| 1. |
- Amani, Paul Joseph, 1975-
(författare)
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Does health insurance contribute to improving responsiveness of the health system? : the case of elderly in rural Tanzania
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas.Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and quantile regression models were applied to analyse the association between health insurance and access to healthcare (sub-study 1) and responsiveness (sub-study 2), respectively. For both sub-studies 3 and 4, qualitative content analysis was used to analyse the data.Results: Sub-studies 1 and 2 involved a total of 1899 insured and uninsured elderly, while sub-studies 3 and 4 included 8 health providers and 78 elderlies respectively. Sub-study 1 showed that about 45% of the elderly were insured and HI ownership improved access and utilization of healthcare, both outpatient and inpatient services. In sub-study two, however, health insurance was associated with a lower responsiveness of the healthcare system. In general, all six domains: cleanliness, access, confidentiality, autonomy, communication, and prompt attention were rated high, but three were of concern: waiting time; cleanliness; and communication. Sub-study 3 uncovered several challenges coexisting alongside the provision of insurance benefits and thus contributing to a lower responsiveness. These included shortage of human resources and medical supplies, as well as operational issues related to delays in funding reimbursement. In sub-study 4, the elderly revealed that HI did not meet their expectations, it failed to promote equitable access, provided limited-service benefits and restricted use of services within residential areas. Conclusion: While HI seems to increase the access to and use of healthcare services by the elderly in rural Tanzania, a lower responsiveness by the healthcare system among the insured elderly was reported. Long waiting times, limited-service benefits, restricted use of services within schemes, lack of health workforce in both numbers and skills as well as shortage of medical supplies were important explanations for the lower responsiveness. The results of this thesis, while supporting the national aim of expanding HI in rural areas, also exposed several weaknesses that require immediate attention. There is a need to, first, review the insurance policy to improve its implementation, expand the scope of services coverage, and where possible, to introduce cross-subsidization between the publicly owned schemes; additionally, improvements in the healthcare infrastructure, increasing the number of qualified health workforce and the availability of essential medicines and laboratory services, especially at the primary healthcare facilities, should be prioritized and further investments allocated.
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| 2. |
- Eid Rodríguez, Daniel V., 1980-
(författare)
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The rough journey to access health care : the case of leishmaniasis in the Bolivian rainforest
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Leishmaniasis is a parasitic infectious disease transmitted by vectors that cause three main clinical syndromes: cutaneous (CL), mucosal (ML), and visceral (VL). Since VL is not relevant to this thesis, only CL and ML will be further discussed. Leishmaniasis is present in 98 countries, with more than 350 million people at risk of infection. Leishmaniasis disproportionately affects poor countries and, in particular, remote areas where health services are weaker. Bolivia, a lower-middle-income country, is the fifth country with more cases in Latin America, and case detection and management is the main control strategy of the National Leishmaniasis Control Programme (NLCP). The NLCP provides free treatment to patients, which consists of systemic pentavalent antimonials (SPA) for 20 days. This treatment is highly toxic for patients and costly for the government, resulting in long periods of shortage of the drug. A good alternative to SPA is the use of intralesional pentavalent antimonials (ILPA), which are safer and have similar efficacy to SPA in treating CL. Case detection and management depend on a well-structured health-care system, and the primary level of care is responsible for this task in Bolivian endemic areas. It is well known that health-care access for leishmaniasis patients is limited but the extent and the determinant factors of this problem are unknown. The aim of this thesis is to assess health-care access among patients with leishmaniasis in a Bolivian rainforest rural area, addressing four specific questions: Who is most vulnerable to CL?; What is the extent of their lack of access to health care?; How do the dimensions of access and the quality of care influence health-care utilization in a context of vulnerability?; and how can a change in NLCP policy related to the treatment of CL improve the level of access to health care?Methods: This thesis is based on four studies that use quantitative and qualitative methods. Data collection was conducted through surveys, in-depth interviews and revision of official documents. Sub-study 1 was based on a cross-sectional study conducted in two communities of Cochabamba and assessed risk factors for CL using multivariate analysis. Sub-study 2 used the method of capture−recapture to assess the level of under-reporting of the national register for the period of 2013−2014, using Chapman’s formula. Sub-study 3 was conducted through in-depth interviews applied to 14 participants, using thematic analysis. Sub-study 4 was an economic evaluation that used data from surveys with physicians, official documents and key informants and compared the costs of systemic pentavalent antimonials (SPA) and intralesional pentavalent antimonials (ILPA) from the perspective of the Ministry of Health (MoH) and society. Additionally, a budget impact analysis of the implementation of ILPA in hypothetical scenarios of increasing level of demand was carried out.Main findings: Sub-study 1 showed that gender/sex was the only statistically significant factor associated with CL, with men being the most affected group. Other classical factors, such as animal ownership, house materials and protective measures were, however, not related to CL. Sub-study 2 revealed a high level of under-reporting (73%) of CL in the study area, and this under-reporting was higher among men compared to women. Sub-study 3 showed that the lack of availability, accessibility, affordability and quality of care were the main factors that limited the access to care of CL and ML patients. In sub-study 4, the economic analysis pointed out that the use of ILPA was cost-saving for the MoH and society, and the budget analysis confirmed that the implementation of ILPA as first-line treatment was not only cost-saving for the MoH, but it would also increase the number of patients accessing the treatment.Conclusions: The predominance of a sylvatic pattern of transmission, with men as the most affected group, demands new approaches to prevention related to occupational activities. The NLCP policy related to case management has been essential to reducing economic barriers for patients with leishmaniasis; however, there are still a considerable amount of cases who do not have access to the treatment. Lacko f health services, equipment and drugs, as well as difficulties in reaching health services, the high costs of seeking health care and the low quality of care are important factors that must be addressed to fulfil the right to health care for these patients. Finally, new therapeutic alternatives, such as ILPA, must be considered to reduce problems of affordability, adherence, as well as side effects to the treatment. This information can be used to develop targeted interventions aimed at increasing the access to health care of people with leishmaniasis in the rainforest of Bolivia.
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| 3. |
- Baroudi, Mazen, 1984-
(författare)
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Leaving the door ajar : young migrants’ sexual and reproductive health in Sweden
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Young people and migrants are both prioritized groups regarding sexual and reproductive health and rights (SRHR), but studies about the sexual andreproductive health (SRH) of young migrants in Sweden are scarce. The aim of this thesis was to study the SRH of young migrants in Sweden, and specifically to: 1) explore how do young migrants understand SRH, and how do they experience their sexual rights; and 2) examine how do young migrants perceive and experience the process of accessing SRH services, including their approachability, acceptability, adequacy and quality.This thesis is built upon three studies, which collected quantitative data (a national survey – Papers 1 and 2, and a youth clinics survey – Paper 3) and qualitative data (a qualitative study – Paper 4). The national survey is a population-based cross sectional study, which recruited 1773 newly arrived young migrants aged 16 to 29 years through visits to schools and other venues, letters sent home, and via a web survey. The data was analysed through descriptive statistics (Paper 1) and multivariate multiple linear regression (Paper 2). The youth clinic survey is a clinic-based cross-sectional study whichrecruited 1089 youths (118 had at least one parent born outside Sweden/Scandinavia) aged 16 to 25 years after their visit to a youth clinic in the four most northern regions in Sweden. I used multi-level analysis to analyse the data. The qualitative study builds upon 13 semi-structured interviews with newly arrived Arabic-speaking migrant men, which were analysed through qualitative thematic analysis.Young migrants understood SRH as both “essential” and a “right”. The sexual rights of young migrants in Sweden were less fulfilled, compared to those of other young people in Sweden, and there were differences between the various groups of young migrants. The rights of men; people identifying as non-binary; people identifying as lesbian, gay, bisexual or asexual (LGBA); those born in South Asia; those without a residence permit; and people of low economic status were fulfilled to a lesser extent compared to their counterparts.Studying the process of accessing SRH services – including sexual education and information, and services related to sexual function, sexually transmitted diseases and gender-based violence, as well as infertility, pregnancy, delivery, contraceptives and abortion – showed barriers and facilitators. SRH serviceswere to a large extent non-approachable; almost half of those who needed these services in the national survey did not use them. SRH services were perceived, with some exceptions, as acceptable due to the “open environment” of Sweden; however, some young migrants faced a lack of cultural sensitivity in iv SRH services, low parental support, and fear of exposure, which decreased their acceptability of the services. Regarding adequacy, young migrants complained about long waiting times for receiving care particularly specialised care, and that SRH services did not take their problems seriously. Those who visited youth clinics, however, perceived them as providing convenient and timely services. The quality of SRH services was perceived as good in general; the majority of young migrants were satisfied with SRH services in the national survey and perceived youth clinics as very friendly. However, negative experiences were reported in the national survey, where almost half of those who visited SRH services had at least one negative experience in the five domains of respect, equity, quality of consultation, privacy and non-prejudice. Migrant youths also reported worse experiences in the youth clinic survey than Swedish/Scandinavian youths in the domains of respect, equity and quality of consultation. Their legal entitlement to access most SRH services, the availability of good quality services and the “open environment” facilitate young migrants’ access to SRH services, however, their limited access to sexual education and to information about the health system, and cultural insensitivity and cultural racism when providing information and services, are serious barriers to young migrants’ access to SRH services.
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| 4. |
- Gebrehiwet, Tesfay Gebregzabher, 1966-
(författare)
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No woman should die while giving life : Does the Health Extension Program improveaccess to maternal health services in Tigray, Ethiopia?
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Ensuring access to universal primary health care is essential to secure a safe and pleasant motherhood and to provide compassionate care for mothers and newborns.However, inequalities in the access to maternal health services still remain a prominent problem in many countries. As part of reducing inequalities, Ethiopia launched the Health Extension Program (HEP) in 2003. The HEP is a community based program designed with a defined package of essential promotive, preventive and basic curative services targeting households, particularly mothers and children. Despite the construction of over 600 health posts and deploying more than 1200 Health Extension Workers (HEWs), preliminary data suggests a low utilization of maternal health care services. This thesis explores the HEP contribution in improving women’s access to maternal health care, and the reasons for the low use of maternal health care services from the perspectives of the involved actors in the Tigray region in Ethiopia. The five dimensions of access were used as a framework to explore the access to maternal health care utilization in this setting.Methods: A total of four districts were included in the study. Both quantitative and qualitative methods were applied. In the first sub-study, we assessed the HEP and its association with change in the utilization of antenatal, delivery and postnatal care services. Retrospective longitudinal data for 10 years was extracted from three selected districts and checked for accuracy. Segmented linear regression technique was used to control the secular trends adjusted for correlation of the data. For the second sub-study, we conducted a cross sectional survey with 1115 women (aged 15-49 years who had given birth within five years prior to the survey period) to determine the prevalence of antenatal care and institutional delivery utilization and explore their determinant factors of low utilization. For the third sub-study, we conducted six focus group discussions (FGDs) with a total of 51 women to explore women’s experiences of childbirth and maternal care. An interview with eight HEWs and four midwives were carried out to capture health workers’ perspective on access to maternal health care services in the fourth sub-study. Grounded theory for the former, and thematic analysis for the latter were used for the analysis.Main findings: The finding of the first sub-study showed a statistically significant upward trend for delivery care (DC) and postnatal care (PNC) in all facilities during the HEP late implementation period (July 2008-June 2012). In addition, a substantial trend of antenatal care (ANC) service use was observed at health centres after the intervention. In the second sub-study, the determinant predictors for ANC utilization were: proximity to health facilities, to be married, ≥5 years of education and having non-farming husbands. The last three factors were also significantly associated with institutional delivery, but also lower parity, previous history of obstructed/prolonged labour and ANC counselling. Findings from the qualitative studies pointed out that elderly women influenced women’s decision making about where to give birth. Women were mostly positive about giving birth at health facilities, but were concerned about the poor quality of care, inaccessibility and unavailability of transport. From the health workers’ perspective: specialized performance of hospital services, community assistance during referral and an increased awareness among women regarding the benefits of giving birth at a health facility were perceived as facilitators for institutional deliveries. Poor perceived competence of HEWs, poor conditions of health care facilities and inaccessibility of transportation, among others, were perceived as barriers for giving birth at health facilities.Conclusion: Overall, this research revealed a considerable contribution of the HEP in improving the access and coverage of maternal health services (ANC, DC and PNC). However, cultural traditions, scattered localities, mountainous roads without adequate transportation and low quality of care are still the major obstacles to accessing the services. Mechanisms need to be designed to enable health facility access of safe delivery for women in hard to reach areas, improving the proficiency of health workers and introducing a women centered approach that enhances acceptability of the services.
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| 5. |
- Mamani-Ortiz, Yercin, 1985-
(författare)
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Cardiovascular disease prevention in Cochabamba, Bolivia : the importance of preventable risk factor distribution and inequalities for policy implementation
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The increase in the prevalence of cardiovascular diseases (CVDs) and cardiovascular risk factors (CVRFs) is considered one of the most important public health problems in Latin American (LA) countries. Accordingly, an accurate and comprehensive picture of the CVRFs situation is needed to prevent CVDs and consequently support the development of health policies to improve population health and reduce health inequalities. Objective: To estimate the distribution of CVRFs and to examine social inequalities in these factors in Cochabamba – Bolivia to provide useful information for public health practice and decision-making. Methods: This thesis is based on four studies that used quantitative and qualitative methods. For sub-studies 1, 2, and 3, 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. To sub-study 1, the prevalence of relevant behavioural risk factors and anthropometric measures were calculated, and then odds ratios were estimated for each CVRFs. Regarding sub-study 2, an intersectionality approach based on the method suggested by Jackson et al. was used to analyze the ethnic and gender inequalities in obesity followed by the Oaxaca-Blinder decomposition to estimate the contributions of explanatory factors underlying the observed intersectional disparities. For sub-study 3, bivariate and multivariable regression analyses were carried out to analyze the association between access to CVDs healthcare and to preventive activities for CVRFs, with demographic and socioeconomic factors, and healthcare needs. Finally, to sub-study 4, in-depth interviews were conducted among 14 key informants focusing on aspects related to the implementation process of the CVDs policy. The interviews were recorded, transcribed verbatim, and analyzed using reflexive thematic analysis.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 studied. The prevalence of the metabolic risk factors were: 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 (mestizo men). The joint disparity showed that the obesity prevalence was 7.26 percentage points higher in the doubly advantaged mestizo men than in the doubly disadvantaged Indigenous women. The lower prevalence of obesity in the doubly disadvantaged group of Indigenous women was mainly due to ethnic differences alone. Health behaviours were important factors in explaining the intersectional inequalities, while differences in socioeconomic and demographic factors played a less important role.The analysis also suggested a horizontal inequity in education, job status, region, and health insurance ownership regarding access to healthcare for CVDs and preventive activities for CVRFs. In the case of healthcare access, a lower probability of accessing healthcare for those with no formal education (OR=0.63; 95% CI=0.49-0.82) compared to those with higher education was found. Participation in preventive activities was significantly less among those with low educational levels, with the lowest participation observed in people with no formal education (OR=0.51; 95% CI=0.40-0.63). Individuals who were retired (OR=0.72; 95% CI=0.53-0.99), and those living in the Andean (OR=0.51; 95% CI=0.44-0.60) and Southern cone (OR=0.53; 95% CI=0.45-0.64) also displayed lower odds of participation. The challenges highlighted for the implementation of the CVDs policy in the Bolivian primary healthcare system were: the importance of i) local research, ii) a functional surveillance system, iii) effective leadership and coordination, iv) investments in municipal and community-level initiatives, and v) the need for health personnel capacity building. Conclusion: The prevalence of all CVRFs in Cochabamba was high, and nearly two-thirds of the population reported four or more risk factors simultaneously. The intersectional disparities illustrate that abdominal obesity was not distributed according to expected patterns of structural disadvantages in the intersectional spaces of ethnicity and gender in Bolivia. While vertical equity was observed in access to healthcare and in the participation of preventive activities, a horizontal inequity regarding education, region, and health insurance ownership was found. In addition, our findings highlighted five main challenges in the implementation of the CVDs policy in the Bolivian primary healthcare system; including local research; a functional surveillance system; leadership and governance; investment in municipal and community-level; and Health personnel for the implementation of CVD policy and its prevention strategies. The information generated by this study provides evidence for health policymakers at the regional level to carry out specific interventions to prevent CVDRFs both at the population and at the individual level. It is important to understand the contribution of socioeconomic factors and health needs in the process of formulating strategies that seek to reduce inequalities in access to healthcare in Cochabamba and nationally.
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| 6. |
- 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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| 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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| 8. |
- Goicolea, Isabel, 1971-
(författare)
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Adolescent pregnancies in the Amazon basin of Ecuador : a rights and gender approach to girls' sexual and reproductive health
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Adolescent pregnancy has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. In Ecuador, where 20% of girls aged between 15-19 years get pregnant, the adolescent fertility rate has increased and inequalities between adolescent girls from different educational, socio-economic levels and geographical regions are prominent: 43% of illiterate adolescents become pregnant compared to 11% with secondary education. The highest adolescent fertility rates are found in the Amazon Basin. The overall aim of this study was to explore adolescent pregnancy in the Amazon Basin of Ecuador (Orellana province) from a rights and gender approach. Specific aims and methodologies included: to explore women‟s reproductive health situation, focusing on government‟s obligations, utilization of services, inequities and implementation challenges, assessed through a community-based cross-sectional survey and a policy analysis (Paper I); to examine risk factors associated with adolescent pregnancy, through a case-control study (Paper II); to explore experiences and emotions around pregnancy and motherhood among adolescent girls, using content analysis (Paper III); and to analyze providers‟ and policy makers‟ discourses on adolescent pregnancies (Paper IV). Reproductive health status findings for women in Orellana indicated a reality more dismal than that depicted in official national health data and policies. Inequities existed within the province, with rural indigenous women having reduced access to reproductive health services. In Orellana, 37.4% of girls aged 15-19 had experienced pregnancy, almost double the national average. Risk factors associated with adolescent pregnancy at the behavioral level included early sexual debut and non-use of contraception, and at the structural level poverty, having suffered from sexual abuse, and family disruption. Gender inequity played a key role through the machismo-marianismo system. Girls were raised to be fearful and ignorant regarding sexuality and reproduction, to be submissive and obedient, to be fatalistic, and to accept the established order of the male and adult dominance. Sexuality was conceptualized as negative, while motherhood was idealized. Those gender structures constrained girls‟ agency, making them less able to make choices regarding their sexual and reproductive lives. Providers‟ discourses and practices were also strongly influenced by gender structures. Adolescent sexuality was not sanctioned, girls‟ access to contraceptives still faced opposition, adolescent autonomy was regarded as dangerous, and pregnancy and reproductive health issues were conceptualized as girls‟ responsibility. However, mechanisms of resistance and challenge were also found both among adolescent girls and providers. Programs addressing adolescent pregnancies in the area need to look at the general situation of women‟s reproductive health and address the gaps regarding access and accountability. Adolescent pregnancy prevention programs should acknowledge the key role of structural factors and put emphasis on gender issues. Gender inequity affects many of the factors that influence adolescent pregnancies; sexual abuse, girls‟ limited access to use contraceptives, and girls‟ curtailed capability to decide regarding marriage or sexual intercourse, are strongly linked with young women‟s subordination. By challenging negative attitudes towards adolescents‟ sexuality, the encounter between providers and adolescents could become an opportunity for strengthening girls‟ reproductive and sexual agency.
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| 9. |
- Gotfredsen, Anne, 1981-
(författare)
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Carving out collective spaces : Exploring the complexities of gender and everyday stressors within rural youth leisure
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The reasons why young people are increasingly suffering frommental health problems, and the opportunities to turn this development aroundare globally debated. Stressors such as education, relationships, futuretrajectories of housing and employment all constitute important factors affectingyoung people’s mental health, leading to stress and achievement pressureespecially among girls and young women. The need to reduce individualization ofyoung people’s health problems, and instead encourage spaces for collectivesupport, action, and change has been called for in previous studies. Leisureparticipation has the potential to be such a collective space where young peopletogether can respond to stressors experienced in their daily life. Apart fromstudies on individual behavior change, leisure participation has been anoverlooked arena within public health and within research on young people’smental health and stress in particular. The complexity of youth leisure, especiallyin relation to gender and spatiality, calls for further investigation, exploring thesocial places of leisure that young people create themselves.Aim: The aim of this thesis is to understand how places of youth leisure areperceived and collectively constructed as social factors of youth mental health,and to analyze the strategies developed within these places to handle and respondto the everyday stressors experienced by young people.Conceptual framework: The analysis builds on four conceptual sections: (i)The stress process model explores stressors as situated in a wider social context,where social factors shape both the stressors that affect mental health, theresources to handle those stressors as well as the mental health outcomes. (ii) Thesocial practice theory highlights how social practices within places of leisure canbe identified as resources in relation to responses to stressors. (iii) The thirdsection of the framework takes on the relationship between stress, leisure, andpost-feminist perspectives on gender and successful femininity. The final section(iv) outlines leisure as a spatial (re)construction; emphasizing rural space andplace in relation to gender, stress, and precarity.Methods: This thesis builds on two sub-studies, generating three papers. SubstudyI is based on data from individual interviews with eight adult leaders fromdifferent leisure organizations (paper 1), and sub-study II (paper 2 and 3) is basedon an ethnographic multiple-case study with 16 girls (age 14-21) from two leisureorganizations. The setting for both sub-studies is rural northern Sweden. Thematerial from the ethnographic study was collected through participatoryobservations and focus group discussions using photo elicitation. For the first andsecond paper, thematic analysis was used as an analytical strategy, while a4discursive psychology approach (interpretative repertoires) was used for the thirdand final paper.Results: The first part of the results concerns how girls and adult leadersperceived and experienced daily stressors within the context of youth leisure.Such stressors were represented by the high demands girls face in relation toachievement pressure and time management, school, gender norms andexpectations, but also in relation to their leisure engagement. The second partexplores how the girls and adult leaders developed and negotiated strategies torespond to stressors, within the context of leisure. Responses were constructedthrough daily social practices within the context of leisure e.g. through sharingexperiences of stress with each other, based on a sense of belonging and trust. Inthe final part, rurality holds a central position in how place and space werediscursively constructed by the participants, in relation to leisure, gender, andstressors. Here, one of the main results in the third part was the complexity ofhow the participants’ constructed leisure as a place of wellbeing. In order to buildand maintain a space that enabled responses to stressors, the girls constantlyneeded to invest time, engagement, achievements, and emotions. In addition,places of leisure needed to be constructed in certain ways to be perceived asbeneficial and ‘positive’, for example as a place marked by respectability and selfdevelopment.This illustrates the precarity of youth leisure where educational andlabor-market opportunities have changed how young people now understand freetime as something that should be ‘productive and meaningful’. The metaphor of‘carving out spaces’ speaks for the effort the girls had to make in order to createand sustain such places; not only in relation to a successful femininity, but alsoin relation to the rural community and the survival of rural places of leisure.Conclusions: This study contributes to a better understanding of youth leisure,and how to build sustainable and inclusive places of leisure from a gender andrural perspective. Places of leisure and civic engagement are perceived asimportant social factors of youth mental health, and needs to be taken intoconsiderations when young people’s stress and mental health are discussed.Places of youth leisure are spaces where responses to everyday stressors can becollectively developed. At the same time, youth leisure is also precarious,demanding, and contributes to the reproduction of gendered discourses onrespectability and responsibility, both in relation to a successful femininity, butalso in making it work for the rural collective.
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| 10. |
- Linander, Ida, 1987-
(författare)
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“It was like I had to fit into a category” : people with trans experiences navigating access to trans-specific healthcare and health
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Trans issues have received increased attention over the last couple of years and important changes have been made in the legislation relating to gender reassignment and in trans-specific healthcare practices. At the same time, many people with trans experiences report poor mental health, bad experiences when encountering the healthcare and a tendency to postpone seeking care due to being badly treated. Previous research has also shown that gender norms guide the evaluation that precedes access to gender-confirming medical procedures. Critical studies examining practices within trans-specific healthcare in the Swedish context and health among people with trans experiences are limited, especially qualitative interview studies involving people with trans experiences.Aim: To analyse how constructions of trans experiences and gender can affect trans-specific healthcare practices, experiences of navigating access to gender- confirming medical procedures, inhabitancy of different spaces and, ultimately, health.Conceptual framework: Three areas of theory are used for the conceptual framework: trans studies, queer phenomenology and Foucauldian theories of power and governmentality.Methods: The thesis includes three sub-studies (generating four articles): two interview studies that build on interviews with 18 people with trans experiences, and a policy analysis of the guidelines for trans-specific healthcare published by the Swedish National Board of Health and Welfare. For the interview studies, grounded theory and thematic analysis were used as the analytical method. The guidelines were analysed using Bacchi’s method: “What’s the problem represented to be?”.Results: The participants experienced trans-specific healthcare as difficult to navigate due to waiting times, lack of knowledge and/or support and relationships of dependency between healthcare users and providers. In the evaluation, gender is reconstructed as linear – stereotypical, binary and stable – and the space for action available to care-seekers is affected by discourses existing both inside and outside trans-specific healthcare. The difficulties in navigating access to care were experienced as creating ill-health. In order to negotiate access to gender-confirming medical procedures, the participants took responsibility for the care process by, for example, ordering hormones from abroad, acquiring medical knowledge and finding alternative support. The linear gendered positioning was variously resisted, negotiated and embraced by the participants.The analysis of the guidelines showed that gender identity is constructed as a fixed linear essence but that the guidelines also open up space for a non-linear embodiment. Gender dysphoria is closely constructed in relation to psychiatric knowledge and mental health and the gate-keeping function among mental healthcare professionals is reconstituted in the guidelines. Hence, care-seekers are constructed as not competent enough to make decisions concerning access to gender-confirming medical procedures.The participants experienced several different spaces, such as bars, public toilets and changing rooms, gyms and cafés, as unsafe and as contributing to ill-health. In order to overcome the barriers to comfortably inhabiting spaces, the participants performed a kind of labour; for example, preparing in order to visit public baths and to answer transphobic comments and questions. Some spaces, such as trans-separatist, feminist and queer spaces, were experienced as safer and contributed to improved health through experiences of belonging, being able to share bad experiences and being able to relax.Conclusions: Trans-specific healthcare practices need to become more affirming and change so that care-seekers have more space for self- determination. Trans-specific healthcare needs more resources in order to decrease waiting times, improve knowledge and support, and hence to improve access to gender-confirming medical procedures. Actions need to be initiated to make spaces safer in order to improve the health of people with trans experiences.
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| 11. |
- 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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| 12. |
- Sirili, Nathanael, 1984-
(författare)
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Health workforce development post-1990s health sector reforms : the case of medical doctors in Tanzania
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania.Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted.Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention.Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended.
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