| 1. |
- Mathias, Kaaren, 1969-
(författare)
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Shadows and light : examining community mental health competence in North India
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundGlobally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the states of Uttar Pradesh and Uttarakhand, India, this thesis examines the complex relationships between individuals, communities and the social environment in relation to mental health. North India is characterised by stark gender and socio-economic inequalities and social exclusion for people with psycho-social disability (PPSD) and mental health services in these study areas were essentially absent. Community mental health competency means people are collectively able to participate in efforts to promote, prevent, treat and advocate for mental health. This thesis reflexively examines the presence and absence of community mental health competence in the upper Ganges region.MethodsA mixed methods approach allowed for a multi-level examination of community mental health competence, and generated four sub-studies. In-depth interviews with thirteen PPSD and eighteen caregivers in Bijnor and Saharanpur (Uttar Pradesh state) were carried out in 2013 providing data for qualitative analysis. These data were analysed using qualitative content analysis to examine experiences of exclusion and inclusion of PPSD in sub-study I, and thematic analysis to examine the gendered experiences of caregivers in sub-study II. A community based sample of 960 people in Dehradun district (Uttarakhand) were surveyed in 2014 to examine the prevalence, treatment gap and social determinants of depression in substudy III, and the attitudes and preferred social distance from people with depression and psychosis were investigated in sub-study IV. Multi-variate regression analysis in both studies was conducted with Stata software Version 13.1.ResultsWithin the domain of knowledge, relatively low community mental health literacy, a diverse range of explanatory models of mental health, and creative and persistent efforts in helpseeking were the themes identified. Within the domain of safe social spaces, social exclusion was harsh and prevalent for PPSD, with contrasting sub-domains of belonging, social support, social participation and ahimsa (non-violence). Women were disadvantaged more than men in most spheres of caregiving.Social determinants of depression with an adjusted odds ratio of more than 2.0 included being a member of the most oppressed caste or tribal group, having taken a recent loan, and not completing primary schooling. The prevalence of depression was 6.0% in the community sample, and there was a 100% treatment gap for counselling, and a 96% treatment gap for anti-depressant therapy, even though 79% of those with depression had visited a primary care provider in the previous three months. Social determinants of health and access to care are proposed as additional domains of community mental health competency. The prevailing gender regime that values males and disadvantages women influenced every domain of community mental health competency, particularly increasing caregiver burden, social exclusion and experiences of physical violence for women. ConclusionsIn this thesis I have refined and strengthened a conceptual framework that portrays community mental health competence as a tree, where foundational roots of social determinants of mental health support four branches depicting access to care, knowledge, safe social spaces and partnerships for action. This tree model proposes that all five domains must operate in unison to support action for community mental health involving: development of community knowledge; promoting social inclusion, gender equality and participation; addressing upstream health determinants; and increasing access to mental health care.
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| 2. |
- Anticona Huaynate, Cynthia, 1983-
(författare)
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Lead exposure in indigenous children of the Peruvian Amazon : seeking the hidden source,venturing into participatory research
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction. In 2006, a Peruvian environmental agency reported the presence of elevated blood lead levels (BLLs) in indigenous communities of the Corrientes river basin. This is a territory in the Peruvian Amazon where oil activity has been associated with serious environmental effects, with impact on an ongoing social conflict. This PhD project aimed to determine the lead sources, risk factors and pathways in children of these communities and to suggest control and prevention strategies. Given the arguments attributing the lead source to the oil activity pollution, the second objective was to clarify any potential connection between the two. This project was conducted by a collaborative research partnership with the regional health authorities and the community-based organization. The third objective was to characterize the challenges, facilitating factors and the lessons learned from the research process.Methods. Two epidemiological studies were conducted. Study I (2009) was carried out in three communities and study II (2010) in six communities with different levels of exposure to oil activity. The participants were children 0–17 years old. Data collection included: determination of BLLs, hemoglobin levels and anthropometric indicators, a risk factor questionnaire, an environmental assessment and a risk map. Data analysis included univariate, bivariate and multivariate logistic regression. Data for the third objective came from field notes, documents, interviews and a process of collective reflection.Results. Study I (n= 221) found no significant difference in the geometric mean(GM) BLLs between the communities exposed and not exposed to oil activity. Older age and being a boy were found as risk factors for BLLs ≥ 10 μg/dL. In study II (n= 346), age stratified logistic regression models indicated that children 0–3 years whose mothers had BLLs ≥ 10 μg/dL, children 0–6 years who played with pieces of lead and children 7–17 years who fished 3 times or more per weekor chewed pieces of lead to manufacture fishing sinkers had a significant increased risk of having BLLs ≥ 10 μg/dL. Children who lived in communities near oil battery facilities also had a significant increased risk of having BLLs ≥ 10 μg/dL. In both studies, environmental samples showed lead concentrations below reference levels. The challenges and facilitating factors identified focused on five interrelated themes: i) mutual trust, ii) multiple agendas, iii) equal participation, iv) competing research paradigms and v) complex and unexpected findings.Conclusions. Metal lead appeared to be the main source of exposure. Playing with pieces of lead and chewing pieces of lead to construct fishing sinkers appeared to be pathways of exposure for children aged 0–6 years and 7–17 years, respectively. Mothers’ BLLs > 10 μg/dL was a risk factor for BLLs > 10 μg/dL in children aged 0–3 years. Living in a community with high exposure to oil activity was a risk factor for BLLs > 10 μg/dL. The identified connection with oil activity was the proximity of communities to oil battery facilities and thus greater access to lead from cables and other industrial waste. Despite the numerous challenges, participatory research appears to be the most appropriate approach for this type of context. The study findings led us to recommend:i) a comprehensive community-based lead control and prevention plan,ii) the introduction of substitute non-harmful material(s) for fishing sinkers and iii) secure containment of the oil company’s waste deposits.
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| 3. |
- Córdoba Doña, Juan Antonio, 1962-
(författare)
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Withstanding austerity : economic crisis and health inequalities in Spain
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Along with the austerity measures introduced in many countries, the economic crisis affecting Europe since 2008 seems to have impacted many aspects of the health of the Spanish population and has had a negative effect on the provision health services. An increasing body of knowledge has shown a clear impact of the current crisis on suicidal behaviour and mental health, and a less consistent effect on physical health and access to healthcare. However, little is known about the impact of the crisis on social inequalities in health and healthcare access, an area on which the present study seeks to shed light in the context of Spain, and specifically Andalusia, a region hit very hard by the crisis.Objective: To study the impact of the economic crisis starting in 2008 on health, health inequalities and health service utilisation in Spain and Andalusia and the roles of socio-demographic factors in these associations.Methods: Death rates were analysed to study the annual percent change in overall and cause-specific mortality in Spain between 1999 and 2011, and the Longitudinal Database of the Andalusian Population was used to study educational inequalities in overall mortality from 2002 to 2010 (study 1). To calculate suicide attempt rates, information from 2003 to 2012 on 11,494 men and 12,886 women provided by the Health Emergencies Public Enterprise Information System in Andalusia was utilised. The association between unemployment and suicide attempts was studied through linear regression models (study 2). Two waves of the Andalusian Health Survey (2007 and 2011–12) provided data for the third and fourth studies of this thesis. Educational and employment status inequalities in poor mental health in relation with the crisis were analysed through Poisson regression models (study 3). The change in inequalities (pre-crisis–crisis) in health care utilisation outcomes (general practitioner, specialist, hospitalisation and emergency attendance) was measured by the change in horizontal inequality indices. A decomposition analysis of change in inequality between periods was performed using the Oaxaca approach (study 4).Results: Study 1: Overall mortality in Spain decreased steadily during the period, with annual percent changes of -2.44% in men and -2.20% in women. An increase in educational inequality in mortality was observed in men in Andalusia. In women, the inequalities instead remained stable. Suicide mortality showed a downward trend in both sexes in Spain. Study 2: A sharp increase in suicide attempts in Andalusia was detected after the onset of the crisis in both sexes, with adults aged 35 to 54 years being the most affected. Suicide attempts were associated with unemployment rates only in men. Study 3: Poor mental health increased in working individuals with secondary and primary studies during the crisis compared to the pre-crisis period, while it decreased in the university study group. However, in unemployed individuals poor mental health increased only in the secondary studies group. Financial strain could partly explain the crisis effect on mental health among the unemployed. Study 4: Horizontal inequality in utilisation changed to a greater equality or a more pro-poor inequality in both sexes. In the decomposition analysis, socioeconomic position and health status showed greater contributions to the changes in inequalities.Conclusion: This thesis illustrates the complexity of the influences of the current economic crisis on health inequalities in a Southern European region. Specifically, no noticeable effects of the crisis on overall and suicide mortality were detected; instead, increasing educational inequalities in mortality in men and a large increase in suicide attempts in middle aged men and women were observed. The deterioration in poor mental health was mainly detected in those of intermediate educational level. Economic conditions such as unemployment and financial strain proved to be relevant. Finally, in the light of no increased inequalities in healthcare utilisation, the universal coverage health system seems to buffer the deleterious effect of the crisis and austerity policies in this context.
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| 4. |
- Mamani-Ortiz, Yercin, 1985-
(författare)
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Cardiovascular risk factors in Cochabamba, Bolivia : estimating its distribution and assessing social inequalities
- 2019
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The increase in the prevalence of cardiovascular risk factors (CVRFs) is considered one of the most important public health problems worldwide and especially in Latin American (LA) countries. Although the systematic surveillance of chronic diseases and their risk factors has been recommended, Bolivia has not yet implemented a national strategy to collect and monitor CVRF information. Evidence from previous studies in Bolivia and other Latin American countries has suggested that CVRFs affect women more than men and mestizos more than indigenous people. However, a more accurate and comprehensive picture of the CVRF situation and how ethnicity and gender intersect to affect CVRFs is dearly needed to support the development of health policies to improve population health and reduce inequalities.Objective: to estimate the distribution of CVRFs and to examine intersectional in equalities in Cochabamba – Bolivia in order to provide useful information for public health practice and decision making. The specific objectives are: i) to estimate the prevalence of preventable risk factors associated with CVDs and ii) to assess and explain obesity inequalities in the intersectional spaces of ethnicity and gender.Methods: The data collection procedure was based on the Pan-American version (V2.0) of the WHO STEPS approach adapted to the Bolivian context. Between 2015 and 2016, 10,754 individuals aged over 18 years old were surveyed. The two first stages of the STEPS approach were conducted: a) Step 1 consisted of the application of a questionnaire to collect demographic and lifestyle data; b) Step 2 involved taking measurements of height, weight, blood pressure, and waist circumference of the participants.To achieve objective 1, the prevalence of relevant behavioural risk factors and anthropometric measures were calculated, and then odds ratios/prevalence ratios were estimated for each CVRF, both with crude and adjusted regression models. Regarding objective 2, an intersectionality approach based on the method suggested by Jackson et al. (67) was used to analyse the ethnic and gender inequalities in obesity. Gender and ethnicity information were combined to form four mutually exclusive intersectional positions: i) the dually disadvantaged group of indigenous women; ii) the dually advantaged group of mestizo men; and the singly disadvantaged groups of iii) indigenous men and iv) mestizo women. Joint and excess intersectional disparities in abdominal obesity were estimated as absolute prevalence differences between binary groups, using binomial regression models. The Oaxaca-Blinder decomposition was applied to estimate the contributions of explanatory factors underlying the observed intersectional disparities.Main findings: Our findings revealed that Cochabamba had a high prevalence of CVRFs, with significant variations among the different socio-demographic groups. Indigenous populations and those living in the Andean region showed, in general, a lower prevalence for most of the risk factors evaluated. The prevalence of behavioural risk factors were: current smoking (11.6%); current alcohol consumption (42.76%); low consumption of fruits and vegetables (76.73%); and low level of physical activity (64.77%). The prevalence of metabolic risk factors evaluated were: being overweight (35.84%); obesity (20.49%); abdominal obesity (54.13%); and raised blood pressure (17.5%). It is important to highlight that 40.7% of participants had four or more CVRFs simultaneously.Dually and singly disadvantaged groups (indigenous women, indigenous men, and mestizo women) were less obese than the dually advantaged group (mestizomen). The joint disparity showed that the obesity prevalence was 7.26 percentage points higher in the doubly advantaged mestizo men (MM) than in the doubly disadvantaged indigenous women (IW). Mestizo men (MM) had an obesity prevalence of 4.30 percentage points higher than mestizo women (MW) and 9.18 percentage points higher than indigenous men (IM). The resulting excess intersectional disparity was 6.22 percentage points, representing -86 percentage points of the joint disparity. The lower prevalence of obesity in the doubly disadvantaged group of indigenous women (7.26 percentage points) was mainly due to ethnic differences alone. However, they had higher obesity than expected when considering both genders alone and ethnicity alone. Health behaviours were important factors in explaining the intersectional inequalities, while differences in socioeconomic and demographic factors played less important roles.Conclusion: The prevalence of all CVRFs in Cochabamba was high, and nearly two-thirds of the population reported two or more risk factors simultaneously. The intersectional disparities illustrate that abdominal obesity is not distributed according to expected patterns of structural disadvantages in the intersectional spaces of ethnicity and gender in Bolivia. A high social advantage was related to higher rates of abdominal obesity, with health behaviours as the most important factors explaining the observed inequalities. The information generated by this study provides evidence for health policymakers at the regional level and a baseline data for department-wide action plans to carry out specific interventionsin the population and on individual levels.
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| 5. |
- Abraha Derbew, Atakelti, 1976-
(författare)
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Bridging gaps in under-five child health : a comprehensive assessment of their social determinants and the health system performance in Tigray, Ethiopia
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Achieving the Sustainable Development targets related to child health necessitates a deep understanding of the multifaceted factors influencing their health.Aim: To comprehensively examine the social determinants of the access to, and quality of, child health services, and the performance of the health system in the region of Tigray.Methods: The study was conducted in six randomly selected rural districts of Tigray. The study employed focus group discussions and interviews (sub-study I), a retrospective case-control study (sub-study-II), a capture recapture method (sub-study III), and a two-stage mortality survey (sub-study IV).Results: Sub-study I: underscored a good knowledge on the causes and management of common childhood morbidity, and that the health posts were conveniently located and provided trusted services. However, several barriers to using health services were identified. These included cultural beliefs, seasonal mobility, economic constraints, limited decision-making power for women, and accessibility challenges.Sub-study II: Revealed that only 76% of eligible children born to HIV-positive mothers were tested, with 17% testing positive for HIV, and only 29% of them linked to anti-retroviral treatment.Sub-study III showed that the concordance correlation coefficient between the Family Folder data and the household survey for the total population, reproductive age women, and under-five year child population were all above 0.73, while they were close to zero for other child health parameters. Tracing and recording neonatal deaths, and the aggregation of data at various levels were the major operational challanges.Sub-study IV identified infectious diseases (52.9%), neonatal causes (35.6%), nutritional disorders (6.6%) and external causes (4.3%) as the major causes of child death. The cause for 76 (16.2%) children was indeterminate. Tracing neonatal deaths and logistical challenges, especially in remote areas were the major operational issues of conducting the mortality survey.Conclusion: In spite of the improvements in health literacy, access to cost-free reproductive, maternal, neonatal and child health services and improved utilization, various interrelated social determinants, including cultural beliefs, financial barriers and health system-related factors continue to hinder the optimal utilization of essential child health services. Moreover, the health system’s performance in the prevention of mother-to-child transmission of HIV and its effect in reducing mortality among exposed children is generally poor. Policymakers in the region should focus on tackling those social determinants, including the health system, to improve children´s health. The community health information system showed promising potential. However, the operational issue of capturing neonatal deaths adequately and the process by which community data can be aggregated upwards through the health system has to be improved. The study underscored the viability of implementing a cause-specific mortality survey using health extension workers, and the need to standardize data collection tools and logistics before implementation on a larger scale.
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| 6. |
- Forouzan, Ameneh Setareh, 1967-
(författare)
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Assessing responsiveness in the mental health care system : the case of Tehran
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Understanding health service user perceptions of the quality of care is critical to developing measures to increase the utilisation of healthcare services. To relate patient experiences to a common set of standards, the World Health Organization (WHO) developed the concept of health system responsiveness. This measures what happens during user’s interactions with the system, using a common scale, and requires that the user has had a specified encounter, which they evaluate. The concept of responsiveness has only been used in a very few studies previously to evaluate healthcare sub-systems, such as mental healthcare. Since the concept of responsiveness had not been previously applied to a middle income country, such as Iran, there is a need to investigate its applicability and to develop a valid instrument for evaluating health system performance. The aim of this study is to assess the responsiveness of the mental healthcare system in Tehran, the capital of Iran, in accordance with the WHO responsiveness concept.Methods: This thesis is a health system research, based on qualitative and quantitative methods. During the qualitative phase of the study, six focus group discussions were carried out in Tehran, from June to August 2010. In total, 74 participants, comprising 21 health providers and 53 users of the mental healthcare system, were interviewed. Interviews were analysed through content analysis. The coding was synchronised between the researchers through two discussion sessions to ensure the credibility of the findings. The results were then discussed with two senior researchers to strengthen plausibility. Responses were examined in relation to the eight domains of the WHO’s responsiveness model.In accordance with the WHO health system responsiveness questionnaire and the findings of the qualitative studies, a Farsi version of the Mental Health System Responsiveness Questionnaire (MHSRQ) was tailored to suit the mental healthcare system in Iran. This version was tested in a cross-sectional study at nine public mental health clinics in Tehran. A sample of 500 mental health services patients was recruited and subsequently completed the questionnaire. The item missing rate was used to check the feasibility, while the reliability of the scale was determined by assessing the Cronbach’s alpha and item total correlations. The factor structure of the questionnaire was investigated by performing confirmatory factor analysis (CFA).To assess how the domains of responsiveness were performing in the mental healthcare system, I used the data collected during the second phase of the study. Utilising the same method used by the WHO for its responsiveness survey, we evaluated the responsiveness of outpatient mental healthcare, using a validated Farsi questionnaire.Results: There were many commonalities between the findings of my study and the eight domains of the WHO responsiveness model, although some variations were found. Effective care was a new domain generated from my findings. In addition, the domain of prompt attention was included in two newly labelled domains: attention and access to care. Participants could not differentiate autonomy from choice of healthcare provider, believing that free choice is part of autonomy. Therefore these domains were unified under the name of autonomy. The domains of quality of basic amenities, access to social support, dignity, and confidentiality were considered important for the responsiveness concept. Some differences regarding how these domains should be defined were observed, however.The results of the qualitative study were used to tailor a Farsi version of the MHSRQ. A satisfactory feasibility, as the item missing value was lower than 5.2%, was found. With the exception of the access domain, the reliability of the different domains in the questionnaire was within a desirable range. The factor loading showed an acceptable uni-dimensionality of the scale, despite the fact that the three items related to access did not perform well. The CFA also indicated good fit indices for the model (CFI = 0.99, GFI = 0.97, IFI = 0.99, AGFI = 0.97).The results of the mental healthcare system responsiveness survey showed that, on average, 47% of participants reported experiencing poor responsiveness. Among the responsiveness domains, confidentiality and dignity were the best performing factors, while autonomy, access to care and quality of basic amenities were the worst performing. Respondents who reported their social status as low were more likely to experience poor responsiveness overall. Autonomy, quality of basic amenities and clear communication were dimensions that performed poorly but were considered to be highly important by the study participants.Conclusion and implications: This is the first time that mental healthcare system responsiveness has been measured in Iran. Our results showed that the concept of responsiveness developed by the WHO is applicable to mental health services in this country. Dignity and confidentiality were domains which performed well, while the domains of autonomy, quality of basic amenities and access performed poorly. Any improvement in these poorly performing domains is dependent on resources. In addition, attention and access to care, which were rated high in importance and poor in performance, should be priority areas for intervention and the reengineering of referral systems and admission processes. The role of subjective social status in responsiveness should be further studied. These findings might help policymakers to better understand what is required for the improvement of mental health services.
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| 7. |
- Ram Jat, Tej, 1976-
(författare)
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Maternal health and health care in Madhya Pradesh state of India : an exploration using a human rights lens
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pregnancy and motherhood are natural processes in the lives of women of reproductive age. These processes are generally considered to be positive and fulfilling experiences. However, for various reasons, many women end up dying as a result of these processes. Improving maternal health and reducing maternal mortality are accepted as human rights challenges and prioritized in several international declarations and national policies. However, progress in achieving these objectives still remains poor.This thesis aims to explore the maternal health and healthcare in the Indian state of Madhya Pradesh through a human rights lens. A human rights lens provides a framework to study various aspects of the problem of maternal health from a human rights perspective. It helps in highlighting the gaps and challenges related to political priority, sociocultural, economic and individual-level factors and the availability, accessibility, acceptability and quality of maternal healthcare services. A combination of quantitative and qualitative research methodologies was applied in four sub-studies conducted in Madhya Pradesh. The specific objectives were: to investigate, by using John W. Kingdon’s multiple-streams model of agenda setting, why and how maternal health became a political priority in the state (Paper I); to estimate the effects of individual-, community- and district-level characteristics on the utilization of maternal health services with special reference to antenatal care, skilled attendance at delivery and post-natal care (Paper II); to analyse sociocultural and service delivery related dimensions of maternal deaths in rural central India through a human rights lens (Paper III); and to evaluate the technical efficiency of the public district hospitals using data envelopment analysis (Paper IV).The findings of the first qualitative study indicated that various developments at international, national and state level brought the issue of maternal health to the priority political agenda in Madhya Pradesh state. This resulted in the introduction of new policies and programmes and more resources were allocated for improving maternal health. However, several challenges still remain in ensuring proper implementation of these programmes and policies. The quantitative study on factors affecting the use of maternal health services revealed that 61.7% of women used antenatal care at least once, 49.8% of women used skilled attendance at delivery and 37.4% of women used post-natal care during their most recent pregnancy. The household’s socio-economic status and mother’s education emerged as the most important factors associated with the use of antenatal care and skilled attendance at delivery. Delivery by skilled personnel and the use of antenatal care were the most important factors in the use of post-natal care. This study highlighted the need to identify and focus on community- and district-level intervention along with addressing the individual-level factors.The findings of the third qualitative sub-study revealed that all pregnant women in the study tried to access medical assistance for obstetric complications but various factors delayed appropriate care. The underestimation of complication symptoms by family members, gender inequity and the negative perceptions regarding delivery services deferred decisions to seek care. Transportation problems and care seeking at multiple facilities also constrained timely reaching of appropriate health facilities. Negligence by health staff in providing care, and unavailability of blood and emergency obstetric care services, delayed the receiving of adequate care after reaching a health facility. This study indicates that normative elements of a human rights approach to maternal health, i.e. availability, accessibility, acceptability and quality, were not fully upheld. The deceased women and their relatives were unable to claim their entitlements and the duty bearers could not meet their obligations despite their conscious efforts to improve maternal health. In the last study, the results of data envelopment analysis revealed that half of the district hospitals (20) in the study were operating inefficiently.This research establishes a need to give special attention to addressing challenges in the maternal health programmes at the implementation level as well as tackling the social determinants of maternal health. In order to increase the utilization of maternal health services in the state, the need to identify and focus on community- and district- as well as individual level interventions is emphasized. In order to prevent maternal deaths, a need for further concentrated efforts is underlined with a view to honouring human rights elements of maternal health by better community education, women’s empowerment and health system strengthening with the provision of appropriate and timely services including emergency obstetric care of good quality. It also highlights a need to identify the causes of the observed inefficiencies and to take appropriate measures to increase the efficiency of district hospitals.
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