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  • 151.
    Kalengayi, Faustine K Nkulu
    et al.
    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.
    Nordstrand, Annika
    Ahlm, Clas
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.
    Ahlberg, Beth M
    'It is a dilemma': perspectives of nurse practitioners on health screening of newly arrived migrants2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 27903Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Screening newly arrived migrants from countries with high burden of communicable diseases of public health significance is part of the Swedish national strategy against the spread of these diseases. However, little is known about its implementation.

    OBJECTIVE: This study aimed at exploring caregivers' experiences in screening newly arrived migrants to generate knowledge that could inform policy and clinical practice.

    DESIGN: Using an interpretive description framework, we conducted semistructured interviews between November and December 2011 in four Swedish counties, with 15 purposively selected nurses with experience in screening migrants. Data were analyzed using thematic analysis.

    RESULTS: Participants described a range of challenges including discordant views between migrants and the nurses about medical screening, inconsistencies in rules and practices, and conflicting policies. Participants indicated that sociocultural differences resulted in divergent expectations with migrants viewing the participants as agents of migration authorities. They also expressed concern over being given a new assignment without training and being expected to share responsibilities with staff from other agencies without adequate coordination. Finally, they indicated that existing policies can be confusing and raise ethical issues. All these were compounded by language barriers, making their work environment extremely complex and stressful.

    CONCLUSIONS: These findings illuminate complex challenges that could limit access to, uptake, and delivery of health screening and undermine public health goals, and highlight the need for a multilevel approach. This entails avoiding the conflation of migration with health issues, harmonizing existing policies to make health care services more accessible and acceptable to migrants, and facilitating health professionals' work in promoting public health, improving interagency collaboration and the skills of all staff involved in understanding and effectively responding to migrants' needs, and improving migrants' health literacy through community outreach interventions.

  • 152. Kamuzora, Peter
    et al.
    Maluka, Stephen
    Ndawi, Benedict
    Byskov, Jens
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, article id 22669Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Community participation in priority setting in health systems has gained importance all over the world, particularly in resource-poor settings where governments have often failed to provide adequate public-sector services for their citizens. Incorporation of public views into priority setting is perceived as a means to restore trust, improve accountability, and secure cost-effective priorities within healthcare. However, few studies have reported empirical experiences of involving communities in priority setting in developing countries. The aim of this article is to provide the experience of implementing community participation and the challenges of promoting it in the context of resource-poor settings, weak organizations, and fragile democratic institutions.

    DESIGN: Key informant interviews were conducted with the Council Health Management Team (CHMT), community representatives, namely women, youth, elderly, disabled, and people living with HIV/AIDS, and other stakeholders who participated in the preparation of the district annual budget and health plans. Additionally, minutes from the Action Research Team and planning and priority-setting meeting reports were analyzed.

    RESULTS: A number of benefits were reported: better identification of community needs and priorities, increased knowledge of the community representatives about priority setting, increased transparency and accountability, promoted trust among health systems and communities, and perceived improved quality and accessibility of health services. However, lack of funds to support the work of the selected community representatives, limited time for deliberations, short notice for the meetings, and lack of feedback on the approved priorities constrained the performance of the community representatives. Furthermore, the findings show the importance of external facilitation and support in enabling health professionals and community representatives to arrive at effective working arrangement.

    CONCLUSION: Community participation in priority setting in developing countries, characterized by weak democratic institutions and low public awareness, requires effective mobilization of both communities and health systems. In addition, this study confirms that community participation is an important element in strengthening health systems.

  • 153. Kananura, Rornald Muhumuza
    et al.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Mutebi, Aloysius
    Namazzi, Gertrude
    Kiwanuka, Suzanne Namusoke
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waiswa, Peter
    Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1362826Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

    Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

    Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

    Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge.

    Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.

  • 154. Kanjala, Chifundo
    et al.
    Alberts, Marianne
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Burger, Sandra
    Spatial and temporal clustering of mortality in Digkale HDSS in rural northern South Africa2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 59-63Article in journal (Refereed)
    Abstract [en]

    Although cause-specific mortality data were not available, the rise in mortality in the 15-49-year age group over time and in areas closer to conurbations strongly suggests that the clustering observed was due to the development of HIV/AIDS-related mortality, as seen similarly elsewhere in South Africa. The HIV/AIDS services offered by the local health centre may have contributed to lower relative mortality around that location.

  • 155. Kanungsukkasem, Uraiwan
    et al.
    Ng, Nawi
    Purworejo Health and Demographic Surveillance System, Indonesia.
    Van Minh, Hoang
    Razzaque, Abdur
    Ashraf, Ali
    Juvekar, Sanjay
    Masud Ahmed, Syed
    Huu Bich, Tran
    Fruit and vegetable consumption in rural adults population in INDEPTH HDSS sites in Asia2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Low fruit and vegetable consumption is among the top 10 risk factors contributing to mortality worldwide. WHO/FAO recommends intake of a minimum of 400 grams (or five servings) of fruits and vegetables per day for the prevention of chronic diseases such as heart diseases, cancer, diabetes, and obesity.

    OBJECTIVE: This paper examines the fruit and vegetable consumption patterns and the prevalence of inadequate fruit and vegetable consumption (less than five servings a day) among the adult population in rural surveillance sites in five Asian countries.

    DATA AND METHODS: The analysis is based on data from a 2005 cross-site study on non-communicable disease risk factors which was conducted in nine Asian INDEPTH Health and Demographic Surveillance System (HDSS) sites. Standardised protocols and methods following the WHO STEPwise approach to risk factor surveillance were used. The total sample was 18,429 adults aged 25-64 years. Multivariate logistic regression analysis was performed to assess the association between socio-demographic factors and inadequate fruit and vegetable consumption.

    RESULTS: Inadequate fruit and vegetable consumption was common in all study sites. The proportions of inadequate fruit and vegetable consumption ranged from 63.5% in men and 57.5% in women in Chililab HDSS in Vietnam to the whole population in Vadu HDSS in India, and WATCH HDSS in Bangladesh. Multivariate logistic regression analysis in six sites, excluding WATCH and Vadu HDSS, showed that being in oldest age group and having low education were significantly related to inadequate fruit and vegetable consumption, although the pattern was not consistent through all six HDSS.

    CONCLUSIONS: Since such a large proportion of adults in Asia consume an inadequate amount of fruits and vegetables, despite of the abundant availability, education and behaviour change programmes are needed to promote fruit and vegetable consumption. Accurate and useful information about the health benefits of abundant fruit and vegetable consumption should be widely disseminated.

  • 156.
    Kasenga, Fyson
    et al.
    Malamulo SDA Hospital, Makwasa, Malawi.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    Objective: To study how the demand for antenatal care (ANC), HIV testing and hospital delivery was influenced by policy changes among pregnant women in rural Malawi.

    Design: Retrospective analysis of monthly reports.

    Setting: Malamulo SDA hospital in Thyolo district, Makwasa, Malawi.

    Methods: Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used.

    Results: The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery.

    Conclusions: Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.

  • 157. Kerber, Kate
    et al.
    Peterson, Stefan
    Saving Newborn Lives, Save the Children, London, UK.
    Waiswa, Peter
    Special issue: newborn health in Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 27365Article in journal (Refereed)
  • 158.
    Khan, Ashraful Islam
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Effects of pre- and postnatal nutrition interventions on child growth and body composition: the MINIMat trial in rural Bangladesh2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, article id 22476Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Nutritional insults and conditions during fetal life and infancy influence subsequent growth and body composition of children.

    OBJECTIVES: Effects of maternal food and micronutrient supplementation and exclusive breastfeeding counseling on growth of offspring aged 0-54 months and their body composition at 54 months of age were studied.

    METHODS: In the MINIMat trial (ISRCTN16581394) in Matlab, Bangladesh, pregnant women were randomized to early (around 9 weeks) or usual invitation (around 20 weeks) to food supplementation and to one of the three daily micronutrient supplements: 30-mg Fe and 400-µg folic acid (Fe30F), 60-mg Fe and 400-µg folic acid (Fe60F), and multiple micronutrient supplements (MMS). The supplements were also randomized to exclusive breastfeeding (EBF) counseling or to usual health messages.

    RESULTS: No differences in background characteristics were observed among the intervention groups. There was also no differential effect of prenatal interventions on birthweight or birthlength. Early food supplementation reduced the level of stunting from early infancy up to 54 months of age among boys (average difference - 6.5% units, 95% confidence interval [CI] 1.7-11.3, p=0.01) but not among girls (average difference - 2.4% units, 95% CI -2.2-7.0, p=0.31). MMS resulted in more stunting compared to standard Fe60F (average difference - 4.8% units, 95% CI 0.8-8.9, p=0.02). Breastfeeding counseling prolonged the duration of EBF (difference - 35 days, 95% CI 30.6-39.5, p<0.001). Neither pregnancy interventions nor breastfeeding counseling influenced the body composition of children at 54 months of age.

    CONCLUSION: Early food supplementation during pregnancy reduced the occurrence of stunting among boys aged 0-54 months, while prenatal MMS increased the proportion of stunting. Food and micronutrient supplementation or EBF intervention did not affect body composition of offspring at 54 months of age. The effects of prenatal interventions on postnatal growth suggest programming effects in early fetal life.

  • 159.
    Kien, Vu Duy
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center for Population Health Sciences, Hanoi School of Public Health, Hanoi, Vietnam; Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam.
    Lee, Hwa-Young
    Nam, You-Seon
    Oh, Juhwan
    Giang, Kim Bao
    Van Minh, Hoang
    Trends in socioeconomic inequalities in child malnutrition in Vietnam: findings from the Multiple Indicator Cluster Surveys, 2000-20112016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 29263Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Child malnutrition is not only a major contributor to child mortality and morbidity, but it can also determine socioeconomic status in adult life. The rate of under-five child malnutrition in Vietnam has significantly decreased, but associated inequality issues still need attention.

    OBJECTIVE: This study aims to explore trends, contributing factors, and changes in inequalities for under-five child malnutrition in Vietnam between 2000 and 2011.

    DESIGN: Data were drawn from the Viet Nam Multiple Indicator Cluster Survey for the years 2000 and 2011. The dependent variables used for the study were stunting, underweight, and wasting of under-five children. The concentration index was calculated to see the magnitude of child malnutrition, and the inequality was decomposed to understand the contributions of determinants to child malnutrition. The total differential decomposition was used to identify and explore factors contributing to changes in child malnutrition inequalities.

    RESULTS: Inequality in child malnutrition increased between 2000 and 2011, even though the overall rate declined. Most of the inequality in malnutrition was due to ethnicity and socioeconomic status. The total differential decomposition showed that the biggest and second biggest contributors to the changes in underweight inequalities were age and socioeconomic status, respectively. Socioeconomic status was the largest contributor to inequalities in stunting.

    CONCLUSIONS: Although the overall level of child malnutrition was improved in Vietnam, there were significant differences in under-five child malnutrition that favored those who were more advantaged in socioeconomic terms. The impact of socioeconomic inequalities in child malnutrition has increased over time. Multifaceted approaches, connecting several relevant ministries and sectors, may be necessary to reduce inequalities in childhood malnutrition.

  • 160.
    Kien, Vu Duy
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam.
    Van Minh, Hoang
    Giang, Kim Bao
    Weinehall, Lars
    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.
    Horizontal inequity in public health care service utilization for non-communicable diseases in urban Vietnam2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 24919Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A health system that provides equitable health care is a principal goal in many countries. Measuring horizontal inequity (HI) in health care utilization is important to develop appropriate and equitable public policies, especially policies related to non-communicable diseases (NCDs). DESIGN: A cross-sectional survey of 1,211 randomly selected households in slum and non-slum areas was carried out in four urban districts of Hanoi city in 2013. This study utilized data from 3,736 individuals aged 15 years and older. Respondents were asked about health care use during the previous 12 months; information included sex, age, and self-reported NCDs. We assessed the extent of inequity in utilization of public health care services. Concentration indexes for health care utilization and health care needs were constructed via probit regression of individual utilization of public health care services, controlling for age, sex, and NCDs. In addition, concentration indexes were decomposed to identify factors contributing to inequalities in health care utilization. RESULTS: The proportion of healthcare utilization in the slum and non-slum areas was 21.4 and 26.9%, respectively. HI in health care utilization in favor of the rich was observed in the slum areas, whereas horizontal equity was achieved among the non-slum areas. In the slum areas, we identified some key factors that affect the utilization of public health care services. CONCLUSION: Our results suggest that to achieve horizontal equity in utilization of public health care services, policy should target preventive interventions for NCDs, focusing more on the poor in slum areas.

  • 161.
    Kiguli, Juliet
    et al.
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Namusoko, Sarah
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Kerber, Kate
    Saving Newborn Lives program, Save the Children, Cape Town, South Africa.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Waiswa, Peter
    Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.
    Weeping in silence: community experiences of stillbirths in rural eastern Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 24011Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Stillbirths do not register amongst national or global public health priorities, despite large numbers and known solutions. Although not accounted in statistics - these deaths count for families. Part of this disconnect is that very little is known about the lived experiences and perceptions of those experiencing this neglected problem.

    OBJECTIVE:

    This study aimed to explore local definitions and perceived causes of stillbirths as well as coping mechanisms used by families affected by stillbirth in rural eastern Uganda.

    DESIGN:

    A total of 29 in-depth interviews were conducted with women who had a stillbirth (14), men whose wives experienced a stillbirth (6), grandmothers (4), grandfathers (1), and traditional birth attendants (TBAs) (4). Participants were purposively recruited from the hospital maternity ward register, with additional recruitment done through community leaders and other participants. Data were analysed using content analysis.

    RESULTS:

    Women and families affected by stillbirth report pregnancy loss as a common occurrence. Definitions and causes of stillbirth included the biomedical, societal, and spiritual. Disclosure of stillbirth varies with women who experience consecutive or multiple losses, subject to potential exclusion from the community and even the family. Methods for coping with stillbirth were varied and personal. Ritual burial practices were common, yet silent and mainly left to women, as opposed to public mourning for older children. There were no formal health system mechanisms to support or care for families affected by stillbirths.

    CONCLUSION:

    In a setting with strong collective ties, stillbirths are a burden borne by the affected family, and often just by the mother, rather than the community as a whole. Strategies are needed to address preventable stillbirths as well as to follow up with supportive services for those affected.

  • 162. Kim, Sung Wook
    et al.
    Skordis-Worrall, Jolene
    Haghparast-Bidgoli, Hassan
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Socio-economic inequity in HIV testing in Malawi2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, p. 1-15Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Human immunodeficiency virus (HIV) is a significant contributor to Malawi's burden of disease. Despite a number of studies describing socio-economic differences in HIV prevalence, there is a paucity of evidence on socio-economic inequity in HIV testing in Malawi.

    OBJECTIVE: To assess horizontal inequity (HI) in HIV testing in Malawi.

    DESIGN: Data from the Demographic and Health Surveys (DHSs) 2004 and 2010 in Malawi are used for the analysis. The sample size for DHS 2004 was 14,571 (women =11,362 and men=3,209), and for DHS 2010 it was 29,830 (women=22,716 and men=7,114). The concentration index is used to quantify the amount of socio-economic-related inequality in HIV testing. The inequality is a primary method in this study. Corrected need, a further adjustment of the standard decomposition index, was calculated. Standard HI was compared with corrected need-adjusted inequity. Variables used to measure health need include symptoms of sexually transmitted infections. Non-need variables include wealth, education, literacy and marital status.

    RESULTS: Between 2004 and 2010, the proportion of the population ever tested for HIV increased from 15 to 75% among women and from 16 to 54% among men. The need for HIV testing among men was concentrated among the relatively wealthy in 2004, but the need was more equitably distributed in 2010. Standard HI was 0.152 in 2004 and 0.008 in 2010 among women, and 0.186 in 2004 and 0.04 in 2010 among men. Rural-urban inequity also fell in this period, but HIV testing remained pro-rich among rural men (HI 0.041). The main social contributors to inequity in HIV testing were wealth in 2004 and education in 2010.

    CONCLUSIONS: Inequity in HIV testing in Malawi decreased between 2004 and 2010. This may be due to the increased support to HIV testing by global donors over this period.

  • 163.
    Kinsman, John
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norris, Shane A
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Twine, Rhian
    Riggle, Kari
    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. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Mathebula, Jennifer
    Ngobeni, Sizzy
    Monareng, Nester
    Micklesfield, Lisa K
    A model for promoting physical activity among rural South African adolescent girls2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 28790Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In South Africa, the expanding epidemic of non-communicable diseases is partly fuelled by high levels of physical inactivity and sedentary behaviour. Women especially are at high risk, and interventions promoting physical activity are urgently needed for girls in their adolescence, as this is the time when many girls adopt unhealthy lifestyles.

    OBJECTIVE: This qualitative study aimed to identify and describe facilitating factors and barriers that are associated with physical activity among adolescent girls in rural, north-eastern South Africa and, based on these, to develop a model for promoting leisure-time physical activity within this population.

    DESIGN: The study was conducted in and around three secondary schools. Six focus group discussions were conducted with adolescent girls from the schools, and seven qualitative interviews were held with sports teachers and youth leaders. The data were subjected to thematic analysis.

    RESULTS: Seven thematic areas were identified, each of which was associated with the girls' self-reported levels of physical activity. The thematic areas are 1) poverty, 2) body image ideals, 3) gender, 4) parents and home life, 5) demographic factors, 6) perceived health effects of physical activity, and 7) human and infrastructural resources. More barriers to physical activity were reported than facilitating factors.

    CONCLUSIONS: Analysis of the barriers found in the different themes indicated potential remedial actions that could be taken, and these were synthesised into a model for promoting physical activity among South African adolescent girls in resource-poor environments. The model presents a series of action points, seen both from the 'supply-side' perspective (such as the provision of resources and training for the individuals, schools, and organisations which facilitate the activities) and from the 'demand-side' perspective (such as the development of empowering messages about body image for teenage girls, and encouraging more parental involvement). The development of physical activity interventions that incorporate this supply- and demand-side model would represent an additional tool for ongoing efforts aimed at tackling the expanding non-communicable disease epidemic in South Africa, and in other resource-constrained settings undergoing rapid health transitions.

  • 164. Kiwanuka, Suzanne Namusoke
    et al.
    Akulume, Martha
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Balancing the cost of leaving with the cost of living: drivers of long-term retention of health workers: an explorative study in three rural districts in Eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345494Article in journal (Refereed)
    Abstract [en]

    Background: Health worker retention in rural and underserved areas remains a persisting problem in many low and middle income countries, and this directly affects the quality of health services offered.

    Objective: This paper explores the drivers of long-term retention and describes health worker coping mechanisms in rural Uganda.

    Methods: A descriptive qualitative study explored the factors that motivated health workers to stay, in three rural districts of Uganda: Kamuli, Pallisa, and Kibuku. In-depth interviews conducted among health workers who have been retained for at least 10 years explored factors motivating the health workers to stay within the district, opportunities, and the benefits of staying.

    Results: Twenty-one health workers participated. Ten of them male and 11 female with the age range of 33-51 years. The mean duration of stay among the participants was 13, 15, and 26 years for Kamuli, Kibuku, and Pallisa respectively. Long-term retention was related to personal factors, such as having family ties, community ties, and opportunities to invest. The decentralization policy and pension benefits also kept workers in place. Opportunities for promotion or leadership motivated long stay only if they came with financial benefits. Workload reportedly increased over the years, but staffing and emoluments had not increased. Multiple job, family support, and community support helped health workers cope with the costs of living, and holding a secure pensionable government job was valued more highly than seeking uncertain job opportunities elsewhere.

    Conclusion: The interplay between the costs of leaving and the benefit of staying is demonstrated. Family proximity, community ties, job security, and pension enhance staying, while higher costs of living and an unpredictable employment market make leaving risky. Health workers should be able to access investment opportunities in order to cope with inadequate remuneration. Promotions and leadership opportunities only motivate if accompanied by financial benefits.

  • 165.
    Kjellström, Tord
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. National Centre for Epidemiology and Population Health.
    Gabrysch, Sabine
    Lemke, Bruno
    Dear, Keith
    The 'Hothaps' programme for assessing climate change impacts on occupational health and productivity: an invitation to carry out field studies2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 81-87Article in journal (Refereed)
    Abstract [en]

    The 'high occupational temperature health and productivity suppression' programme (Hothaps) is a multi-centre health research and prevention programme aimed at quantifying the extent to which working people are affected by, or adapt to, heat exposure while working, and how global heating during climate change may increase such effects. The programme will produce essential new evidence for local, national and global assessment of negative impacts of climate change that have largely been overlooked. It will also identify and evaluate preventive interventions in different social and economic settings.

    Hothaps includes studies in any part of the world where hourly heat exposure exceeds physiological stress limits that may affect workers. This usually happens at temperatures above 25 degrees C, depending on humidity, wind movement and heat radiation. Working people in low and middle-income tropical countries are particularly vulnerable, because many of them are involved in heavy physical work, either outdoors in strong sunlight or indoors without effective cooling. If high work intensity is maintained in workplaces with high heat exposure, serious health effects can occur, including heat stroke and death.

    Depending on the type of occupation, the required work intensity, and the level of heat stress, working people have to slow down their work in order to reduce internal body heat production and the risk of heat stroke. Thus, unless preventive interventions are used to reduce the heat stress on workers, their individual health and productivity will be affected and economic output per work hour will be reduced. Heat also influences other daily physical activities, unrelated to work, in all age groups. Poorer people without access to household or workplace cooling devices are most likely to be affected.

    The Hothaps programme includes a pilot study, heat monitoring of selected workplaces, qualitative studies of perceived heat impacts and preventative interventions, quantitative studies of impacts on health and productivity, and assessments of local impacts of climate change taking into account different applications of preventative interventions.

    Fundraising for the global programme is in progress and has enabled local field studies to start in 2009. Local funding support is also of great value and is being sought by several interested scientific partners. The Hothaps team welcomes independent use of the study protocols, but would be grateful for information about any planned, ongoing or completed studies of this type. Coordinated implementation of the protocols in multi-centre studies is also welcome. Eventually, the results of the Hothaps field studies will be used in global assessments of climate change-induced heat exposure increase in workplaces and its impacts on occupational health and productivity. These results will also be of value for the next assessment by the Intergovernmental Panel on Climate Change (IPCC) in 2013.

  • 166.
    Kjellström, Tord
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    McMichael, Anthony J.
    Climate change threats to population health and well-being: the imperative of protective solutions that will last2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. Article nr 20816-Article in journal (Refereed)
    Abstract [en]

    Background: The observational evidence of the impacts of climate conditions on human health is accumulating. A variety of direct, indirect, and systemically mediated health effects have been identified. Excessive daily heat exposures create direct effects, such as heat stroke (and possibly death), reduce work productivity, and interfere with daily household activities. Extreme weather events, including storms, floods, and droughts, create direct injury risks and follow-on outbreaks of infectious diseases, lack of nutrition, and mental stress. Climate change will increase these direct health effects. Indirect effects include malnutrition and under-nutrition due to failing local agriculture, spread of vector-borne diseases and other infectious diseases, and mental health and other problems caused by forced migration from affected homes and workplaces. Examples of systemically mediated impacts on population health include famine, conflicts, and the consequences of large-scale adverse economic effects due to reduced human and environmental productivity. This article highlights links between climate change and non-communicable health problems, a major concern for global health beyond 2015. Discussion: Detailed regional analysis of climate conditions clearly shows increasing temperatures in many parts of the world. Climate modelling indicates that by the year 2100 the global average temperature may have increased by 3-4 degrees C unless fundamental reductions in current global trends for greenhouse gas emissions are achieved. Given other unforeseeable environmental, social, demographic, and geopolitical changes that may occur in a plus-4-degree world, that scenario may comprise a largely uninhabitable world for millions of people and great social and military tensions. Conclusion: It is imperative that we identify actions and strategies that are effective in reducing these increasingly likely threats to health and well-being. The fundamental preventive strategy is, of course, climate change mitigation by significantly reducing global greenhouse gas emissions, especially long-acting carbon dioxide (CO2), and by increasing the uptake of CO2 at the earth's surface. This involves urgent shifts in energy production from fossil fuels to renewable energy sources, energy conservation in building design and urban planning, and reduced waste of energy for transport, building heating/cooling, and agriculture. It would also involve shifts in agricultural production and food systems to reduce energy and water use particularly in meat production. There is also potential for prevention via mitigation, adaptation, or resilience building actions, but for the large populations in tropical countries, mitigation of climate change is required to achieve health protection solutions that will last.

  • 167.
    Klingberg-Allvin, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Atuhairwe, S
    Cleeve, A
    Byamugisha, J K
    Larsson, E C
    Makenzius, M
    Oguttu, M
    Gemzell-Danielsson, K
    Co-creation to scale up provision of simplified high-quality comprehensive abortion care in East Central and Southern Africa2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1490106Article in journal (Refereed)
    Abstract [en]

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

  • 168. Kowal, Paul
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Health Research Umeå, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Health Research Umeå, INDEPTH Network, Accra, Ghana and Purworejo HDSS, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
    Naidoo, Nirmala
    Abdullah, Salim
    Bawah, Ayaga
    Binka, Fred
    Chuc, Nguyen T K
    Debpuur, Cornelius
    Ezeh, Alex
    Xavier Gómez-Olivé, F
    Hakimi, Mohammad
    Hirve, Siddhivinayak
    Hodgson, Abraham
    Juvekar, Sanjay
    Kyobutungi, Catherine
    Menken, Jane
    Van Minh, Hoang
    Mwanyangala, Mathew A
    Razzaque, Abdur
    Sankoh, Osman
    Kim Streatfield, P
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Health Research Umeå.
    Wilopo, Siswanto
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Health Research Umeå.
    Chatterji, Somnath
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Centre for Global Health Research Umeå, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Ageing and adult health status in eight lower-income countries: the INDEPTH WHO-SAGE collaboration2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, no Supplement 2, p. 11-22Article in journal (Refereed)
    Abstract [en]

    Background: Globally, ageing impacts all countries, with a majority of older persons residing in lower- and middle-income countries now and into the future. An understanding of the health and well-being of these ageing populations is important for policy and planning; however, research on ageing and adult health that informs policy predominantly comes from higher-income countries. A collaboration between the WHO Study on global AGEing and adult health (SAGE) and International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH), with support from the US National Institute on Aging (NIA) and the Swedish Council for Working Life and Social Research (FAS), has resulted in valuable health, disability and well-being information through a first wave of data collection in 2006-2007 from field sites in South Africa, Tanzania, Kenya, Ghana, Viet Nam, Bangladesh, Indonesia and India.

    Objective: To provide an overview of the demographic and health characteristics of participating countries, describe the research collaboration and introduce the first dataset and outputs. Methods: Data from two SAGE survey modules implemented in eight Health and Demographic Surveillance Systems (HDSS) were merged with core HDSS data to produce a summary dataset for the site-specific and cross-site analyses described in this supplement. Each participating HDSS site used standardised training materials and survey instruments. Face-to-face interviews were conducted. Ethical clearance was obtained from WHO and the local ethical authority for each participating HDSS site.

    Results: People aged 50 years and over in the eight participating countries represent over 15% of the current global older population, and is projected to reach 23% by 2030. The Asian HDSS sites have a larger proportion of burden of disease from non-communicable diseases and injuries relative to their African counterparts. A pooled sample of over 46,000 persons aged 50 and over from these eight HDSS sites was produced. The SAGE modules resulted in self-reported health, health status, functioning (from the WHO Disability Assessment Scale (WHODAS-II)) and well-being (from the WHO Quality of Life instrument (WHOQoL) variables). The HDSS databases contributed age, sex, marital status, education, socio-economic status and household size variables.

    Conclusion: The INDEPTH WHO-SAGE collaboration demonstrates the value and future possibilities for this type of research in informing policy and planning for a number of countries. This INDEPTH WHO- SAGE dataset will be placed in the public domain together with this open-access supplement and will be available through the GHA website (www.globalhealthaction.net) and other repositories. An improved dataset is being developed containing supplementary HDSS variables and vignette-adjusted health variables. This living collaboration is now preparing for a next wave of data collection.

  • 169.
    Laisser, Rose M
    et al.
    Institute of Allied Health Sciences Midwifery School, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
    Nyström, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Lugina, Helen I
    Archbishop Anthony Mayalla School of Nursing, Weill Bugando University College of Health Sciences, Mwanza, Tanzania.
    Emmelin, Maria
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Screening of women for intimate partner violence: a pilot intervention at an outpatient department in Tanzania2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 7288-Article in journal (Refereed)
    Abstract [en]

    Intimate partner violence (IPV) is a public health problem in Tanzania with limited health care interventions.

    OBJECTIVES:

    To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges.

    METHODS:

    Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during March-April 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data.

    RESULTS:

    Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women hospital' only indicated a concern that abused men would be neglected.

    CONCLUSIONS:

    Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.

  • 170.
    Laisser, Rose M
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindmark, Gunilla
    Lugina, Helen I
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Clinical Sciences, Social Medicine and Global Health, Lund University, Malmö, Sweden.
    Screening of women for intimate partner violence: a pilot intervention at an outpatient department in Tanzania2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. Article nr 7288-Article in journal (Refereed)
    Abstract [en]

    Intimate partner violence (IPV) is a public health problem in Tanzania with limited health care interventions.

    OBJECTIVES: To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges.

    METHODS: Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during March-April 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data.

    RESULTS: Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women hospital' only indicated a concern that abused men would be neglected.

    CONCLUSIONS: Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.

  • 171. Leitao, Jordana
    et al.
    Chandramohan, Daniel
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jakob, Robert
    Bundhamcharoen, Kanitta
    Choprapawon, Chanpen
    de Savigny, Don
    Fottrell, Edward
    França, Elizabeth
    Frøen, Frederik
    Gewaifel, Gihan
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Krishnan, Anand
    Kumar, Vishwajeet
    Masanja, Honorati
    Nichols, Erin
    Notzon, Francis
    Rasooly, Mohammad Hafiz
    Sankoh, Osman
    Spiegel, Paul
    AbouZahr, Carla
    Amexo, Marc
    Kebede, Derege
    Alley, William Soumbey
    Marinho, Fatima
    Ali, Mohamed
    Loyola, Enrique
    Chikersal, Jyotsna
    Gao, Jun
    Annunziata, Giuseppe
    Bahl, Rajiv
    Bartolomeus, Kidist
    Boerma, Ties
    Ustun, Bedirhan
    Chou, Doris
    Muhe, Lulu
    Mathai, Matthews
    Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 21518-Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems.

    METHODS: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification.

    FINDINGS: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach.

    CONCLUSIONS: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.

  • 172.
    Lena, Karlsson
    et al.
    Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR). Umeå University, Faculty of Social Sciences, Department of Sociology.
    Häggström Lundevaller, Erling
    Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Schumann, Barbara
    Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR). Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    The association between cold extremes and neonatal mortality in Swedish Sápmi from 1800–18952019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1623609Article in journal (Refereed)
    Abstract [en]

    Background: Studies in which the association between temperature and neonatal mortality (deaths during the first 28 days of life) is tracked over extended periods that cover demographic, economic and epidemiological transitions are quite limited. From previous research about the demographic transition in Swedish Sápmi, we know that infant and child mortality was generally higher among the indigenous (Sami) population compared to non-indigenous populations.

    Objective: The aim of this study was to analyse the association between extreme temperatures and neonatal mortality among the Sami and non-Sami population in Swedish Sápmi (Lapland) during the nineteenth century.

    Methods: Data from the Demographic Data Base, Umeå University, were used to identify neonatal deaths. We used monthly mean temperature in Tornedalen and identified cold and warm month (5th and 95th) percentiles. Monthly death counts from extreme temperatures were modelled using negative binomial regression. We computed relative risks (RR) with 95% confidence intervals (CI), adjusting for time trends and seasonality.

    Results: Overall, the neonatal mortality rate was higher among Sami compared to non-Sami infants (62/1,000 vs 35/1,000 live births), although the differences between the two populations decreased after 1860. For the Sami population prior 1860, the results revealed a higher neonatal incidence rate during cold winter months (< -15.4 °C, RR=1.60, CI 1.14–2.23) compared to infants born during months of medium temperature). No association was found between extreme cold months and neonatal mortality for non-Sami populations. Warm months (+15.1 °C) had no impact on Sami or non-Sami populations.

    Conclusions: This study revealed the role of environmental factors (temperature extremes) on infant health during the demographic transition where cold extremes mainly affected the Sami population. Ethnicity and living conditions contributed to differential weather vulnerability.

  • 173.
    Lillo-Crespo, Manuel
    et al.
    Univ Alicante, Spain.
    Riquelme, Jorge
    Univ Alicante, Spain.
    Macrae, Rhoda
    Univ West Scotland, UK.
    De Abreu, Wilson
    Univ Porto, Portugal.
    Hanson, Elizabeth
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Holmerova, Iva
    Univ Karlova Praze, Czech Republic.
    Jose Cabanero, Ma
    Univ Alicante, Spain.
    Ferrer, Rosario
    Univ Alicante, Spain.
    Tolson, Debbie
    Univ West Scotland, UK.
    Experiences of advanced dementia care in seven European countries: implications for educating the workforce2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1478686Article in journal (Refereed)
    Abstract [en]

    Background: There is a paucity of robust research concerning the care experiences of peoplewith advanced dementia within Europe. It is essential to understand these experiences if weare to address care inequalities and create impactful dementia policies to improve servicesthat support individuals and enable family caring. Objectives: To identify the strengths and weaknesses in daily life perceived by people with dementia and family caring across Europe by exemplifying experiences and the range of typical care settings for advanced dementia care in seven partner countries. Methods: Twenty two in-depth qualitative case studies were completed in seven European countries across a range of care settings considered typical within that country. Narrative accounts of care illuminated a unique set of experiences and highlighted what was working well (strengths or positive aspects) and not so well (weaknesses or negative aspects) for people with advanced dementia and family caring. A constant comparative method of analysis through thematic synthesis was used to identify the common themes. Results: Eight key themes were identified; Early diagnosis, good coordination between service providers, future planning, support and education for carers, enabling the person with dementia to live thebest life possible and education on advanced dementia for professional and family caregiverswere all significant and recurring issues considered important for care experiences to bepositive. Conclusion: People with advanced dementia may have limited opportunities for self-realization and become increasingly reliant on the support of others to maximize their health and well-being. Careful attention must be given to their psychosocial well-being, living environment and family caring to enable them to live the best life possible. Building on what the case studies tell us about what works well, we discuss the potential for integrating the findings into interprofesional learning solutions for the professional workforce across Europe to champion practice-based change.

  • 174.
    Lindahl, Bernt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Increasing glucose concentrations and prevalence of diabetes mellitus in northern Sweden, 1990-20072010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5222-Article in journal (Refereed)
    Abstract [en]

    Background: The prevalence of diabetes in the world is projected to rise from 2.8% in the year 2000 to 4.4% in 2030, an increase suggesting an ongoing global epidemic of diabetes.

    Objective: To examine time trends in fasting and 2-h glucose concentrations, prevalence and 10-year cumulative incidence of diabetes, and the role of education in these trends. Design: Each year the Vasterbotten Intervention Programme invites all 40, 50, and 60-year-old individuals to a health survey, which includes a cardiovascular risk factor screening and oral glucose tolerance test. The cross-sectional part of the study is based on health examinations conducted between 1990 and 2007 (n = 102,822). The prospective subset (panel dataset) of the study is based on individuals who have had two health examinations 10 years apart and were not defined as having diabetes at their first health examination (n = 23,546).

    Results: Between 1990 and 2007, the mean population fasting glucose concentration increased 0.5 mmol/L. Comparing the prevalence in 1990-1995 with 2002-2007 demonstrated a significant 44% increase in men (p < 0.001) and a significant 17% increase in women (p < 0.001). Socioeconomic status, here represented by education, clearly influenced both prevalence and incidence of diabetes and glucose concentration. In all time periods and in all age groups, individuals with low education were more likely to have or get diabetes. The 10-year risk of developing diabetes was four to five times higher in the oldest age group (50-60 years) compared with the youngest (30-40 years). A 30% reduction in the 10-year risk of developing diabetes was found in women (p < 0.001) between 2000-2003 and 2004-2007.

    Conclusions: Despite a clear increase in glucose concentrations and diabetes prevalence between 1990 and 2007, especially in men, there was a decline in the 10-year risk of developing diabetes in women between 2000-2003 and 2004-2007.

  • 175.
    Lu, Sai San Moon
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. a Department of Preventive and Social Medicine, University of Medicine Mandalay, Mandalay, Myanmar.
    Stewart Williams, Jennifer
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Research Centre for Generational Health and Ageing, Faculty of Health, University of Newcastle, New Lambton Heights, NSW, Australia.
    Nilsson Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Inequalities in early childhood mortality in Myanmar: Association between parents' socioeconomic status and early childhood mortality2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1603516Article in journal (Refereed)
    Abstract [en]

    Background: Despite global achievements in reducing early childhood mortality, disparities remain. There have been empirical studies of inequalities conducted in low- and middle-income countries. However, there have been no epidemiological studies on socioeconomic inequalities and early childhood survival in Myanmar.

    Objective: To estimate associations between two measures of parental socioeconomic status - household wealth and education - and age-specific early childhood mortality in Myanmar.

    Methods: Using cross-sectional data obtained from the Myanmar Demographic Health Survey (2015-2016), univariate and multiple logistic regressions were performed to investigate associations between household wealth and highest attained parental education, and under-5, neonatal, post-neonatal and child mortality. Data for 10,081 children born to 5,932 married women (aged 15-49 years) 10 years prior to the survey, were analysed.

    Results: Mortality during the first five years was associated with household wealth. In multiple logistic models, wealth was protective for post-neonatal mortality. After adjusting for individual proximate determinants, the odds of post-neonatal mortality in the richest households were 85% lower (95% CI: 50-96%) than in the poorest households. However, significant association was not found between wealth and neonatal mortality. Parental education was important for early childhood mortality; the highest benefit from parental education was for child mortality in the one- to five-year age bracket. After adjusting for proximate determinants, children with a higher educated parent had 95% (95% CI 77-99%) lower odds of death in this age group compared with children whose parents' highest educational attainment was at primary level. The association between parental education and neonatal mortality was not significant.

    Conclusions: In Myanmar, household wealth and parental education are important for childhood survival before five years of age. This study identified nuanced age-related differences in associations. Health policy must take socioeconomic determinants into account in order to address unfair inequalities in early childhood mortality.

  • 176. Lucas, Henry
    et al.
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Distance- and blended-learning in global health research: potentials and challenges2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 33429Article in journal (Refereed)
  • 177.
    Mahiti, Gladys Reuben
    et al.
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Mbekenga, Columba K.
    School of Nursing and Midwifery, Agakhan University, Dar es Salaam, Tanzania.
    Kiwara, Angwara Dennis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of 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.
    Perceptions about the cultural practices of male partners during postpartum care in rural Tanzania: a qualitative study2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1361184Article in journal (Refereed)
    Abstract [en]

    Background: Men play an important role in maternal health. The postpartum period is a critical stage, yet there is a scarcity of research that explores men's involvement during this stage.

    Objective: The aim of the study was to explore male partners' perceptions of the cultural practices during postpartum care in rural Tanzania.

    Methods: Fourteen focus group discussions were conducted with 93 men, with an age range of 19-65 years, in August 2013. The study was conducted in the Kongwa District, located in the Dodoma region in central Tanzania. Qualitative data were digitally recorded, transcribed verbatim and analyzed using content analysis.

    Results: Four categories emerged, namely: 'Men as providers and, occasionally, care takers', 'Men as decision makers', 'Diverse perceptions of sexual abstinence' and 'Barriers for men in using/accompanying partners to use reproductive and child healthcare services'. The crosscategory theme 'Men during postpartum: remaining powerful but excluded' refers to how men are in a powerful position above women in different aspects of life. Elderly women played an important role in caring for postpartum mothers and their newborns, but men were the ones making the final decision about where to seek care. Traditional practices isolated men from their partners for a certain period, and enforced sexual abstinence for the women during the postpartum period. However, cultural norms permitted men to engage in extramarital relations. Reproductive and child healthcare services were perceived by men as not welcoming the male partners, and local gender norms discouraged men from accompanying their partners to seek services.

    Conclusions: In this study, we found that men perceived their role during the postpartum period as financial providers, decision makers and, occasionally, care givers. Men also held diverse perceptions with regard to sexual abstinence and felt excluded from participating in maternal healthcare services.

  • 178.
    Mahiti, Gladys Reuben
    et al.
    Dar es Salaam, Tanzania.
    Mkoka, Dickson Ally
    Dar es Salaam, Tanzania.
    Kiwara, Angwara Dennis
    Dar es Salaam, Tanzania.
    Mbekenga, Columba Kokusiima
    Dar es Salaam, Tanzania.
    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.
    Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-9, article id 28567Article in journal (Refereed)
    Abstract [en]

    Background: Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. Design: We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. Results: 'Three categories emerged that reflected women's perceptions of maternal health care services: "mothers perceive that maternal health services are beneficial," "barriers to accessing maternal health services" such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and "ambivalence regarding the quality of maternal health services" reflecting that women had both positive and negative perceptions in relation to quality of health care services offered'. Conclusions: Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women.

  • 179. Massad, Eduardo
    et al.
    Amaku, Marcos
    Bezerra Coutinho, Francisco Antonio
    Kittayapong, Pattamaporn
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Theoretical impact of insecticide-impregnated school uniforms on dengue incidence in Thai children2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Background: Children carry the main burden of morbidity and mortality caused by dengue. Children spend a considerable amount of their day at school; hence strategies that reduce human-mosquito contact to protect against the day-biting habits of Aedes mosquitoes at schools, such as insecticide-impregnated uniforms, could be an effective prevention strategy.

    Methodology: We used mathematical models to calculate the risk of dengue infection based on force of infection taking into account the estimated proportion of mosquito bites that occur in school and the proportion of school time that children wear the impregnated uniforms. Principal findings: The use of insecticide-impregnated uniforms has efficacy varying from around 6% in the most pessimistic estimations, to 55% in the most optimistic scenarios simulated.

    Conclusions: Reducing contact between mosquito bites and human hosts via insecticide-treated uniforms during school time is theoretically effective in reducing dengue incidence and may be a valuable additional tool for dengue control in school-aged children. The efficacy of this strategy, however, is dependent on the compliance of the target population in terms of proper and consistent wearing of uniforms and, perhaps more importantly, the proportion of bites inflicted by the Aedes population during school time.

  • 180. Massad, Eduardo
    et al.
    Tan, Ser-Han
    Khan, Kamran
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Public Health, University of Heidelberg, Germany ; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
    Estimated Zika virus importations to Europe by travellers from Brazil2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, p. 1-7, article id 31669Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Given the interconnectivity of Brazil with the rest of the world, Zika virus (ZIKV) infections have the potential to spread rapidly around the world via viremic travellers. The extent of spread depends on the travel volume and the endemicity in the exporting country. In the absence of reliable surveillance data, we did mathematical modelling to estimate the number of importations of ZIKV from Brazil into Europe.

    DESIGN: We applied a previously developed mathematical model on importations of dengue to estimate the number of ZIKV importations into Europe, based on the travel volume, the probability of being infected at the time of travel, the population size of Brazil, and the estimated incidence of ZIKV infections.

    RESULTS: Our model estimated between 508 and 1,778 imported infections into Europe in 2016, of which we would expect between 116 and 355 symptomatic Zika infections; with the highest number of importations being into France, Portugal and Italy.

    CONCLUSIONS: Our model identified high-risk countries in Europe. Such data can assist policymakers and public health professionals in estimating the extent of importations in order to prepare for the scale up of laboratory diagnostic assays and estimate the occurrence of Guillain-Barré Syndrome, potential sexual transmission, and infants with congenital ZIKV syndrome.

  • 181.
    Mee, Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Madhavan, Sangeetha
    Kabudula, Chodziwadziwa
    Gómez-Olivé, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Hargreaves, James
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 24826Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.

    DESIGN: This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.

    RESULTS: Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.

    CONCLUSIONS: In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.

  • 182.
    Mehdiyar, Manijeh
    et al.
    Department of Infectious Diseases, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
    Andersson, Rune
    Department of Infectious Diseases, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
    Hjelm, Katarina
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Povlsen, Lene
    Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark.
    HIV-positive migrants’ encounters with the Swedish health care system2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 31753Article in journal (Refereed)
    Abstract [en]

    Background: There is limited knowledge about human immunodeficiency virus (HIV)-positive migrants and their experiences in the Swedish health care system. It is necessary to increase our knowledge in this field to improve the quality of care and social support for this vulnerable group of patients.

    Objective: The aim of this study was to describe the experiences of HIV-positive migrants and their encounters with the health care system in Sweden.

    Design: This is a Grounded Theory study based on qualitative interviews with 14 HIV-positive migrants living in Sweden, aged 29–55 years.

    Results: ‘A hybrid of access and adversity’ was identified as the core category of the study. Three additional categories were ‘appreciation of free access to treatment’, ‘the impact of the Swedish Disease Act on everyday life’, and ‘encountering discrimination in the general health care system’. The main finding indicated that participants experienced frustration and discrimination because they were required to provide sexual partners with information about their HIV status, which is compulsory under the Swedish Disease Act. The study also showed that the bias or fear regarding HIV infection among general health care professionals outside of the infectious diseases clinics limited the access to the general health care system for HIV-positive migrants.

    Conclusions: The HIV-positive migrants appreciated the free access to antiviral therapy, but wished to have more time for patient–physician communications. The participants of this study felt discrimination in health care settings outside of the infectious diseases clinics. There is a need to reduce the discrimination in general health care services and to optimize the social support system and social network of this vulnerable group.

  • 183. Minh An, Dao Thi
    et al.
    Nguyen, Ngoc Thi Bich
    Nilsson, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Influenza-like illness in a Vietnamese province: epidemiology in correlation with weather factors and determinants from the surveillance system2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 23073Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Seasonal influenza affects from 5 to 15% of the world's population annually and causes an estimated 250,000-500,000 deaths worldwide. The World Health Organization (WHO) recommends 'sentinel surveillance' for influenza-like illness (ILI) because it is simple and calls for standardized methods at a relatively low cost that can be implemented throughout the world. In Vietnam, ILI is a key priority for public health also because of its annually recurring temporal pattern. Two major factors, on which the spread of influenza depends, are the strain of the virus and its rate of mutation, since flu strains constantly mutate as they compete with host immune systems. In the context of global climate change, the role of climatic factors has been discussed, as they may significantly contribute to the cause of large outbreaks of ILI. OBJECTIVES: 1) To describe the epidemiology of ILI in Ha Nam province, Vietnam; 2) to seek scientific evidence on the association of ILI occurrence with weather factors in Ha Nam province; and 3) to analyze factors from the Ha Nam ILI surveillance system that contribute to explaining the correlation between the ILI and the weather factors. DESIGN: A data set of 89,270 monthly reported ILI cases from 2008 to 2012 in Ha Nam was used to describe ILI epidemiological characteristics. Spearman correlation analyses between ILI cases and weather factors were conducted to identify which preceding period of months and weather patterns influenced the occurrence of ILI cases. Ten in-depth interviews with health workers in charge of recording and reporting ILI cases at different levels of the ILI surveillance system were conducted to gain a deeper understanding of factors contributing to explaining the relation between the ILI and the weather factors. RESULTS: The results indicated that the ILI occurred annually in all districts of the Ha Nam province in the five studied years. An epidemic occurred in 2009 with the number of cases three times higher than the average threshold. There was a relation between the ILI cases in the previous 1 month with ILI cases of the following month. A seasonal cycle of ILI and correlation between weather elements were not clearly detected. A qualitative study showed that the number of ILI cases reported by the Provincial Preventive Medicine Centre (PPMC) in Ha Nam might not have reflected the accurate number of seasonal ILI occurring in this area. This was due to three gaps in the ILI surveillance system that initially were detected through key in-depth interviews in the Duy Tien and Binh Luc districts. They reported inconsistent ways of recording and reporting ILI cases among communes, lack of ILI survey forms, and irregular and delayed feedback from the PPMC. CONCLUSIONS: There were no clear patterns of association between weather factors and ILI cases detected from the five studied years. The number of ILI cases reported by the PPMC in Ha Nam may not reflect adequately the actual number of seasonal ILI occurring in this area due to three weak points in the ILI surveillance system initially detected through the case of the Duy Tien and Binh Luc districts. These three weak points of the system should be examined by a study conducted in the remaining districts in Ha Nam.

  • 184. Minh An, Dao Thi
    et al.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Epidemiology of dengue fever in Hanoi from 2002 to 2010 and its meteorological determinants2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 23074Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Dengue fever (DF) is a growing public health problem in Vietnam. The disease burden in Vietnam has been increasing for decades. In Hanoi, in contrast to many other regions, extrinsic drivers such as weather have not been proved to be predictive of disease frequency, which limits the usefulness of such factors in an early warning system. AIMS: The purpose of this research was to review the epidemiology of DF transmission and investigate the role of weather factors contributing to occurrence of DF cases. METHODS: Monthly data from Hanoi (2002-2010) were used to test the proposed model. Descriptive time-series analysis was conducted. Stepwise multivariate linear regression analysis assuming a negative binomial distribution was established through several models. The predictors used were lags of 1-3 months previous observations of mean rainfall, mean temperature, DF cases, and their interactions. RESULTS: Descriptive analysis showed that DF occurred annually and seasonally with an increasing time trend in Hanoi. The annual low occurred from December to March followed by a gradual increase from April to July with a peak in September, October. The amplitude of the annual peak varied between years. Statistically significant relationships were estimated at lag 1-3 with rainfall, autocorrelation, and their interaction while temperature was estimated as influential at lag 3 only. For these relationships, the final model determined a correlation of 92% between predicted number of dengue cases and the observed dengue disease frequencies. CONCLUSIONS: Although the model performance was good, the findings suggest that other forces related to urbanization, density of population, globalization with increasing transport of people and goods, herd immunity, government vector control capacity, and changes in serotypes are also likely influencing the transmission of DF. Additional research taking into account all of these factors besides climatic factors is needed to help developing and developed countries find the right intervention for controlling DF epidemics, and to set up early warning systems with high sensitivity and specificity. Immediate action to control DF outbreak in Hanoi should include an information, communication, and education program that focuses on training Hanoi residents to more efficiently eliminate stagnant puddles and water containers after each rainfall to limit the vector population growth.

  • 185. Mocumbi, Sibone
    et al.
    McKee, Kevin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Munguambe, Khátia
    Chiau, Rogério
    Högberg, Ulf
    Hanson, Claudia
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Göteborgs universitet.
    Sevene, Esperança
    Bergström, Anna
    Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1532631Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

    OBJECTIVES: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

    METHODS: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach's α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

    RESULTS: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

    CONCLUSIONS: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants' responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

  • 186.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique.
    McKee, Kevin
    Munguambe, Khátia
    Chiau, Rogério
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Hanson, Claudia
    Wallin, Lars
    Sevene, Esperança
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Ready to deliver maternal and newborn care?: Health providers' perceptions of their work context in rural Mozambique2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1532631Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

    OBJECTIVES: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

    METHODS: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach's α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

    RESULTS: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

    CONCLUSIONS: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants' responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

  • 187.
    Moshi, Haleluya
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Faculty of Rehabilitation Medicine, Physiotherapy Department, Kilimanjaro Christian Medical University College, Moshi, Tanzania.
    Sundelin, Gunnevi
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Sahlen, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Nursing.
    Sörlin, Ann
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Traumatic spinal cord injury in the north-east Tanzania: describing incidence, etiology and clinical outcomes retrospectively2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1355604Article in journal (Refereed)
    Abstract [en]

    Background: Causes, magnitude and consequences of traumatic spinal cord injury depend largely on geography, infrastructure, socioeconomic and cultural activities of a given region. There is a scarcity of literature on profile of traumatic spinal cord injury to inform prevention and rehabilitation of this health condition in African rural settings, particularly Tanzania. Objective: To describe the incidence, etiology and clinical outcomes of traumatic spinal cord injury and issues related to retrospective study in underdeveloped setting.

    Methods: Records for patients with traumatic spinal cord injury for five consecutive years (2010–2014) were obtained retrospectively from the admission wards and health records archives of the Kilimanjaro Christian Medical Center. Sociodemographic, cause, complications and patients’ condition on discharge were recorded and analyzed descriptively.

    Results: The admission books in the wards registered 288 new traumatic spinal cord injury cases from January 2010 to December 2014. Of the 288 cases registered in the books, 224 were males and 64 females with mean age 39.1(39.1 ± 16.3) years and the majority of individuals 196(68.1%) were aged between 16 and 45 years. A search of the hospital archives provided 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). Cervical 81(39.9%) and lumbar 71(34.74%) spinal levels were the most affected. The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million population. The most docu- mented complications were pressure ulcers 42(19.7%), respiratory complications 32(15.0%) and multiple complications 28(13.1%). The mean length of hospital stay was 64.2 ± 54.3 days and the mortality rate was 24.4%.

    Conclusion: Prevention of traumatic spinal cord injury in North-east Tanzania should consider falls (particularly from height) as the leading cause, targeting male teenagers and young adults. Pressure ulcers, respiratory complications, in-hospital mortality and availability of wheelchairs should be addressed. 

  • 188. Mossong, Joël
    et al.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Herbst, Kobus
    Who died of what in rural KwaZulu-Natal, South Africa: a cause of death analysis using InterVA-42014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 25496Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: For public health purposes, it is important to see whether men and women in different age groups die of the same causes in South Africa.

    OBJECTIVE: We explored sex- and age-specific patterns of causes of deaths in a rural demographic surveillance site in northern KwaZulu-Natal in South Africa over the period 2000-2011.

    DESIGN: Deaths reported through the demographic surveillance were followed up by a verbal autopsy (VA) interview using a standardised questionnaire. Causes of death were assigned likelihoods using the publicly available tool InterVA-4. Cause-specific mortality fractions were determined by age and sex.

    RESULTS: Over the study period, a total of 5,416 (47%) and 6,081 (53%) deaths were recorded in men and women, respectively. Major causes of death proportionally affecting more women than men were (all p<0.0001): human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (20.1% vs. 13.6%), other and unspecified cardiac disease (5.9% vs. 3.2%), stroke (4.5% vs. 2.7%), reproductive neoplasms (1.7% vs. 0.4%), diabetes (2.4% vs. 1.2%), and breast neoplasms (0.4% vs. 0%). Major causes of deaths proportionally affecting more men than women were (all p<0.0001) assault (6.1% vs. 1.7%), pulmonary tuberculosis (34.5% vs. 30.2%), road traffic accidents (3.0% vs. 1.0%), intentional self-harm (1.3% vs. 0.3%), and respiratory neoplasms (2.5% vs. 1.5%). Causes of death due to communicable diseases predominated in all age groups except in older persons.

    CONCLUSIONS: While mortality during the 2000s was dominated by tuberculosis and HIV/AIDS, we found substantial sex-specific differences both for communicable and non-communicable causes of death, some which can be explained by a differing sex-specific age structure. InterVA-4 is likely to be a valuable tool for investigating causes of death patterns in other similar Southern African settings.

  • 189. Murray, Natasha
    et al.
    Jansarikij, Suphachai
    Olanratmanee, Phanthip
    Maskhao, Pongsri
    Souares, Aurélia
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Public Health, University of Heidelberg, Heidelberg, Germany ; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
    Kittayapong, Pattamaporn
    Louis, Valérie R
    Acceptability of impregnated school uniforms for dengue control in Thailand: a mixed methods approach2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 24887-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: As current dengue control strategies have been shown to be largely ineffective in reducing dengue in school-aged children, novel approaches towards dengue control need to be studied. Insecticide-impregnated school uniforms represent an innovative approach with the theoretical potential to reduce dengue infections in school children.

    OBJECTIVES: This study took place in the context of a randomised control trial (RCT) to test the effectiveness of permethrin-impregnated school uniforms (ISUs) for dengue prevention in Chachoengsao Province, Thailand. The objective was to assess the acceptability of ISUs among parents, teachers, and principals of school children involved in the trial.

    METHODOLOGY: Quantitative and qualitative tools were used in a mixed methods approach. Class-clustered randomised samples of school children enrolled in the RCT were selected and their parents completed 321 self-administered questionnaires. Descriptive statistics and logistic regression were used to analyse the quantitative data. Focus group discussions and individual semi-structured interviews were conducted with parents, teachers, and principals. Qualitative data analysis involved content analysis with coding and thematic development.

    RESULTS: The knowledge and experience of dengue was substantial. The acceptability of ISUs was high. Parents (87.3%; 95% CI 82.9-90.8) would allow their child to wear an ISU and 59.9% (95% CI 53.7-65.9) of parents would incur additional costs for an ISU over a normal uniform. This was significantly associated with the total monthly income of a household and the educational level of the respondent. Parents (62.5%; 95% CI 56.6-68.1) indicated they would be willing to recommend ISUs to other parents.

    CONCLUSIONS: Acceptability of the novel tool of ISUs was high as defined by the lack of concern along with the willingness to pay and recommend. Considering issues of effectiveness and scalability, assessing acceptability of ISUs over time is recommended.

  • 190. Musenge, Eustasius
    et al.
    Vounatsou, Penelope
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    The contribution of spatial analysis to understanding HIV/TB mortality in children: a structural equation modelling approach2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, p. 38-48, article id 19266Article in journal (Refereed)
    Abstract [en]

    Background: South Africa accounts for more than a sixth of the global population of people infected with HIV and TB, ranking her highest in HIV/TB co-infection worldwide. Remote areas often bear the greatest burden of morbidity and mortality, yet there are spatial differences within rural settings.

    Objectives: The primary aim was to investigate HIV/TB mortality determinants and their spatial distribution in the rural Agincourt sub-district for children aged 1-5 years in 2004. Our secondary aim was to model how the associated factors were interrelated as either underlying or proximate factors of child mortality using pathway analysis based on a Mosley-Chen conceptual framework.

    Methods: We conducted a secondary data analysis based on cross-sectional data collected in 2004 from the Agincourt sub-district in rural northeast South Africa. Child HIV/TB death was the outcome measure derived from physician assessed verbal autopsy. Modelling used multiple logit regression models with and without spatial household random effects. Structural equation models were used in modelling the complex relationships between multiple exposures and the outcome (child HIV/TB mortality) as relayed on a conceptual framework.

    Results: Fifty-four of 6,692 children aged 1-5 years died of HIV/TB, from a total of 5,084 households. Maternal death had the greatest effect on child HIV/TB mortality (adjusted odds ratio = 4.00; 95% confidence interval = 1.01-15.80). A protective effect was found in households with better socio-economic status and when the child was older. Spatial models disclosed that the areas which experienced the greatest child HIV/TB mortality were those without any health facility.

    Conclusion: Low socio-economic status and maternal deaths impacted indirectly and directly on child mortality, respectively. These factors are major concerns locally and should be used in formulating interventions to reduce child mortality. Spatial prediction maps can guide policy makers to target interventions where they are most needed.

  • 191. Mutebi, Aloysius
    et al.
    Kananura, Rornald Muhumuza
    Ekirapa-Kiracho, Elizabeth
    Bua, John
    Kiwanuka, Suzanne Namusoke
    Nammazi, Gertrude
    Paina, Ligia
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health, Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1347363Article in journal (Refereed)
    Abstract [en]

    Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services.

    Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda.

    Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively.

    Results: Almost a quarter of the savings groups had 5-14 members and slightly more than half of the saving groups had 15-30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks, respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders, irregular attendance of meetings (22%), and lack of training on management and leadership (19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results.

    Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.

  • 192.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Neonatal mortality: an invisible and marginalised trauma2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5724-Article, review/survey (Refereed)
    Abstract [en]

    Neonatal mortality is a major health problem in low and middle income countries and the rate of improvement of newborn survival is slow. This article is a review of the PhD thesis by Mats Målqvist, titled 'Who can save the unseen - Studies on neonatal mortality in Quang Ninh province, Vietnam,' from Uppsala University. The thesis aims to investigate structural barriers to newborn health improvements and determinants of neonatal death. The findings reveal a severe under-reporting of neonatal deaths in the official health statistics in Quang Ninh province in northern Vietnam. The neonatal mortality rate (NMR) found was four times higher than what was reported to the Ministry of Health. This underestimation of the problem inhibits adequate interventions and efforts to improve the survival of newborns and highlights the invisibility of this vulnerable group.

    The findings of the thesis also point at an inequity in survival chances based on ethnicity of the mother. Newborns of ethnic minority mothers were at a twofold risk of dying within the first 4 weeks of life compared to their peers belonging to the hegemonic group of Kinh (OR 2.08, 95% CI: 1.39-3.10). This increased risk was independent of maternal education and household economic status. Neonatal mortality was also associated with home deliveries, non-attendance to antenatal care and distance to the health care facilities. However, ethnic minority mothers still had an increased risk of experiencing a neonatal death even if they attended antenatal care, delivered at, or lived close to a health facility. This example of ethnic inequity highlights the importance to target those most in need.

  • 193.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Preserving misconceptions or a call for action? - A hermeneutic re-reading of the Nativity story2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Behaviour is guided by perceptions and traditions. As such, understanding culture and religion is important in order to understand healthcare behaviour. Religious perceptions shape a person's understanding of the world and are maintained through texts and tradition. One such important religious text in relation to sexual and reproductive health is the Nativity story. This account of the conception and birth of Jesus is well known in the Christian cultural sphere and beyond, and it has for generations shaped perceptions of childbirth.

    METHODS: This paper attempts a re-reading of the Nativity story using a hermeneutic approach.

    RESULTS AND CONCLUSION: This reveals a dual understanding of the Nativity, not just as an account of immaculate transcendence and a rosy Christmas tale, but as a source of identification for pregnant women and mothers and a call to action for improved maternal and child healthcare.

  • 194.
    Målqvist, Mats
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Hoa, Dinh Thi Phuong
    Hanoi School of Public Health, Hanoi, Vietnam.
    Liem, Nguyen Thanh
    Research Institute for Child Health (RICH), National Hospital of Pediatrics, Hanoi, Vietnam.
    Thorson, Anna
    Division of Global Health (IHCAR), Department of Public Health, Karolinska Institutet, Solna, Sweden.
    Thomsen, Sarah
    Division of Global Health (IHCAR), Department of Public Health, Karolinska Institutet, Solna, Sweden.
    Ethnic minority health in Vietnam: a review exposing horizontal inequity2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-19Article, review/survey (Refereed)
    Abstract [en]

    Background:

    Equity in health is a pressing concern and reaching disadvantaged populations is necessary to close the inequity gap. To date, the discourse has predominately focussed on reaching the poor. At the same time and in addition to wealth, other structural determinants that influence health outcomes exist, one of which is ethnicity. Inequities based on group belongings are recognised as 'horizontal', as opposed to the more commonly used notion of 'vertical' inequity based on individual characteristics.

    Objective:

    The aim of the present review is to highlight ethnicity as a source of horizontal inequity in health and to expose mechanisms that cause and maintain this inequity in Vietnam.

    Design:

    Through a systematic search of available academic and grey literature, 49 publications were selected for review. Information was extracted on: a) quantitative measures of health inequities based on ethnicity and b) qualitative descriptions explaining potential reasons for ethnicity-based health inequities.

    Results:

    Five main areas were identified: health-care-seeking and utilization, maternal and child health, nutrition, infectious diseases, and oral health and hygiene. Evidence suggests the presence of severe health inequity in health along ethnic lines in all these areas. Research evidence also offers explanations derived from both external and internal group dynamics to this inequity. It is reported that government policies and programs appear to be lacking in culturally adaptation and sensitivity, and examples of bad attitudes and discrimination from health staff toward minority persons were identified. In addition, traditions and patriarchal structures within ethnic minority groups were seen to contribute to the maintenance of harmful health behaviors within these groups.

    Conclusion:

    Better understandings of the scope and pathways of horizontal inequities are required to address ethnic inequities in health. Awareness of ethnicity as a determinant of health, not only as a covariate of poverty or living area, needs to be improved, and research needs to be designed with this in mind.

  • 195.
    Målqvist, Mats
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pun, Asha
    UN Health Section, UNICEF, Nepal.
    Raaijmakers, Hendrikus
    UN Health Section, UNICEF, Nepal.
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). UN Health Section, UNICEF, Nepal.
    Persistent inequity in maternal health care utilization in Nepal despite impressive overall gains2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1356083Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal health care utilization is at the core of global public health provision and an area of focus in the now-concluded Millennium Development Goal agenda.

    OBJECTIVE: This study aims to examine trends in maternal health care utilization over the last 15 years in Nepal, focusing on coverage and equity.

    METHODS: This paper used data from the Demographic Health Survey (DHS) 2001, 2006 and 2011 and Multiple Indicator Cluster Survey (MICS), 2014. Coverage rates were calculated and logistic regression models used to examine inequity.

    RESULTS: Impressive gains were found in antenatal care (ANC) attendance, which increased from nearly half of women attending (49%) in 2001 to 88% in 2014, and the rate of facility delivery increased from just 7-44%. This development did not, however, influence the equity gap in ANC and skilled attendance at birth, as women from low socioeconomic backgrounds were six times more likely to deliver without skilled assistance than those from high socioeconomic backgrounds (AdjOR 6.38 CI 95% 4.57-8.90) in 2014.

    CONCLUSION: These persistent equity gaps call for targeted interventions focusing on the most disadvantaged and vulnerable women in order to achieve the new Sustainable Development Goal of universal health coverage.

  • 196.
    Nalwadda, Christine K
    et al.
    School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    Waiswa, Peter
    School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    Guwatudde, David
    School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    Kerber, Kate
    Saving Newborn Lives, Save the Children, Cape Town, South Africa.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kiguli, Juliet
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
    'As soon as the umbilical cord gets off, the child ceases to be called a newborn': sociocultural beliefs and newborn referral in rural Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 24386Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The first week of life is the time of greatest risk of death and disability, and is also associated with many traditional beliefs and practices. Identifying sick newborns in the community and referring them to health facilities is a key strategy to reduce deaths. Although a growing area of interest, there remains a lack of data on the role of sociocultural norms and practices on newborn healthcare-seeking in sub-Saharan Africa and the extent to which these norms can be modified.

    OBJECTIVE:

    This study aimed to understand the community's perspective of potential sociocultural barriers and facilitators to compliance with newborn referral.

    METHOD:

    In this qualitative study, focus group discussions (n=12) were conducted with mothers and fathers of babies aged less than 3 months. In addition, in-depth interviews (n=11) were also held with traditional birth attendants and mothers who had been referred by community health workers to seek health-facility-based care. Participants were purposively selected from peri-urban and rural communities in two districts in eastern Uganda. Data were analysed using latent content analysis.

    RESULTS:

    The community definition of a newborn varied, but this was most commonly defined by the period between birth and the umbilical cord stump falling off. During this period, newborns are perceived to be vulnerable to the environment and many mothers and their babies are kept in seclusion, although this practice may be changing. Sociocultural factors that influence compliance with newborn referrals to seek care emerged along three sub-themes: community understanding of the newborn period and cultural expectations; the role of community health actors; and caretaker knowledge, experience, and decision-making autonomy.

    CONCLUSION:

    In this setting, there is discrepancy between biomedical and community definitions of the newborn period. There were a number of sociocultural factors that could potentially affect compliance to newborn referral. The widely practised cultural seclusion period, knowledge about newborn sickness, individual experiences in households, perceived health system gaps, and decision-making processes were facilitators of or barriers to compliance with newborn referral. Designers of newborn interventions need to address locally existing cultural beliefs at the same time as they strengthen facility care.

  • 197. Namazzi, Gertrude
    et al.
    Okuga, Monica
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University, School of Public Health (MakSPH), Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Kakaire, Ayub
    Namutamba, Sarah
    Mutebi, Aloysius
    Kiwanuka, Suzanne Namusoke
    Ekirapa-Kiracho, Elizabeth
    Waiswa, Peter
    Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345495Article in journal (Refereed)
    Abstract [en]

    Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

    Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

    Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

    Results: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (>= 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

    Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.

  • 198.
    Namazzi, Gertrude
    et al.
    School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
    Waiswa, Peter
    School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
    Nakakeeto, Margaret
    Kampala Children's Hospital, Kampala, Uganda.
    Nakibuuka, Victoria K
    St. Raphael of St. Francis Hospital, Nsambya, Kampala, Uganda.
    Namutamba, Sarah
    School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
    Najjemba, Maria
    Ministry of Health, Kampala, Uganda.
    Namusaabi, Ruth
    Ministry of Health, Kampala, Uganda.
    Tagoola, Abner
    Ministry of Health, Kampala, Uganda.
    Nakate, Grace
    Ministry of Health, Kampala, Uganda.
    Ajeani, Judith
    Ministry of Health, Kampala, Uganda.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Byaruhanga, Romano N
    St. Raphael of St. Francis Hospital, Nsambya, Kampala, Uganda.
    Strengthening health facilities for maternal and newborn care: experiences from rural eastern Uganda2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, article id 24271Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities.

    OBJECTIVE:

    This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme.

    DESIGN:

    This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening.

    RESULTS:

    Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs.

    CONCLUSION:

    Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities.

  • 199. Nasreen, Hashima-E
    et al.
    Nahar, Shamsun
    Al Mamun, Mahfuz
    Afsana, Kaosar
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Oral misoprostol for preventing postpartum haemorrhage in home births in rural Bangladesh: how effective is it?2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 7017-Article in journal (Refereed)
    Abstract [en]

    AIMS: Evidence exists about prevention of postpartum haemorrhage (PPH) by oral administration of misoprostol in low-income countries, but effectiveness of prevention by lay community health workers (CHW) is not sufficient. This study aimed to investigate whether a single dose (400 µg) of oral misoprostol could prevent PPH in a community home-birth setting and to assess its acceptability and feasibility among rural Bangladeshi women.

    METHODS: This quasi-experimental trial was conducted among 2,017 rural women who had home deliveries between November 2009 and February 2010 in two rural districts of northern Bangladesh. In the intervention district 1,009 women received 400 µg of misoprostol immediately after giving birth by the lay CHWs, and in the control district 1,008 women were followed after giving birth with no specific intervention against PPH. Primary PPH (within 24 hours) was measured by women's self-reported subjective measures of the normality of blood loss using the 'cultural consensus model.' Baseline data provided socio-economic, reproductive, obstetric, and bleeding disorder information.

    FINDINGS: The incidence of primary PPH was found to be lower in the intervention group (1.6%) than the control group (6.2%) (p<0.001). Misoprostol provided 81% protection (RR: 0.19; 95% CI: 0.08-0.48) against developing primary PPH. The proportion of retained and manually removed placentae was found to be higher in the control group compared to the intervention group. Women in the control group were more likely to need an emergency referral to a higher level facility and blood transfusion than the intervention group. Unexpectedly few women experienced transient side effects of misoprostol. Eighty-seven percent of the women were willing to use the drug in future pregnancy and would recommend to other pregnant women.

    CONCLUSION: Community-based distribution of oral misoprostol (400 µg) by CHW appeared to be effective, safe, acceptable, and feasible in reducing the incidence of PPH in rural areas of Bangladesh. This strategy should be scaled up across the country where access to skilled attendance is limited.

  • 200. Ndila, Carolyne
    et al.
    Bauni, Evasius
    Mochamah, George
    Nyirongo, Vysaul
    Makazi, Alex
    Kosgei, Patrick
    Tsofa, Benjamin
    Nyutu, Gideon
    Etyang, Anthony
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Williams, Thomas N
    Causes of death among persons of all ages within the Kilifi Health and Demographic Surveillance System, Kenya, determined from verbal autopsies interpreted using the InterVA-4 model2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 25593Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The vast majority of deaths in the Kilifi study area are not recorded through official systems of vital registration. As a result, few data are available regarding causes of death in this population.

    OBJECTIVE: To describe the causes of death (CODs) among residents of all ages within the Kilifi Health and Demographic Surveillance System (KHDSS) on the coast of Kenya.

    DESIGN: Verbal autopsies (VAs) were conducted using the 2007 World Health Organization (WHO) standard VA questionnaires, and VA data further transformed to align with the 2012 WHO VA instrument. CODs were then determined using the InterVA-4 computer-based probabilistic model.

    RESULTS: Five thousand one hundred and eighty seven deaths were recorded between January 2008 and December 2011. VA interviews were completed for 4,460 (86%) deaths. Neonatal pneumonia and birth asphyxia were the main CODs in neonates; pneumonia and malaria were the main CODs among infants and children aged 1-4, respectively, while HIV/AIDS was the main COD for adult women of reproductive age. Road traffic accidents were more commonly observed among men than women. Stroke and neoplasms were common CODs among the elderly over the age of 65.

    CONCLUSIONS: We have established the main CODs among people of all ages within the area served by the KHDSS on the coast of Kenya using the 2007 WHO VA questionnaire coded using InterVA-4. We hope that our data will allow local health planners to estimate the burden of various diseases and to allocate their limited resources more appropriately.

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