mehdi
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dejman, Masoumeh
    Rafeiey, Hassan
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Testing the WHO responsiveness concept in the Iranian mental healthcare system: a qualitative study of service users2011In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 1, article id 325Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 35.
    Forouzan, Setareh
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Padyab, Mojgan
    Umeå University, Faculty of Social Sciences, Department of Social Work. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Rafiey, Hassan
    Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Iran.
    Ghazinour, Mehdi
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dejman, Masoumeh
    Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Measuring the mental health care system responsiveness: results of an outpatient survey in Tehran2016In: Frontiers In Public Health, ISSN 2296-2565, Vol. 3, article id 285Article in journal (Refereed)
    Abstract [en]

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

  • 36.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India.
    Muraleedharan, V. R.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings2019In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 44Article in journal (Refereed)
    Abstract [en]

    Background: Accountability is increasingly being demanded of public services and is a core aspect of most recent frameworks of health system strengthening. Community-based accountability is an increasingly used strategy, and wasa core aspect of India's flagship National Rural Health Mission (NRHM; 2005-2014). Research on policy implementation has called for policy analysts to go beyond the superficial articulation of a particular policy intervention to study the underlying meaning this has for policy-makers and other actors of the implementation process and to the way in which problems sought to be addressed by the policy have been identified and problematised'.

    Methods: This research, focused on state level officials and health NGO leaders, explores the meanings attached to the concept of accountability among a number of key actors during the implementation of the NRHM in the south Indian state of Tamil Nadu. The overall research was guided by an interpretive approach to policy analysis and the problematisation lens. Through in-depth interviews we draw on the interviewees' perspectives on accountability.

    Results: The research identifies three distinct perspectives on accountability among the key actors involved in the implementation of the NRHM. One perspective views accountability as the achievement of pre-set targets, the other as efficiency in achieving these targets, and the final one as a transformative process that equalises power differentials between communities and the public health system. We also present the ways in which these differences in perspectives are associated with different programme designs.

    Conclusions: This research underlines the importance of going beyond the statements of policy to exploring the underlying beliefs and perspectives in order to more comprehensively understand the dynamics of policy implementation; it further points to the impacts of these perspectives on the design of initiatives in response to the policy.

  • 37.
    Gaitonde, Rakhal
    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.
    Muraleedharan, V R
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Community Action for Health in India's National Rural Health Mission: One policy, many paths2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 188, p. 82-90Article in journal (Refereed)
    Abstract [en]

    Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

  • 38.
    Gangane, Nitin
    et al.
    Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Anshu, Anshu
    Manvatkar, Shiva
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Prevalence and Risk Factors for Patient Delay Among Women With Breast Cancer in Rural India2016In: Asia-Pacific journal of public health, ISSN 1941-2479, Vol. 28, no 1, p. 72-82Article in journal (Refereed)
    Abstract [en]

    Delay in seeking health care by women with breast cancer increases mortality risk. This study was conducted in rural India to identify risk factors associated with patient delay. A total of 212 women with primary breast cancer diagnosed between 2010 and 2012 were interviewed. Sociodemographic characteristics, time interval between seeking medical attention and appearance of symptoms, and reasons for delay were inquired. Patient delay was defined as more than 3 months between date of first symptoms and medical consultation. Logistic regression was applied to assess associations between potential risk factors and patient delay. Almost half the women with breast cancer experienced patient delay. Age more than 60 years (odds ratio = 4.9, 95% confidence interval = 1.3-18.0) was significantly associated with patient delay. Only 6.6% of patients had heard about breast self-examination. Significantly higher number of patients with delay presented with advanced clinical stage (P = .000). Health education programs should be introduced with specific strategies to shorten patient delay.

  • 39.
    Gangane, Nitin
    et al.
    Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Khairkar, Pravin
    Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Hurtig, 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.
    Quality of Life Determinants in Breast Cancer Patients in Central Rural India2017In: Asian Pacific Journal of Cancer Prevention, ISSN 1513-7368, Vol. 18, no 12, p. 3325-3332Article in journal (Refereed)
    Abstract [en]

    Introduction: Breast cancer is the most frequently diagnosed cancer among women throughout world, with incidence rates increasing in India. Improved survival in breast cancer patients has resulted in their quality of life (QOL) becoming an important issue. Identifying determinants for QOL may provide insights into how to improve their living conditions. This study aimed to assess socio-demographic and clinical factors, as well as the role of self-efficacy, in relation to QOL among women with breast cancer in rural India. Methods: A total of 208 female patients with infiltrating carcinoma of the breast participated in the study. A questionnaire was administered that included sections for socio-demographic characteristics, clinical stage of the cancer and patient delay in seeking health care. A standardized instrument to measure self-efficacy was applied. To assess QOL, the WHOQOL – BREF instrument was used. Results: The overall mean score for QOL was 59.3. For domain 1 (physical health) the mean score across all groups was 55.5, for psychological health 58.2, for social relationships 63.2 and for environmental factors, 60.4. The environmental domain in QOL was negatively associated with lower education. Being divorced/widowed/unmarried had a negative association with the psychological health and social relationship dimensions, whereas higher income was positively associated with QOL parameters such as psychology, social relationships and environmental factors. Self-efficacy was positively associated with all four domains of QOL. Conclusions: The present study demonstrated a moderate QOL in women with breast cancer in rural India. Young age, lack of education and being without a partner were negatively related to QOL, and employment as casual and industrial workers, high monthly family income and higher self-efficacy were positively associated with QOL. A comprehensive public health initiative is required, including social, financial and environmental support, that can provide better QOL for breast cancer survivors.

  • 40.
    Gangane, Nitin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    System delay of diagnosis and treatment experienced by women with breast cancer in rural IndiaIn: Article in journal (Refereed)
  • 41.
    Gangane, Nitin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Women's Knowledge, Attitudes, and Practices about Breast Cancer in a Rural District of Central India2015In: Asian Pacific Journal of Cancer Prevention, ISSN 1513-7368, Vol. 16, no 16, p. 6863-6870Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Breast cancer accounted for almost 25% of all cancers in women globally in 2012. Although breast cancer is the most prevalent cancer in India, there is no organised national breast cancer screening programme. Local studies on the burden of breast cancer are essential to develop effective context-specific strategies for an early detection breast cancer programme, considering the cultural and ethnic heterogeneity in India. This study examined the knowledge, attitudes, and practices about breast cancer in rural women in Central India.

    MATERIALS AND METHODS: This community-based cross sectional study was conducted in Wardha district, located in Maharashtra state in Central India in 2013. The sample included 1000 women (609 rural, 391 urban) aged 13-50 years, selected as representative from each of the eight development blocks in the district, using stratified cluster sampling. Trained social workers interviewed women and collected demographic and socio-economic data. The instrument also assessed respondents' knowledge about breast cancer and its symptoms, risks, methods of screening, diagnosis and treatment, as well as their attitudes towards breast cancer and self- reported practices of breast cancer screening. Chi-square and t-test were applied to assess differences in the levels of knowledge, attitude, and practice (the outcome variables) between urban and rural respondents. Multivariable linear regression was conducted to analyse the relationship between socio-demographic factors and the outcome variables.

    RESULTS: While about two-thirds of rural and urban women were aware of breast cancer, less than 7% in rural and urban areas had heard about breast self-examination. Knowledge about breast cancer, its symptoms, risk factors, diagnostic modalities, and treatment was similarly poor in both rural and urban women. Urban women demonstrated more positive attitudes towards breast cancer screening practices than their rural counterparts. Better knowledge of breast cancer symptoms, risk factors, diagnosis, and treatment correlated significantly with older age, higher levels of education, and being office workers or in business.

    CONCLUSIONS: Women in rural Central India have poor knowledge about breast cancer, its symptoms and risk factors. Breast self-examination is hardly practiced, though the willingness to learn is high. Positive attitudes towards screening provide an opportunity to promote breast self-examination.

  • 42. Gatimu, Samwel Maina
    et al.
    Milimo, Benson Williesham
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Nursing I, University of the Basque country.
    Prevalence and determinants of diabetes among older adults in Ghana2016In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, article id 1174Article in journal (Refereed)
    Abstract [en]

    Background: Diabetes is one of the leading non-communicable diseases in Africa, contributing to the increasing disease burden among the old adults. Thus, the aim of this study was to determine the prevalence and determinants of diabetes among adults aged 50 years and above in Ghana. Methods: A cross sectional study based on data collected from Study of Ageing and Adult Health (SAGE) Wave 1 from 2007 to 2008. Data was collected from 5565 respondents of whom 4135 were aged 50+ years identified using a multistage stratified clusters design. Bivariate and hierarchical multivariable logistic regression models were used to examine the association of the determinants and diabetes. Results: The weighted prevalence of diabetes among the adults aged 50 years and above in Ghana was 3.95% (95% Confidence Interval: 3.35-4.55) with the prevalence being insignificantly higher in females than males (2.16%, 95% CI: 1. 69-2.76 vs. 1.73%, 95% CI: 1.28-2.33). Low level of physical activity (Adjusted Odds Ratio [AOR] 2.11, 95% CI: 1.21-3.69) and obesity (AOR 4.81, 95% CI: 1.92-12.0) were associated with increased odds of diabetes among women while old age (AOR 2.58, 95% CI: 1.29-5.18) and university (AOR 12.8, 95% CI: 4.20-39.1), secondary (AOR 3.61, 95% CI: 1.38-9.47) and primary education (AOR 2.71, 95% CI: 1.02-7.19) were associated with increased the odds of diabetes among men. Conclusion: The prevalence of diabetes among old adults shows a similar trend with that of the general population. However, the prevalence may have been underestimated due to self-reporting and a high rate of undiagnosed diabetes. In addition, the determinants of diabetes among older adults are a clear indication of the need for diabetes prevention programme targeting the young people and that are gender specific to reduce the burden of diabetes at old age. Physical activity and nutrition should be emphasised in any prevention strategy.

  • 43.
    Gebrehiwet, Tesfay
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health extension program and its association with change in utlization of selected maternal health services in Tigray regionArticle in journal (Refereed)
  • 44.
    Gebrehiwot, Tesfay Gebregzabher
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing. 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.
    The Health Extension Program and Its Association with Change in Utilization of Selected Maternal Health Services in Tigray Region, Ethiopia: A Segmented Linear Regression Analysis2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 7, article id e0131195Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2003, the Ethiopian Ministry of Health established the Health Extension Program (HEP), with the goal of improving access to health care and health promotion activities in rural areas of the country. This paper aims to assess the association of the HEP with improved utilization of maternal health services in Northern Ethiopia using institution-based retrospective data.

    METHODS: Average quarterly total attendances for antenatal care (ANC), delivery care (DC) and post-natal care (PNC) at health posts and health care centres were studied from 2002 to 2012. Regression analysis was applied to two models to assess whether trends were statistically significant. One model was used to estimate the level and trend changes associated with the immediate period of intervention, while changes related to the post-intervention period were estimated by the other.

    RESULTS: The total number of consultations for ANC, DC and PNC increased constantly, particularly after the late-intervention period. Increases were higher for ANC and PNC at health post level and for DC at health centres. A positive statistically significant upward trend was found for DC and PNC in all facilities (p<0.01). The positive trend was also present in ANC at health centres (p = 0.04), but not at health posts.

    CONCLUSION: Our findings revealed an increase in the use of antenatal, delivery and post-natal care after the introduction of the HEP. We are aware that other factors, that we could not control for, might be explaining that increase. The figures for DC and PNC are however low and more needs to be done in order to increase the access to the health care system as well as the demand for these services by the population. Strengthening of the health information system in the region needs also to be prioritized.

  • 45.
    Gebrehiwot, Tesfay
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Making pragmatic choices: women's experiences of delivery care in Northern Ethiopia2012In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 12, no 113Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women's experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.

    METHODS: We used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.

    RESULTS: One core category emerged, 'making pragmatic choices', which connected the categories 'aiming for safer deliveries', 'embedded in tradition', and 'medical knowledge under constrained circumstances'. In this setting, women -- aiming for safer deliveries -- made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category 'embedded in tradition', was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category 'medical knowledge under constrained circumstances', and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.

    CONCLUSIONS: Although women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained.

  • 46.
    Gebrehiwot, Tesfay
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing. 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.
    Health workers' perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, article id 137Article in journal (Refereed)
    Abstract [en]

    Background: Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. Ethiopia is a major contributor to the worldwide death toll of mothers with a maternal mortality ratio of 676 per 100,000 live births. The Ethiopian Ministry of Health launched a community-based health-care system in 2003, the Health Extension Programme (HEP), to tackle maternal mortality. Despite strong efforts, universal access to services remains limited, particularly skilled delivery attendance. With the help of 'the three delays' framework, this study explores health-service providers' perceptions of facilitators and barriers to the utilization of institutional delivery in Tigray, a northern region of Ethiopia.

    Methods: Twelve in-depth interviews were carried out with eight health extension workers (HEWs) and four midwives. Each interview lasted between 90 and 120 minutes. Data were analysed through a thematic analysis approach.

    Results: Three themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources. These themes represent the three steps in the path towards receiving adequate institutional delivery care at a health facility. Of the themes, 'increased community awareness', 'organization of the community' and 'hospital with specialized staff' were recognized as facilitators. On the other hand, 'delivery as a natural event', 'cultural tradition and rituals', 'inaccessible transport', 'unmet community expectation' and 'shortage of skilled human resources' were represented as barriers to institutional delivery.

    Conclusions: The participants in this study gave emphasis to the major barriers to institutional delivery that are closely connected with the three delays model. Despite the initiatives being implemented by the Tigray Regional Health Bureau, much is still needed to enhance the humanization approach of delivery care on a broader level of the region. A quick solution is needed to address the major issue of lack of transport accessibility. The poor capacity of the HEWs to provide delivery services, calls for reconsidering staffing patterns of remote health posts and readdressing the issue of downgraded health facilities would address unmet community needs.

  • 47.
    Goicoela, Isabel
    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.
    Wulff, Marianne
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Women's reproductive rights in the Amazon basin of Ecuador: Challenges for transforming policy into practicce2008In: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 10, no 2, p. 91-103Article in journal (Refereed)
  • 48.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carson, Dean
    Umeå University, Arctic Research Centre at Umeå University. Demography and Growth Planning, Northern Institute, Charles Darwin University, Darwin, Australia; Centre for Rural Medicine, Storuman, Sweden.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health care access for rural youth on equal terms?: A mixed methods study protocol in northern Sweden2018In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 6Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The purpose of this paper is to propose a protocol for researching the impact of rural youth health service strategies on health care access. There has been no published comprehensive assessment of the effectiveness of youth health strategies in rural areas, and there is no clearly articulated model of how such assessments might be conducted. The protocol described here aims to gather information to; i) Assess rural youth access to health care according to their needs, ii) Identify and understand the strategies developed in rural areas to promote youth access to health care, and iii) Propose actions for further improvement. The protocol is described with particular reference to research being undertaken in the four northernmost counties of Sweden, which contain a widely dispersed and diverse youth population.

    METHODS: The protocol proposes qualitative and quantitative methodologies sequentially in four phases. First, to map youth access to health care according to their health care needs, including assessing horizontal equity (equal use of health care for equivalent health needs,) and vertical equity (people with greater health needs should receive more health care than those with lesser needs). Second, a multiple case study design investigates strategies developed across the region (youth clinics, internet applications, public health programs) to improve youth access to health care. Third, qualitative comparative analysis of the 24 rural municipalities in the region identifies the best combination of conditions leading to high youth access to health care. Fourth, a concept mapping study involving rural stakeholders, care providers and youth provides recommended actions to improve rural youth access to health care.

    DISCUSSION: The implementation of this research protocol will contribute to 1) generating knowledge that could contribute to strengthening rural youth access to health care, as well as to 2) advancing the application of mixed methods to explore access to health care.

  • 49.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Marchal, Bruno
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Searching for best practices of youth friendly services - a study protocol using qualitative comparative analysis in Sweden2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 321Article in journal (Refereed)
    Abstract [en]

    Background: Swedish youth clinics constitute one of the most comprehensive and consolidated examples of a nationwide network of health care services for young people. However, studies evaluating their 'youth-friendliness' and the combination of factors that makes them more or less 'youth-friendly' have not been conducted. This protocol will scrutinise the current youth-friendliness of youth clinics in northern Sweden and identify the best combination of conditions needed in order to implement the criteria of youth-friendliness within Swedish youth clinics and elsewhere.

    Methods/design: In this study, we will use qualitative comparative analysis to analyse the conditions that are sufficient and/or necessary to implement Youth Friendly Health Services in 20 selected youth-clinics (cases). In order to conduct Qualitative Comparative Analysis, we will first identify the outcomes and the conditions to be assessed. The overall outcome - youth-friendliness - will be assessed together with specific outcomes for each of the five domains - accessible, acceptable, equitable, appropriate and effective. This will be done using a questionnaire to be applied to a sample of young people coming to the youth clinics. In terms of conditions, we will first identify what might be the key conditions, to ensure the youth friendliness of health care services, through literature review, interviews with professionals working at youth clinics, and with young people. The combination of conditions and outcomes will form the hypothesis to be further tested later on in the qualitative comparative analysis of the 20 cases. Once information on outcomes and conditions is gathered from each of the 20 clinics, it will be analysed using Qualitative Comparative Analysis.

    Discussion: The added value of this study in relation to the findings is twofold: on the one hand it will allow a thorough assessment of the youth-friendliness of northern Swedish youth clinics. On the other hand, it will extract lessons from one of the most consolidated examples of differentiated services for young people. Methodologically, this study can contribute to expanding the use of Qualitative Comparative Analysis in health systems research.

  • 50.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mechanisms for achieving adolescent-friendly services: a realist evaluation approach2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, p. 18748-Article in journal (Refereed)
    Abstract [en]

    Background: Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach.

    In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent.

    Methods: The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes.

    Results: The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored.

    Conclusion: The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process.

    Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.

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