| 1. |
- Gangane, Nitin, 1961-
(författare)
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Breast cancer in rural India : knowledge, attitudes, practices; delays to care and quality of life
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Cancer is a major public health problem globally. The incidence of cancer is increasing rapidly in many low- and middle-income countries like India due to the epidemiological transition. At present, breast cancer is the leading cancer in females in many countries including India. In spite of all of the epidemiological evidence pointing towards a surge in breast cancer cases, the National Cancer Control Programme of India has not yet taken sufficient measures to understand the disease burden and to plan a course of action to cope with the increasing cancer burden. Aim: The aim of this thesis is to explore the knowledge, attitudes, and practices regarding breast cancer in a predominantly rural district of central India along with identifying the determinants of delays to care and quality of life (QoL) in breast cancer patients. This understanding may help to strengthen the health system by improving breast cancer control and management programmes and the delivery of care.Methods: This thesis combines findings from two cross-sectional studies in the predominantly rural district of Wardha. The first study was a population-based crosssectional survey conducted on 1000 women, in which face-to-face interviews were conducted with the help of a questionnaire covering demographic and socio-economic information, knowledge, attitudes and practices regarding breast cancer screening and breast cancer. The Chi-square test for proportions and t-test for means were used and multivariable linear regression analysis was performed to study the association between socio-demographic factors and knowledge, attitude and practices. The second study was a patient-based cross-sectional study conducted in 212 breast cancer patients. All 212 breast cancer patients were included for patient delay. However, 208 female breast cancer patients could be included for system delay, quality of life and self-efficacy, as there was some information lacking in 4 patients. Information on socio-demographic characteristics, patient and system delays and also reasons for the delays were collected. The study also utilised WHOQOL–BREF for QoL and selfefficacy measurements in breast cancer patients. Socio-demographic determinants were examined by frequencies and means and multivariable logistic and linear regression analysis to assess the relationship between exposure and outcome variables.Results: One third of the respondents had not heard about breast cancer, and more than 90% of women from both rural and semi-urban areas were not aware of breast self-examination. Patient delay of more than 3 months was observed in almost half of participants, while a system delay of more than 12 weeks was seen in 23% of the breast cancer patients. The late clinical stage of the disease was also significantly associated with patient delay. The most common reason for patient delay was painlessness of the breast lump. Incorrect initial diagnosis or late reference for diagnosis were the most common reasons for diagnostic delay while the high cost of treatment was the most common reason for treatment delay. Self-efficacy was positively associated with QoL, after adjusting for socio-demographic factors, patient delay and clinical stage of disease.Conclusions: Our research showed poor awareness and knowledge about breast cancer, its symptoms and risk factors in women in rural India. Breast self-examination was hardly practiced, although the willingness to learn was high. Although The ideal is to have no delay in diagnosis and treatment, diagnostic and treatment delays observed in the study were not much higher than those reported in the literature, even from countries with good health facilities. However, further research is needed to identify access barriers throughout the process of cancer diagnosis and treatment. The quality of life was moderately good and its strong relationship with self-efficacy makes these two dimensions of breast cancer patients relevant enough to be considered for health workers and policy makers in the future.Interventions focused on improving breast awareness in women and the breast cancer continuum of care should be implemented at a district level. The role of community social health activists in breast cancer prevention should be encouraged and the implementation of an operational national breast cancer program is urgently required.
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| 2. |
- Hii, Yien Ling, 1962-
(författare)
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Climate and dengue fever : early warning based on temperature and rainfall
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Dengue is a viral infectious disease that is transmitted by mosquitoes. The disease causes a significant health burden in tropical countries, and has been a public health burden in Singapore for several decades. Severe complications such as hemorrhage can develop and lead to fatal outcomes. Before tetravalent vaccine and drugs are available, vector control is the key component to control dengue transmission. Vector control activities need to be guided by surveillance of outbreak and implement timely action to suppress dengue transmission and limit the risk of further spread. This study aims to explore the feasibility of developing a dengue early warning system using temperature and rainfall as main predictors. The objectives were to 1) analyze the relationship between dengue cases and weather predictors, 2) identify the optimal lead time required for a dengue early warning, 3) develop forecasting models, and 4) translate forecasts to dengue risk indices.Methods: Poisson multivariate regression models were established to analyze relative risks of dengue corresponding to each unit change of weekly mean temperature and cumulative rainfall at lag of 1-20 weeks. Duration of vector control for localized outbreaks was analyzed to identify the time required by local authority to respond to an early warning. Then, dengue forecasting models were developed using Poisson multivariate regression. Autoregression, trend, and seasonality were considered in the models to account for risk factors other than temperature and rainfall. Model selection and validation were performed using various statistical methods. Forecast precision was analyzed using cross-validation, Receiver Operating Characteristics curve, and root mean square errors. Finally, forecasts were translated into stratified dengue risk indices in time series formats.Results: Findings showed weekly mean temperature and cumulative rainfall preceded higher relative risk of dengue by 9-16 weeks and that a forecast with at least 3 months would provide sufficient time for mitigation in Singapore. Results showed possibility of predicting dengue cases 1-16 weeks using temperature and rainfall; whereas, consideration of autoregression and trend further enhance forecast precision. Sensitivity analysis showed the forecasting models could detect outbreak and non-outbreak at above 90% with less than 20% false positive. Forecasts were translated into stratified dengue risk indices using color codes and indices ranging from 1-10 in calendar or time sequence formats. Simplified risk indices interpreted forecast according to annual alert and outbreak thresholds; thus, provided uniform interpretation.Significance: A prediction model was developed that forecasted a prognosis of dengue up to 16 weeks in advance with sufficient accuracy. Such a prognosis can be used as an early warning to enhance evidence-based decision making and effective use of public health resources as well as improved effectiveness of dengue surveillance and control. Simple and clear dengue risk indices improve communications to stakeholders.
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| 3. |
- Hirve, Siddhivinayak, 1961-
(författare)
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"In general, how do you feel today?" Self-rated health in the context of aging in India
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Most aging research comes from the developed world. Aging research in India is focused on disease states and risk factors. Evidence on elderly health, physical performance and disability to understand the psycho-social or socio-behavioral risk is limited in India. Self-rated health (SRH) is used often in survey settings to quickly assess health status and is known to predict morbidity and mortality. The first wave of the Study on global AGEing and adult health (SAGE) survey provides an opportunity to explore the complex construct of SRH in the context of the aging process in its various key life domains of health, disability, cognition, activities of daily life, work, family, security and well-being in low and middle income settings.Objectives: This research aims to (a) understand pathways through which the social environment, functional disability, health behaviour and chronic disease experience influence SRH, (b) examine the role of SRH in predicting mortality, (c) validate SRH to improve its interpersonal comparability, and (d) assess how well estimates of SRH derived directly from a ‘small area’ survey compare with ‘small area’ estimates derived indirectly from a ‘large area’ survey.Methods: The Vadu Health and Demographic Surveillance System (HDSS) monitor health and demographic trends in a rural population of more than 100 000 in 22 villages in India since 2002. The full and short version of the SAGE survey was implemented in Vadu in 2007-09 among 321 and 5432 individuals aged 50 years and above, respectively. A structural equation model tested pathways through which social and biological factors influenced SRH. A Cox proportional hazard model examined the role of SRH as a predictor for mortality. Anchoring vignettes were used to evaluate SRH for reporting heterogeneity. The Hierarchical Ordered Probit model adjusted SRH for reporting heterogeneity. The SRH prevalence estimates for Vadu derived indirectly (indirect synthetic estimate, empirical Bayes estimate, Hierarchical Bayes estimate) from the national SAGE survey were compared with estimates derived directly from the Vadu SAGE survey, using different design and model-based techniques.Results: Older individuals reported poor SRH compared to those younger. Women rated their quality of life and SRH poorer than men. The effect of age on SRH was mediated through functional disability. Higher socioeconomic status and higher quality of life was in turn associated with better SRH but this relationship lacked statistical significance. Smoking or consumption of tobacco was associated with at least one chronic illness which in turn was associated with poor SRH and quality of life. However the association between chronic illness and SRH and quality of life was not statistically significant. Mortality risk was higher among individuals who reported bad/very bad SRH, disability and lack of spousal support independent of age and sex. There was strong evidence of reporting heterogeneity in SRH that was influenced by age, sex, education and socioeconomic status. The prevalence of ‘good / very good’ SRH was estimated to be 50%. This direct survey estimate compared well with the prevalence estimate of about 45% derived indirectly from model-based small area estimation methods. The indirect synthetic estimate for Vadu (23.2%) was a poor approximation to the direct survey or modelbased estimate.Conclusion: This research establishes the value and utility of SRH as a simple measure of health and predictor of mortality in an aging context. It provides evidence to formulate programs and policies towards an enabling social environment and an ability to function in key life domains of health and well-being. It highlights the need to identify and adjust self-rated responses for interpersonal incomparability prior to making comparisons across individuals or groups of individuals. It highlights the potential of using information from large national surveys by district level managers for planning and evaluation of policies and programs at the district or sub-district level. Finally, this research provides the basis for integrating SRH and related questions into routine HDSS.
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| 4. |
- Karhina, Kateryna, 1982-
(författare)
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Social capital and well-being in the transitional setting of Ukraine
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The military conflict in Ukraine that started in 2014 was accompanied with many changes in the political, economic and social spheres. It brought informal volunteering activities (i.e. one form of social capital) to emerge, function and later to be formalized, in order to support soldiers and their families. This situation is unique given the transitional setting of Ukraine, which has led to comparably low levels of social capital and negative indicators of health and well-being. This thesis aims to explore social capital during military conflict in contemporary Ukraine and to analyze the associations between social capital and well-being, as well as the distribution of social capital among Ukrainian women and men.Methods: The study combines a qualitative and quantitative research design. A case study was conducted using qualitative methodology. Eighteen in-depth interviews were collected with providers and utilizers of volunteering services. Grounded Theory and social action ideal types methodology of Weber were used for the analysis. The quantitative research utilized two secondary datasets. The World Health Survey was utilized to analyze the association between social capital and physical and mental well-being for women (n=1723) and men (n=910) by means of multivariate logistic regression. The European Social Survey (wave 6) was used in order to investigate access to social capital and the determinants of gender inequalities in the access with a sample of 1377 women and 797 men. Multivariate logistic regression and postregression Fairlie’s decomposition analysis were used to analyze the determinants of the inequalities.Results: The key findings of this thesis show that social capital transforms during military conflict and takes particular forms in transitional settings. There are positive and negative effects on well-being connected to crisisrelated volunteering. The associations between social capital and well-being vary for women and men in favour of women. Social capital is unequally distributed between different social groups. Some forms of social capital may have stronger buffering effect on women than men in Ukraine. Access to social capital can be viewed as an indicator for social well-being, and thus social capital can be used both as a determinant and an outcome in social capital and health research.Conclusion: Informal social participation, i.e. volunteering might play an important role in societal crises and needs to be considered in social capital measurements and interventions. Social capital measurements utilized in stable societies do not evidently capture these forms, i.e. it is not taken into account. The associations between social capital and well-being depend on the measurements that are used. Since social capital has both positive and negative effects on well-being, this should be considered in research, policies and practices in order to prevent negative and promote positive outcomes. In Ukraine, as well as in other settings, social capital is an unequal resource for different societal groups. Reducing gender and income inequalities would probably influence the distribution of social capital within the society.
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| 5. |
- Kien, Vu Duy, 1977-
(författare)
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Inequalities in non-communicable diseases in urban Hanoi, Vietnam : health care utilization, expenditure and responsiveness of commune health stations
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Non-communicable diseases (NCDs) are the leading causes of morbidity and mortality among adults in Vietnam. Little is known about the magnitude of socioeconomic inequalities in NCDs and other NCD-related factors in urban areas, in particular among the poor living in slum areas. Understanding these disparities are essential in contributing to the knowledge, needed to reduce inequalities and close the related health gaps burdening the disadvantaged populations in urban areas. Objective: To examine the burden and health system responsiveness to NCDs in Hanoi, Vietnam and investigate the role of socioeconomic inequalities in their prevalence, subsequent healthcare utilization and related impoverishment due to health expenditures. Methods: A cross-sectional study was conducted among 3,736 individuals aged 15 years and over who lived in 1211 randomly selected households in 2013 in urban Hanoi, Vietnam. The study collected information on household’s characteristics, household expenditures, and household member information. A qualitative approach was implemented to explore the responsiveness of commune health stations to the increasing burden of NCDs in urban Hanoi. In-depth interview approach was conducted among health staff involved in NCD tasks at four commune health stations in urban Hanoi. Furthermore, NCD managers at relevance district, provincial and national levels were interviewed. Results: The prevalence of self-reported NCDs was significantly higher among individuals in non-slum areas (11.6%) than those in slum areas (7.9%). However, the prevalence of self-reported NCDs concentrated among the poor in both slum and non-slum areas. In slum areas, the poor needed more health care services, but the rich consumed more health care services. Among households with at least one household member reporting diagnosis of NCDs, the proportion of household facing catastrophic health expenditure and impoverishment were the greater in slum areas than in non-slum areas. Poor households in slum areas were more likely to face catastrophic health expenditure and impoverishment. The poor in non-slum areas were also more likely to face impoverishment if their household members experienced NCDs. Health system responses to NCDs at commune health stations in urban Hanoi were weak, characterized by the lack of health information, inadequate human resources, poor financing, inadequate quality and quantity of services, lack of essential medicines. The commune health stations were not prepared to respond to the rising prevalence of NCDs in urban Hanoi. Conclusion: This thesis shows the existence of socioeconomic inequalities in the prevalence of self-reported NCDs in both non-slum and slum areas in urban Hanoi. NCDs associated with the inequalities in health care utilization, catastrophic health expenditure and impoverishment, particular in slum areas. Appropriate interventions should focus more on specific population groups to reduce the socioeconomic inequalities in the NCD prevalence and health care utilization related to NCDs to prevent catastrophic health expenditure and impoverishment among the households of NCD patients. The functions of commune health stations in the urban setting should be strengthened through the development of NCDs service packages covered by the health insurance.
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| 6. |
- Lestari, Septi Kurnia, 1989-
(författare)
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Active and healthy ageing in Europe : significance of social relationships
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Social relationships have important roles in achieving active and healthy ageing. Social relationships are dynamic across the life course. A myriad of contextual and individual (e.g., sociodemographic and health-related) factors shape the levels of social relationship constructs (e.g., social contact, participation, and support) and how they change over time. This thesis aims to contribute to a better understanding of social relationships among the older European population, the impact of health on social relationships, the influence of social relationships on quality of life, and the impact of the COVID-19 pandemic on the levels of social relationships.Methods: The study subjects were community-dwelling Europeans aged 50 and over who participated in the Survey of Health, Ageing and Retirement in Europe (SHARE) between 2004 and 2020. In Sub-study 1, multilevel growth modelling was used to analyse the trajectories of seven social relationship constructs, i.e., provision and receipt of instrumental support, social contact, and participation in volunteer work, sport/social club, educational activity, and political/community organisation. Sub-study 2 used latent class analysis (LCA) to identify social relationship typologies based on the seven social relationship constructs and perceived emotional support. Next, the associations between frailty and social relationship typologies were analysed using LCA-with-covariates. Sub-study 3 evaluated the possible causal effect of social support provision, support receipt, and participation on quality of life using doubly robust estimation and sensitivity analysis for unobserved confounding. Sub-study 4 used multilevel logistic regression analysis to determine whether individuals’ exposure to COVID-19 and the country’s COVID-19 policies stringency index (S-Index) were associated with the initiation of provision and receipt of instrumental support and volunteering during the first phase of the COVID-19 pandemic. Results: In contrast to instrumental support receipt, the probability of instrumental support provision, social contact, and participation declined slightly over time (Sub-study 1). Four social relationship types were identified: 1) poor, 2) frequent and emotionally close, 3) frequent, emotionally close, and supportive, and 4) frequent, emotionally close, and active (Sub-study 2). Poor self-rated health limited instrumental support provision and increased instrumental support receipt from outside the household (Sub-study 1). Being pre-frail or frail was associated with less active social relationship types, i.e., Types 1, 2, and 3 (Sub-study 2). Social participation and instrumental support provision for people outside the household were correlated with a higher quality of life while receiving instrumental support was associated with a lower quality of life. None of these associations could be considered causal (Sub-study 3). During the COVID-19 pandemic, the level of volunteering and instrumental support provision was lower, but the level of instrumental support receipt was higher than before the pandemic. Being exposed to COVID-19 was positively associated with support receipt initiation. The close ones’ exposure to COVID-19 was positively associated with volunteering, support provision, and support receipt. S-Index was positively associated with instrumental support provision initiation but negatively associated with support receipt initiation (Sub-study 4).Conclusions: A significant share of older Europeans was socially active. Their engagement in social contact, support, and participation changed over time. The four social relationship types revealed the importance of having frequent contact in initiating instrumental support exchange and social participation. Health is a vital determinant of older adults’ social relationships. On the other hand, observed associations indicate that social relationships may influence older adults’ quality of life. The pandemic might lower social support provision and volunteering and increase support receipt levels in the population. However, the pandemic might also encourage older adults to provide help, likely to people within their neighbourhood. Overall, maintaining close social ties, especially with family and close friends, is important to stimulate active engagement in social support exchange and participation, which promotes healthy ageing.
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| 7. |
- Pujilestari, Cahya Utamie, 1982-
(författare)
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Abdominal obesity among older population in Indonesia : socioeconomic and gender inequality, pattern and impacts on disability and death
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Population ageing has contributed to the rise of chronic non-communicable diseases (NCDs). Concurrently, obesity prevalence is increasing in all age groups and has become a serious public health problem. Obesity is the main risk factors of the major chronic NCDs such as type 2 diabetes and has been linked to disability and mortality. Studies of socioeconomic inequalities in obesity among older people in Indonesia are scarce. Understanding socioeconomic inequalities are essential to develop appropriate health programme to improve the population health. This thesis describes the pattern of socioeconomic and gender inequality in abdominal obesity and analyses its impact on disability and all-cause mortality among older people in Indonesia.Methods: This thesis is based on four studies conducted in Purworejo Health and Demographic Surveillance System (HDSS) site in Purworejo district, Central Java, Indonesia. This thesis uses both quantitative and qualitative methods. The qualitative study (sub-study 1) was based on 12 Focus Group Discussions (FGDs) with 68 participants from different age groups, sex, and living area. Content analysis was used to describe the community perceptions on diabetes and its risk factors. The quantitative studies (sub-study 2 to 4) utilized longitudinal panel data from the 1st (n = 11,753 individuals) and 2nd wave (n = 14,235 individuals) of the WHO-INDEPTH Study on global AGEing and adult health (SAGE) conducted among all individuals aged 50 years and older in 2007 and 2010. Sub-study 2 used concentration index and decomposition analysis to analyse the pattern of socioeconomic and gender inequality in abdominal obesity. Sub-study 3 used linear regression to examine the association between abdominal obesity and disability. Sub-study 4 used Cox regression analysis with restricted cubic splines to examine the impact of abdominal obesity on all-cause mortality.Results: The FGDs reveals that the community holds unrealistic optimism in perceiving diabetes its risk factors. The community stated that chronic NCD such as diabetes is caused by modern lifestyles and mostly attacks those who are considered as the wealthy (sub-study 1). Socioeconomic inequality in abdominal obesity exists in Purworejo HDSS. Abdominal obesity was more prevalent among the affluent men and women, with a lesser inequality gaps between rich and poor among women. The main contributing factors to inequalities in abdominal obesity were occupation, wealth index, and education (sub-study 2). In three-year period, the mean waist circumference decreased significantly among the poor. An increase in waist circumference was significantly associated with disability, and the poor people were more disabled compared to the rich (sub-study 3). A U-shaped association was observed between waist circumference and all-cause mortality, particularly among women. This indicated an increased risk of mortality in the lower and upper end of the waist circumference distribution. The poor with low waist circumference had a higher risk of mortality than the rich (sub-study 4).Conclusion: Abdominal obesity was disproportionately more prevalent among older Indonesian women. Though the wealthy people have higher burden of abdominal obesity, the poor people experiences more disability and higher risk of death. Misperception on chronic NCDs and its risk factors exist among the Indonesian population. Abdominal obesity prevention strategies are needed to prevent chronic NCDs, disabilities, and mortality among Indonesian older population. The prevention strategies should be culturally sensitive and address all socioeconomic levels. Special attention should be given to disadvantaged women as the most vulnerable group.
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| 8. |
- Vaezghasemi, Masoud, 1978-
(författare)
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Nutrition transition and the double burden of malnutrition in Indonesia : a mixed method approach exploring social and contextual determinants of malnutrition
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionNutrition transition concerns the broad changes in the human diet that have occurred over time and space. In low- to middle-income countries such as Indonesia, nutrient transition describes shifts from traditional diets high in cereal and fibre towards Western pattern diets high in sugars, fat, and animal-source foods. This causes a swift increase in the prevalence of overweight and obesity while undernutrition remains a great public health concern. Thus a double burden of malnutrition occurs in the population. The main aim of this investigation was to explore social and contextual determinants of malnutrition in Indonesia. The specific objectives were: (i) to examine body mass index (BMI) changes at the population level, and between and within socioeconomic groups; (ii) to estimate which context (i.e., household or district) has a greater effect on the variation of BMI; (iii) to assess the prevalence of double burden households (defined as the coexistence of underweight and overweight individuals residing in the same household) and its variation among communities as well as its determining factors; and (iv) to explore and understand what contributes to a double burden of malnutrition within a household by focusing on gender relations.MethodsA mixed method approach was adopted in this study. For the quantitative analyses, nationally representative repeated cross-sectional survey data from four Indonesian Family Life Surveys (IFLS; 1993, 1997, 2000, 2007) were used. The IFLS contains information about individual-level, household-level and area-level characteristics. The analyses covered single and multilevel regressions. Data for the qualitative component were collected from sixteen focus group discussions conducted in Central Java and in the capital city Jakarta among 123 rural and urban men and women. Connell’s relational theory of gender and Charmaz’s constructive grounded theory were used to analyse the qualitative data.ResultsGreater increases in BMI were observed at higher percentiles compared to the segment of the population at lower percentiles. While inequalities in mean BMI decreased between socioeconomic groups, within group dispersion increased over time. Households were identified as an important social context in which the variation of BMI increased over time. Ignoring the household level did not change the relative variance contribution of districts on BMI in the contextual analysis. Approximately one-fifth of all households exhibited a double burden of malnutrition. Living in households with a higher socioeconomic status resulted in higher odds of double burden of malnutrition with the exception of women-headed households and communities with high social capital. The qualitative analysis resulted in the construction of three categories: capturing the significance of gendered power relations, the emerging obesogenic environment, and generational relations for child malnutrition.ConclusionAt the population level, greater increases in within-group inequalities imply that growing inequalities in BMI were not merely driven by socioeconomic factors. This suggests that other under-recognised social and contextual factors may have a greater effect on the variation in BMI. At the contextual level, recognition of increased variation among households is important for creating strategies that respond to the differential needs of individuals within the same household. At the household level, women’s empowerment and community social capital should be promoted to reduce inequalities in the double burden of malnutrition across different socioeconomic groups. Ultimately community health and nutrition programmes will need to address gender empowerment and engage men in the fight against the emerging obesogenic environment and increased malnutrition that is evident within households, especially overweight and obesity among children.
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| 9. |
- Krishnan, Anand, 1964-
(författare)
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Gender inequity in child survival : travails of the girl child in rural north India
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: While substantial progress has been made globally towards achieving United Nations Millennium Development Goal 4 (MDG 4) on child mortality, the decline is not sufficient to reach the targets set for 2015. The South Asian region, which includes India, was to achieve the MDG 4 target of 39 deaths per 1000 live births by 2015 but was estimated to have reached only 61 by 2011. A part of this under-achievement is due to the gender-differentials in child mortality in South-Asia. The inherent biological advantage of girls, reflected inlower mortality rates as compared to boys globally, is neutralized by their sociocultural disadvantage in India. The availability of technology for prenatal sex determination has promoted sex-linked abortions. Current government efforts include a law that regulates the use of ultrasound and other diagnostic techniquesfor prenatal testing of sex and a conditional cash transfer (CCT) scheme thatinvests a certain amount of funds at the birth of a girl child to attain maturity when the girl turns 18 years of age. This thesis describes the trends in genderspecific mortality during the period 1992-2011 and gender differentials in causes of death among children (paper I), compares gender differentials in child survivalby socio-economic status of the family (paper II), explores the contribution of non-specific effects of diphtheria-tetanus-pertussis (DTP) vaccination to the excess mortality among girls (paper III), and evaluates the impact of CCT schemes of the government and explores community attitudes and practices related to discrimination of girls (paper IV).Methods and Results: This study is set in Ballabgarh Health and DemographicSurveillance System (HDSS) of Haryana State in North India that covered a population of 88,861 across 28 villages in 2011. This study uses the electronic database that houses all individuals enumerated in the HDSS for the period 1992-2011 along with other demographic, socio-economic and health utilization variables. Sex ratio at birth (SRB) was adverse for girls throughout the study period, varying between 821 to 866 girls per 1000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to the increasing neonatal mortality rate and decreasing mortality in subsequent age groups. Mortality rates among girls were 1.6 to 2 times higher than boys during the post-neonatal period (1-11 months) as well as in the 1-4 year age group. Girls reported significantly higher mortality rates due to prematurity (relative risk of 1.52; 95% CI = 1.01-2.29); diarrhoea (2.29;1.59-3.29), and malnutrition (3.37; 2.05-5.53) during 2002-2007. The SRB and neonatal mortality rate were consistently adverse for girls in the advantaged groups. In the 1-36 month age group, girl children had higher mortality than boys in all SES groups. The age at vaccination for and coverage with ivabstractBacillus Calmette–Guérin, DTP, polio and measles vaccines did not differ by sex. There was significant excess mortality among girls as compared to boys in the period after immunization with DTP, for both primary (hazard ratio of 1.65; 95% CI 1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations until the receipt of the next vaccine. No significant excess mortality among girls was noted after exposure to BCG (1.06; 0.67-1.67) or measles (1.34; 0.85-2.12) vaccine. A community survey showed poor awareness of specific government schemes for girl children. Four-fifths of the community wanted government to help families with girl children financially. In-depth interviews of government programme implementers revealed the themes of “conspiracy of silence” that was being maintained by general population, underplaying of the pervasiveness of the problem coupled with a passive implementation of the programme and “a clash between politicians trying to cash in on the public sentiment of need for subsidies for girl children and a bureaucratic approachof accountability which imposed lot of conditionalities and documentations to access these benefits”. While there has been some improvement in investment in girl children for immunization and education during the period 1992 to 2010, these were also seen among boys of the same houses and daughters in-laws who come from outside the state where such schemes are not in place.Conclusions: In the study area, girl children continue to be disadvantaged a tall periods in their childhood including in utero. In the short run, empowerment of individuals by education and increasing wealth without a concomitant change in culture of son-preference is harmful as it promotes the use of sex determination technology and female feticide to achieve desired family size and composition. There is a need to carefully review the use of health-enhancing technologies including vaccines so that they do not cause more harm to society. Current government efforts to address the gender imbalance are not working, as these are not rooted in a larger social context.
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| 10. |
- Muindi, Kanyiva, 1973-
(författare)
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Air pollution in Nairobi slums : sources, levels and lay perceptions
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundAir quality in Africa has remained a relatively under-researched field. Most of the African population is dependent on biomass for cooking and heating, with most of the combustion happening in low efficiency stoves in unvented kitchens. The resulting high emissions are compounded by ingress from poor outdoor air in a context of poor emissions controls. The situation is dire in slum households where homes are crowded and space is limited, pushing households to cook in the same room that is used for sleeping. This study assessed the levels of particulate matter with aerodynamic diameter £ 2.5 microns (PM2.5) in slum households and people's perceptions of and attitudes towards air pollution and health risks of exposure in two slum areas, Viwandani and Korogocho, in the Nairobi city.Methods The study employed both qualitative and quantitative methods. For the quantitative study, we used structured questionnaires to collect data about the source of air pollution among adults aged 18 years and above and pregnant women residing in the two study communities. We used the DustTrak™ air samplers to monitor the indoor PM2.5 levels in selected households. We also collected data on community perceptions on air pollution, annoyance and associated health risks. We presented hotspot maps to portray the spatial distribution of perceptions on air pollution in the study areas. For the qualitative study, we conducted focus group discussions with adult community members. Groups were disaggregated by age to account for different languages used to communicate with the younger and older people. We analysed the qualitative data using thematic analysis.Results Household levels of PM2.5 varied widely across households and ranged from 1 to 12,369μg/m3 (SD=287.11). The household levels of PM2.5 levels were likely to exceed the WHO guidelines given the high levels observed in less than 24 hours of monitoring periods (on average 10.4 hours in Viwandani and 11.8 hours in Korogocho). Most of the respondents did not use ventilation use in the evening which coincided with the use of cookstove and lamp, mostly burning kerosene. The levels of PM2.5 varied by the type of fuels, with the highest emissions in households using kerosene for cooking and lighting. The PM2.5 levels spiked in the evenings and during periods of cooking using charcoal/wood. Despite these high levels, residents perceived indoor air to be less polluted compared with the outdoor air, possibly due to the presence of large sources of emissions near the communities such as dumpsites and industries. The community had mixed perceptions on the health impacts of air pollution, with respiratory illnesses perceived as the main consequence while vector or sanitation related diseases such as diarrhoea was also perceived to be related to air pollution.ConclusionsWith poor housing and reliance on dirty fuels, households in slums face potentially high levels of exposure to PM2.5 with dire implications on health. To address the poor perception on air pollution and knowledge gaps on the health effects of air pollution, education programs need to be developed and tailored. These programs should aim to provide residents with information on air quality and its impact on the health; what they can do as communities as well as empower them to reach out to government/stakeholders for action on outdoor sources of pollution such as emissions from dumpsites or industries. The government has a larger role in addressing some of the key pollution sources through policy formulation and strong implementation/enforcement.
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