1.
Linander, Ida, 1987-, et al.
(författare)
Two Steps Forward, One Step Back: A Policy Analysis of the Swedish Guidelines for Trans-Specific Healthcare
2021
Ingår i: Sexuality Research and Social Policy. - : Springer Science and Business Media LLC. - 1868-9884 .- 1553-6610. ; 18, s. 309-320
Tidskriftsartikel (refereegranskat) abstract
Introduction Sweden has one of the world's longest histories of providing subsidized gender-confirming medical procedures for people with trans experiences. However, until 2015, Swedish trans-specific healthcare lacked formal guidelines. Methods In this study, we analyse the Swedish guidelines for trans-specific healthcare from 2015 using Bacchi's approach: "What's the problem represented to be?" Following this approach, we analyse problem representations in the guidelines with special focus on evaluation, diagnosis of gender dysphoria and criteria for access to care. Results Three problem representations were identified in our analysis: "the problem of (non)linear gender", "the mental health paradox" and "gender dysphoria as a psychiatric, psychological and psychosocial problem". Together, these problem representations construct gender dysphoria as a psychopathology and allocate the decision-making power to mental health care providers. Hence, the guidelines reconstruct the gatekeeping function among care providers while undermining care seekers' ability to attain self-determination. While the guidelines do allow for non-linear embodiment, they simultaneously reconstruct a linear relationship between gender identity and social gender role. Mental healthiness and, for migrants, having a residence permit seem to be favoured in the evaluation of gender dysphoria and for access to gender-confirming medical procedures, while aspects of gender euphoria are silenced. Conclusions We conclude that the guidelines resemble, and have similar effects to, the psychomedical understandings of gender dysphoria prevalent in medical research and practice. At the same time, the guidelines attempt to depathologize trans experiences and open up space for new subjectivities to be eligible for access to gender-confirming medical procedures. Policy Implication The knowledge from this study can be useful when constructing, revising or analysing guidelines for trans-specific healthcare in several contexts.
2.
Sirili, Nathanael, 1984-
(författare)
Health workforce development post-1990s health sector reforms : the case of medical doctors in Tanzania
2018
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.
3.
Mathias, Kaaren, 1969-
(författare)
Shadows and light : examining community mental health competence in North India
2016
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.
4.
Gotfredsen, Anne, 1981-
(författare)
Carving out collective spaces : Exploring the complexities of gender and everyday stressors within rural youth leisure
2021
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.
5.
Gotfredsen, Anne, et al.
(författare)
Precarious leisure in a teenage wasteland? : Intertwining discourses on responsibility and girls' place-making in rural Northern Sweden
2022
Ingår i: Journal of Youth Studies. - : Taylor & Francis. - 1367-6261 .- 1469-9680. ; 25:10, s. 1350-1366
Tidskriftsartikel (refereegranskat) abstract
The relationship with place has been recognized as a significant dimension of rural youth leisure, both through the discursive constructions of place, but also as affective and embodied dimensions. This study captures these processes by applying the concept of place-making as a set of recurrent discursive processes, analyzing how girls in Northern Sweden engage in place-making alongside, beyond, and in contrast to dominant discourses on leisure, rurality and wellbeing. The study draws on data from photo-elicited focus groups with girls from two sports organizations. The discursive psychology analysis resulted in three interpretative repertoires. The first repertoire describes the sharp contrast between discourses of the 'rural dull' and how stressful the participants constructed their own places of leisure. The second illustrates the gendered discourses around what is considered to be productive and respectable leisure. The third shows how the participants are made responsible for the survival of their leisure. Through place-making, the participants shape places of leisure, affecting both themselves and their rural community. They engage in, conform to, and challenge place-making within discourses of responsibility and precariousness, creating space for their own initiatives, which are simultaneously shaped by the material conditions under which these practices take place.
6.
Richter Sundberg, Linda, Ph D, 1975-, et al.
(författare)
How can we strengthen mental health services in Swedish youth clinics? A health policy and systems study protocol
2021
Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:10, s. e048922-e048922
Tidskriftsartikel (refereegranskat) abstract
Introduction: Strengthening first-line mental healthcare services for youth remains a priority for the Swedish government. The government is currently investigating how different sectors involved can be strengthened, butevidence is scarce. Youth clinics play a key role in these discussions, being one of the most trusted services for youth. However, analysis of organisational functions andcoordination with other services is important to strengthen youth clinics’ role in first-line mental healthcare. This study investigates these challenges and aims to analysethe integration of mental healthcare within youth clinics to identify strategies to strengthen first-line mental healthcare for youth in Sweden.Methods and analysis: This study adopts a health policyand systems approach. In the first phase, a formative realist evaluation is conducted to ascertain what works in terms of integrating mental healthcare services within youth clinics, for what type of youth subpopulations and under what circumstances. National-level stakeholders will be interviewed to elicit the programme theory that explains how the intervention is supposed to work. The programme theory will then be tested in three–five cases. The cases will be comprised of youth clinics and their stakeholders. Quantitative and qualitative information will be gathered,including via visual methodologies and questionnaires. The second phase includes a concept mapping study, engaging stakeholders and young people to build consensuson strategies to strengthen the integration of menta lhealthcare into youth clinics.
7.
Linander, Ida, 1987-
(författare)
“It was like I had to fit into a category” : people with trans experiences navigating access to trans-specific healthcare and health
2018
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.
8.
Coe, Anna-Britt, 1967-, et al.
(författare)
How gender hierarchies matter in youth activism : young people's mobilizing around sexual health in Ecuador and Peru
2013
Ingår i: Journal of Youth Studies. - : Routledge. - 1367-6261 .- 1469-9680. ; 16:6, s. 695-711
Tidskriftsartikel (refereegranskat) abstract
Despite a growing body of research on youth activism, few studies examine how this intersects with gender. Our study aimed to explore whether and how young activists themselves perceived gender hierarchies as needing to be addressed through their collective action on sexual health in Peru and Ecuador. Using Grounded Theory, qualitative data was collected and analyzed from young activists across four cases. Cases ranged in complexity from a single youth organization operating at the district level to numerous youth organizations articulating at the national level. We linked the GT analysis to a conceptual framework based on Tayor’s (1999) theorizing of gender and social movements. Accordingly, young activists perceived gender, and even class, “race” and age, as salient to their collective actions. These actions corresponded to the social movement concept of mobilizing structures that consist of pre-existing structures, tactics and organizations. Young activists understood gender and other social categories as imbued by power differentials and therefore as social hierarchies, within which their activism was embedded. The paper thereby demonstrates the need for an enhanced conceptual framework for the study of youth activism and its intersection with gender hierarchies.
9.
Otero-Garcia, Laura, et al.
(författare)
Access to and use of sexual and reproductive health services provided by midwives among rural immigrant women in Spain : midwives' perspectives
2013
Ingår i: Global Health Action. - : Co-action Publishing. - 1654-9716 .- 1654-9880. ; 6:1
Tidskriftsartikel (refereegranskat) abstract
BACKGROUND: There insufficient information regarding access and participation of immigrant women in Spain in sexual and reproductive health programs. Recent studies show their lower participation rate in gynecological cancer screening programs; however, little is known about the participation in other sexual and reproductive health programs by immigrant women living in rural areas with high population dispersion.OBJECTIVES: The objective of this study is to explore the perceptions of midwives who provide these services regarding immigrant women's access and participation in sexual and reproductive health programs offered in a rural area.DESIGN: A qualitative study was performed, within a larger ethnographic study about rural primary care, with data collection based on in-depth interviews and field notes. Participants were the midwives in primary care serving 13 rural basic health zones (BHZ) of Segovia, a region of Spain with high population dispersion. An interview script was designed to collect information about midwives' perceptions on immigrant women's access to and use of the healthcare services that they provide. Interviews were recorded and transcribed with participant informed consent. Data were analyzed based on the qualitative content analysis approach and triangulation of results with fieldwork notes.RESULTS: Midwives perceive that immigrants in general, and immigrant women in particular, underuse family planning services. This underutilization is associated with cultural differences and gender inequality. They also believe that the number of voluntary pregnancy interruptions among immigrant women is elevated and identify childbearing and childrearing-related tasks and the language barrier as obstacles to immigrant women accessing the available prenatal and postnatal healthcare services.CONCLUSIONS: Immigrant women's underutilization of midwifery services may be linked to the greater number of unintended pregnancies, pregnancy terminations, and the delay in the first prenatal visit, as discerned by midwives. Future research should involve samples of immigrant women themselves, to provide a deeper understanding of the current knowledge, attitudes, and practices of the immigrant population regarding reproductive and sexual health to provide better health services.
10.
Goicolea, Isabel, et al.
(författare)
Mechanisms for achieving adolescent-friendly services : a realist evaluation approach
2012
Ingår i: Global Health Action. - : Co-Action Publishing. - 1654-9716 .- 1654-9880. ; 5, s. 18748-
Tidskriftsartikel (refereegranskat) abstract
Background: Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach.In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent.Methods: The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes.Results: The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored.Conclusion: The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process.Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.
