This report presents major findings from a field research conducted in Meskan and Mareko district... more This report presents major findings from a field research conducted in Meskan and Mareko district in south central Ethiopia. The research was conducted by a multidisciplinary team with extensive field research experiences in the areas of domestic violence reproductive health mental health and epidemiology. Over 3000 women were systematically selected for the study both from urban and rural areas. Data were collected using standard questionnaires for domestic violence and mental health developed by the World Health. The results show that 59% of women suffered from sexual violence and 49% from physical violence by a partner at some point in their lives. During the twelve months prior to the survey 44% of women reported sexual violence and 29% suffered partner violence. Major lifetime mental health problems include depressive episode Somatoform disorder and recurrent depressive episodes diagnosed in 6% 3% and 2% of the women respectively. Women who suffered from domestic violence also reported more symptoms of mental distress although the degree of association is not fully explored in this report. The majority of violence reported by women was inflected by intimate partners. The low status of women in the society a lack of general awareness about human/women’s rights and weakness in the law enforcement system are some of the reasons for the wide spread violence. To end violence against women and promote a healthy and secure life for women coordinated efforts by all concerned are needed. Efforts must also focus in improving the conditions of the family as a whole. (authors)
Background: Knowledge about social determinants of health has influenced global health strategies... more Background: Knowledge about social determinants of health has influenced global health strategies, including early childhood interventions. Some psychosocial circumstancessuch as poverty, parental mental health problems, abuse and partner violenceincrease the risk of child maltreatment and neglect. Healthcare professionals' awareness of psychosocial issues is of special interest, since they both have the possibility and the obligation to identify vulnerable children. Methods: Child Health Services health records of 100 children in Malmö, Sweden, who had been placed in, or were to be placed in family foster care, were compared with health records of a matched comparison group of 100 children who were not placed in care. A mixed-method approach integrating quantitative and qualitative analysis was applied. Results: The documentation about the foster care group was more voluminous than for the comparison group. The content was problem-oriented and dominated by severe parental health and social problems, while the child's own experiences were neglected. The professionals documented interaction with healthcare and social functions, but very few reports to the Social Services were noted. For both groups, notes about social structures were almost absent. Conclusions: Child Health Service professionals facing vulnerable children document parental health issues and interaction with healthcare, but they fail to document living conditions thereby making social structures invisible in the health records. The child perspective is insufficiently integrated in the documentation and serious child protection needs remain unmet, if professionals avoid reporting to Social Services.
Background: Public health policy is often concerned with the conflicting values emanating from th... more Background: Public health policy is often concerned with the conflicting values emanating from the individually formulated ethics for curative care and more collectively oriented ethics. In this study we have focused on the pol-ethical considerations involved in Swedish health care politicians' assessment of public health measures. Methods: We described a hypothetical situation In a questionnaire, where a community has a
Objectives: Social capital has been recognized as one important social determinant for health, bu... more Objectives: Social capital has been recognized as one important social determinant for health, but we still have limited knowledge about how it can be used to explain inequality in health. This study investigated the links between individual social capital and self-rated health by gender and educational level, and analyzed if access to social capital might explain the observed disparities in self-rated health between men and women and different educational groups. Study design: A cross-sectional survey in Northern Sweden. Methods: A social capital questionnaire was constructed and mailed to 15 000 randomly selected individuals. Different forms of structural and cognitive social capital were measured. Self-rated health was used as the outcome measure. Crude and adjusted OR and 95% CI were calculated for good selfrated health and access to each form of social capital. Multivariate regression was used to analyze how sociodemographic factors and access to social capital might influence differences in self-rated health by gender and educational level. Results: Access to almost each form of social capital significantly increased the odds for good self-rated health for all groups. A higher education significantly increased the odds for access to each form of social capital, and being a man significantly increased the odds for having access to some forms of social capital. The health advantage for higher educated and men partly decreased when controlling for access to social capital. Conclusions: Access to social capital can partly explain the observed health inequality between men and women and different educational groups. Strengthening social capital might be one way of tackling health inequality. It is important to consider the structural conditions that create unequal opportunities for different groups to access social capital.
Objectives: To study the feasibility of using an abuse screening tool for women attending an outp... more Objectives: To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges. Methods: Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during MarchÁApril 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data. Results: Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women' hospital only indicated a concern that abused men would be neglected. Conclusions: Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.
Objective: To study the implications of policy changes on the demand for antenatal care (ANC), HI... more Objective: To study the implications of policy changes on the demand for antenatal care (ANC), HIV testing and hospital delivery among pregnant women in rural Malawi. Design: Retrospective analysis of monthly reports. Setting: Malamulo SDA hospital in Thyolo district, Makwasa, Malawi. Methods: Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used. Results: The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery. Conclusions: Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.
Objectives: The current aim is to examine the prevalence of intimate partner violence (IPV) among... more Objectives: The current aim is to examine the prevalence of intimate partner violence (IPV) among Thai women residing in Sweden and its association with mental health. We also investigate the potential influence of social isolation and social capital regarding the association between IPV and mental health outcome. Design: A public health questionnaire in Thai was distributed by post to the entire population of Thai women, aged 18Á64, residing in two regions in Sweden since 2006. Items included aspects related to IPV (physical/sexual/emotional), sociodemographic background, physical health, mental health (GHQ-12), social isolation, and social capital (i.e. social trust/participation). Results: The response rate was 62.3% (n 0804). Prevalence of lifetime reported IPV was 22.1%, with 20.5% by a previous partner and 6.7% by a current partner. Previous IPV exposure was significantly related to current IPV exposure, and all IPV exposure measures were significantly related to poor mental health. However, Thai women experiencing IPV by a current partner were more at risk for poor mental health than Thai women with previous or without any experience of IPV. Also, among all women exposed to IPV, those with trust in others and without exposure to social isolation seemed to have partial protection against the adverse mental health consequences associated with IPV. Conclusions: Most Thai women had never been exposed to IPV, and after migrating to Sweden, women had lower IPV exposure than in Thailand. However, the increased risk for poor mental health among those Thai women exposed to IPV suggests the need for supportive measures and targeted interventions to prevent further injuries and adverse health consequences. Although poor mental health in Thai women represents an obstacle for integration, the potential resilience indicated in the group with high social trust and without exposure to social isolation suggests that such aspects be included in the program designed to facilitate integration.
To explore how 12-year-old Swedish children experienced being involved in a coeliac disease (CD) ... more To explore how 12-year-old Swedish children experienced being involved in a coeliac disease (CD) screening. A qualitative approach was used to analyse short narratives written by children who had taken part in a school-based CD screening. Narratives were written after blood sampling, but prior to learning of the test results. Through an oscillation between the texts, codes, subcategories and four categories, a theme was generated describing the children's experience. The theme ''A Journey towards Confidence'' captures the overall experience of the screening. It illustrates that, although some children faced fear or anxiety, overall they had or were provided tools allowing them to cope well and experience a journey towards confidence. The categories describe conditions that contributed to the experience. The first, being involved, reflects the importance of involvement in receiving information and deciding to participate. Being a ''good citizen'' refers to feeling a duty to help and a trust to be treated fairly. Being able to cope with the screening was influenced by the children's ability to manage sensations and support received. The last category, being able to balance risk, illustrates that the children were able to balance the risks of screening when they had a realistic understanding of the disease and their vulnerability and had tamed their anxiety. This study increases the understanding of how 12-year-old Swedish children experienced participating in a CD screening and describes conditions important for a positive experience. We show that, although some children faced anxiety, they had, or were provided with, tools allowing them to cope well and gain confidence.
Background: Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline i... more Background: Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline in HIV prevalence during the past two decades; decreasing from 24% in 1987 to 4.7 in 2009 in the urban district of Bukoba. Access to social capital, both structural and cognitive, might have played a role in this development. The aim was to examine the association between individual structural and cognitive social capital and socio-economic characteristics and the likelihood of being HIV infected.
SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2010
We present data from an exploratory case study characterising the social capital in three case vi... more We present data from an exploratory case study characterising the social capital in three case villages situated in areas of varying HIV prevalence in the Kagera region of Tanzania. Focus group discussions and key informant interviews revealed a range of experiences by community members, leaders of organisations and social groups. We found that the formation of social groups during the early 1990s was partly a result of poverty and the many deaths caused by AIDS. They built on a tradition to support those in need and provided social and economic support to members by providing loans. Their strict rules of conduct helped to create new norms, values and trust, important for HIV prevention. Members of different networks ultimately became role models for healthy protective behaviour. Formal organisations also worked together with social groups to facilitate networking and to provide avenues for exchange of information. We conclude that social capital contributed in changing HIV related risk behaviour that supported a decline of HIV infection in the high prevalence zone and maintained a low prevalence in the other zones.
Objective: This study explores violence against women in a low-income setting in relation to resi... more Objective: This study explores violence against women in a low-income setting in relation to residency and literacy. Setting: The study was conducted within the Butajira Rural Health Programme (a Health and Demographic Surveillance Site), which includes rural and semi-urban settings in south-central Ethiopia.
There are reports indicating a worsening of women's health in transitional rural societies in sub... more There are reports indicating a worsening of women's health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of women's status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty. #
This paper is a follow-up of earlier findings by the Kagera AIDS Research Project (KARP), which d... more This paper is a follow-up of earlier findings by the Kagera AIDS Research Project (KARP), which documented declining trends in the prevalence and incidence of HIV infection in the Kagera region of Tanzania. The paper examines socio-cultural and sexual behavioral changes as possible determinants of the observed declining trends in Bukoba, the largest urban area of the region. The study used in-depth interviews, focus group discussions, field observations and ethnographic assessments to collect the required data. The findings suggest that since the initial years of the epidemic there have been significant changes in sexual behaviors, norms, values, and customs that are considered high-risk for HIV transmission. The findings show an increase in condom use, abstinence, zero grazing (sticking to one sexual partner) and uptake of voluntary HIV testing while traditional practices such as polygamy, widow inheritance, excessive alcohol consumption, and sexual networking are declining. We suggest that these changes are partly a result of the severity of the epidemic itself in the study area, and interventions that have been carried out in this area since 1987. The major interventions have included health education, the distribution of condoms, AIDS education in schools, voluntary HIV counseling and testing. These are encouraging findings that give hope and we believe that other places within Tanzania and other countries experiencing a severe AIDS crisis have much to learn from this experience. However, changes in norms and behavior are vulnerable; people in Kagera are still at risk and there is a need for continued intervention together with monitoring of the direction of the epidemic. r
Growing research on social capital and health has fuelled the debate on whether there is a place ... more Growing research on social capital and health has fuelled the debate on whether there is a place effect on health. A central question is whether health inequality between places is due to differences in the composition of people living in these places (compositional effect) or differences in the local social and physical environments (contextual effects). Despite extensive use of multilevel approaches that allows controlling for whether the effects of collective social capital are confounded by access to social capital at the individual level, the picture remains unclear. Recent studies indicate that contextual effects on health may vary for different population subgroups and measuring "average" contextual effects on health for a whole population might therefore be inappropriate. In this study from northern Sweden, we investigated the associations between collective social capital and self-rated health for men and women separately, to understand if health effects of collective social capital are gendered. Two measures of collective social capital were used: one conventional measure (aggregated measures of trust, participation and voting) and one specific place-related (neighbourhood) measure. The results show a positive association between collective social capital and self-rated health for women but not for men. Regardless of the measure used, women who live in very high social capital neighbourhoods are more likely to rate their health as good-fair, compared to women who live in very low social capital neighbourhoods. The health effects of collective social capital might thus be gendered in favour for women. However, a more equal involvement of men and women in the domestic sphere would potentially benefit men in this matter. When controlling for socioeconomic, sociodemographic and social capital attributes at the individual level, the relationship between women's health and collective social capital remained statistically significant when using the neighbourhood-related measure but not when using the conventional measure. Our results support the view that a neighbourhood-related measure provides a clearer picture of the health effects of collective social capital, at least for women.
There is an ongoing debate about the importance of biomedical and sociodemographic risk factors i... more There is an ongoing debate about the importance of biomedical and sociodemographic risk factors in the prediction of self-rated health. To compare the association of sociodemographic and cardiovascular risk factors and self-rated health in Sweden and the US. Data from two population-based cross-sectional health surveys, one in Sweden and one in the US. The surveys included questionnaire and measured data from 5,461 adults in Sweden and 7,643 in the US. Participants were between 35 and 65 years of age. The odds ratios for poor self-rated health for the included cardiovascular risk factors were greater in the US. Low education was significantly more prevalent among those with self-rated poor health in the US, but not in Sweden. Using Swedes with high education as reference group (OR = 1), adults in the US with low education and 2+ risk factors had a greater than threefold risk (OR = 6.3) of self-rated poor health compared with Swedish low-educated adults with the same risk factor burden (OR = 1.9). The better-educated US adults with 2+ risk factors were significantly more likely to report poor health (OR = 3.4) compared with their Swedish counterparts (OR = 2.4). The interaction between risk factors, education, and self-rated health suggests a frightening picture, especially for the US. Public health interventions for reducing cardiovascular risk factors need to include both population and individual measures. Taking people's overall evaluation of their health into account when assessing total health risk is important.
Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the ... more Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the focus of many agricultural safety campaigns. Traditionally efforts have attempted to persuade farmers through education or community awareness interventions. These efforts have lead to marginal change. In response, a social marketing approach was tested as a means for increasing interest in ROPS retrofitting in New York. An initial phone survey was conducted with a random sample of New York farmers to identify a potential target population. Following target selection, in-depth interviews were conducted to isolate barriers and motivators to retrofitting. This information was used to develop message prototypes which were tested in small focus group discussions. Selected and revised messages, as well as various other incentives developed in response to feedback from interviews, were then tested in a prospective, quasi-randomized controlled trial. Small crop and livestock farms were selected as the intervention target since they represent 86% of New York farms with none or only one ROPS protected tractor. Barriers to retrofitting which were identified in interviews were: 1) constant exposures normalize risk, 2) risk is modeled by significant others and 3) safety in general and retrofitting in particular requires too much time and money. The piloting of ROPS incentives led to a marked increase in ROPS sales in New York. Social Marketing provides a promising framework for the design of agricultural injury prevention programs. The potential implications for other health initiatives seeking to promote behaviour change are also discussed.
Objective: to explore women's experiences of a prevention of mother-to-child transmission (PMTCT)... more Objective: to explore women's experiences of a prevention of mother-to-child transmission (PMTCT) programme in rural Malawi. Design, setting and participants: an exploratory, qualitative study using in-depth interviews with 24 purposively selected women infected with human immunodeficiency virus (HIV). The women were in three groups of eight: (1) those who delivered at the hospital and took nevirapine (NVP) before birth and whose babies received NVP within 72 hours of birth; (2) those who birthed at home and took NVP before birth but their babies never received NVP; and (3) those who birthed at home and did not take NVP and whose babies did not receive NVP. Data were analysed using content analysis. Findings: four themes emerged: (1) 'a wish to confirm and protect' refers to women's decisions to take the HIV test, (2) 'a revelation for action' is an illustration of how the testing may be part of an empowering process, (3) 'a dilemma between silence and openness' points to the dilemma that women are facing in their decision to share or not to share their HIV status with spouse, family, friends and community, and (4) 'a desire challenged by circumstances, chance and tradition' refers to the circumstances and actions which prevent these women from actually delivering at the hospital to protect their babies from HIV infection. Conclusions: the PMTCT programme influences women's lives profoundly, and the importance of quality counselling and strengthening male involvement is stressed as the programme is implemented by an increasing number of service providers.
Grounded theory guided the analysis of 30 in-depth interviews with raped women and community memb... more Grounded theory guided the analysis of 30 in-depth interviews with raped women and community members who had supported raped women in their contact with the police and health care services in Tanzania. The aim of this study was to understand and conceptualize the experiences of the informants by creating a theoretical model focusing on barriers, strategies, and responses during the help seeking process. The results illustrate a process of managing in the contemporary world characterized as walking a path of anger and humiliation. The barriers are illustrated by painful experiences of realizing it's all about money, meeting unprofessionalism and irresponsibility, subjected to unreliable Article at Umea University Library on March 31, 2011 jiv.sagepub.com Downloaded from 2 Journal of Interpersonal Violence XX(X) services, and by being caught in a messed-up system. Negotiating truths and knowing what to do capture the informants' coping strategies. The study indicates an urgent need for improvement in the formal procedures of handling rape cases, improved collaboration between the police and the health care system, as well as specific training for professionals to improve their communication and caring skills.
Study objective-To present a formula for equity adjusted years of life saved (EYLS). Design-A mai... more Study objective-To present a formula for equity adjusted years of life saved (EYLS). Design-A mailed questionnaire. The survey participants were given a scenario describing a trade oV between a health maximisation programme and a programme that is less eYcient, but eliminates social inequalities. Setting-Swedish politicians responsible for health care in the county councils. Participants-A sample of 449 Swedish politicians responsible for health care in the county councils. Main results-The principle of health maximisation was rejected. Under certain conditions, the Swedish politicians are prepared to sacrifice 15 of 100 preventable deaths to achieve equity. Based on the results a formula for EYLS is presented. Conclusions-An equity adjusted formula for years of life saved has been proposed, but must be developed and revised according to each country's specific conditions and value premises. In the future, such formulas could serve the purpose of incorporating explicit considerations of equity into cost eVectiveness analyses.
This report presents major findings from a field research conducted in Meskan and Mareko district... more This report presents major findings from a field research conducted in Meskan and Mareko district in south central Ethiopia. The research was conducted by a multidisciplinary team with extensive field research experiences in the areas of domestic violence reproductive health mental health and epidemiology. Over 3000 women were systematically selected for the study both from urban and rural areas. Data were collected using standard questionnaires for domestic violence and mental health developed by the World Health. The results show that 59% of women suffered from sexual violence and 49% from physical violence by a partner at some point in their lives. During the twelve months prior to the survey 44% of women reported sexual violence and 29% suffered partner violence. Major lifetime mental health problems include depressive episode Somatoform disorder and recurrent depressive episodes diagnosed in 6% 3% and 2% of the women respectively. Women who suffered from domestic violence also reported more symptoms of mental distress although the degree of association is not fully explored in this report. The majority of violence reported by women was inflected by intimate partners. The low status of women in the society a lack of general awareness about human/women’s rights and weakness in the law enforcement system are some of the reasons for the wide spread violence. To end violence against women and promote a healthy and secure life for women coordinated efforts by all concerned are needed. Efforts must also focus in improving the conditions of the family as a whole. (authors)
Background: Knowledge about social determinants of health has influenced global health strategies... more Background: Knowledge about social determinants of health has influenced global health strategies, including early childhood interventions. Some psychosocial circumstancessuch as poverty, parental mental health problems, abuse and partner violenceincrease the risk of child maltreatment and neglect. Healthcare professionals' awareness of psychosocial issues is of special interest, since they both have the possibility and the obligation to identify vulnerable children. Methods: Child Health Services health records of 100 children in Malmö, Sweden, who had been placed in, or were to be placed in family foster care, were compared with health records of a matched comparison group of 100 children who were not placed in care. A mixed-method approach integrating quantitative and qualitative analysis was applied. Results: The documentation about the foster care group was more voluminous than for the comparison group. The content was problem-oriented and dominated by severe parental health and social problems, while the child's own experiences were neglected. The professionals documented interaction with healthcare and social functions, but very few reports to the Social Services were noted. For both groups, notes about social structures were almost absent. Conclusions: Child Health Service professionals facing vulnerable children document parental health issues and interaction with healthcare, but they fail to document living conditions thereby making social structures invisible in the health records. The child perspective is insufficiently integrated in the documentation and serious child protection needs remain unmet, if professionals avoid reporting to Social Services.
Background: Public health policy is often concerned with the conflicting values emanating from th... more Background: Public health policy is often concerned with the conflicting values emanating from the individually formulated ethics for curative care and more collectively oriented ethics. In this study we have focused on the pol-ethical considerations involved in Swedish health care politicians' assessment of public health measures. Methods: We described a hypothetical situation In a questionnaire, where a community has a
Objectives: Social capital has been recognized as one important social determinant for health, bu... more Objectives: Social capital has been recognized as one important social determinant for health, but we still have limited knowledge about how it can be used to explain inequality in health. This study investigated the links between individual social capital and self-rated health by gender and educational level, and analyzed if access to social capital might explain the observed disparities in self-rated health between men and women and different educational groups. Study design: A cross-sectional survey in Northern Sweden. Methods: A social capital questionnaire was constructed and mailed to 15 000 randomly selected individuals. Different forms of structural and cognitive social capital were measured. Self-rated health was used as the outcome measure. Crude and adjusted OR and 95% CI were calculated for good selfrated health and access to each form of social capital. Multivariate regression was used to analyze how sociodemographic factors and access to social capital might influence differences in self-rated health by gender and educational level. Results: Access to almost each form of social capital significantly increased the odds for good self-rated health for all groups. A higher education significantly increased the odds for access to each form of social capital, and being a man significantly increased the odds for having access to some forms of social capital. The health advantage for higher educated and men partly decreased when controlling for access to social capital. Conclusions: Access to social capital can partly explain the observed health inequality between men and women and different educational groups. Strengthening social capital might be one way of tackling health inequality. It is important to consider the structural conditions that create unequal opportunities for different groups to access social capital.
Objectives: To study the feasibility of using an abuse screening tool for women attending an outp... more Objectives: To study the feasibility of using an abuse screening tool for women attending an outpatient department, and describe how health care workers perceived its benefits and challenges. Methods: Prior to screening, 39 health care workers attended training on gender-based violence and the suggested screening procedures. Seven health care workers were arranged to implement screening in 3 weeks, during MarchÁApril 2010. For screening evaluation, health care workers were observed for their interaction with clients. Thereafter, focus group discussions (FGDs) were conducted with 21 health care workers among those who had participated in the training and screening. Five health care workers wrote narratives. Women's responses to screening questions were analyzed with descriptive statistics, whereas qualitative content analysis guided analysis of qualitative data. Results: Of the 102 women screened, 78% had experienced emotional, physical, or sexual violence. Among them, 62% had experienced IPV, while 22% were subjected to violence by a relative, and 9.2% by a work mate. Two-thirds (64%) had been abused more than once; 14% several times. Almost one-quarter (23%) had experienced sexual violence. Six of the health care workers interacted well with clients but three had difficulties to follow counseling guidelines. FGDs and narratives generated three categories Just asking feels good implied a blessing of the tool; what next? indicated ethical dilemmas; and fear of becoming a 'women' hospital only indicated a concern that abused men would be neglected. Conclusions: Screening for IPV is feasible. Overall, the health care workers perceived the tool to be advantageous. Training on gender-based violence and adjustment of the tool to suit local structures are important. Further studies are needed to explore the implications of including abuse against men and children in future screening.
Objective: To study the implications of policy changes on the demand for antenatal care (ANC), HI... more Objective: To study the implications of policy changes on the demand for antenatal care (ANC), HIV testing and hospital delivery among pregnant women in rural Malawi. Design: Retrospective analysis of monthly reports. Setting: Malamulo SDA hospital in Thyolo district, Makwasa, Malawi. Methods: Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used. Results: The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery. Conclusions: Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.
Objectives: The current aim is to examine the prevalence of intimate partner violence (IPV) among... more Objectives: The current aim is to examine the prevalence of intimate partner violence (IPV) among Thai women residing in Sweden and its association with mental health. We also investigate the potential influence of social isolation and social capital regarding the association between IPV and mental health outcome. Design: A public health questionnaire in Thai was distributed by post to the entire population of Thai women, aged 18Á64, residing in two regions in Sweden since 2006. Items included aspects related to IPV (physical/sexual/emotional), sociodemographic background, physical health, mental health (GHQ-12), social isolation, and social capital (i.e. social trust/participation). Results: The response rate was 62.3% (n 0804). Prevalence of lifetime reported IPV was 22.1%, with 20.5% by a previous partner and 6.7% by a current partner. Previous IPV exposure was significantly related to current IPV exposure, and all IPV exposure measures were significantly related to poor mental health. However, Thai women experiencing IPV by a current partner were more at risk for poor mental health than Thai women with previous or without any experience of IPV. Also, among all women exposed to IPV, those with trust in others and without exposure to social isolation seemed to have partial protection against the adverse mental health consequences associated with IPV. Conclusions: Most Thai women had never been exposed to IPV, and after migrating to Sweden, women had lower IPV exposure than in Thailand. However, the increased risk for poor mental health among those Thai women exposed to IPV suggests the need for supportive measures and targeted interventions to prevent further injuries and adverse health consequences. Although poor mental health in Thai women represents an obstacle for integration, the potential resilience indicated in the group with high social trust and without exposure to social isolation suggests that such aspects be included in the program designed to facilitate integration.
To explore how 12-year-old Swedish children experienced being involved in a coeliac disease (CD) ... more To explore how 12-year-old Swedish children experienced being involved in a coeliac disease (CD) screening. A qualitative approach was used to analyse short narratives written by children who had taken part in a school-based CD screening. Narratives were written after blood sampling, but prior to learning of the test results. Through an oscillation between the texts, codes, subcategories and four categories, a theme was generated describing the children's experience. The theme ''A Journey towards Confidence'' captures the overall experience of the screening. It illustrates that, although some children faced fear or anxiety, overall they had or were provided tools allowing them to cope well and experience a journey towards confidence. The categories describe conditions that contributed to the experience. The first, being involved, reflects the importance of involvement in receiving information and deciding to participate. Being a ''good citizen'' refers to feeling a duty to help and a trust to be treated fairly. Being able to cope with the screening was influenced by the children's ability to manage sensations and support received. The last category, being able to balance risk, illustrates that the children were able to balance the risks of screening when they had a realistic understanding of the disease and their vulnerability and had tamed their anxiety. This study increases the understanding of how 12-year-old Swedish children experienced participating in a CD screening and describes conditions important for a positive experience. We show that, although some children faced anxiety, they had, or were provided with, tools allowing them to cope well and gain confidence.
Background: Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline i... more Background: Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline in HIV prevalence during the past two decades; decreasing from 24% in 1987 to 4.7 in 2009 in the urban district of Bukoba. Access to social capital, both structural and cognitive, might have played a role in this development. The aim was to examine the association between individual structural and cognitive social capital and socio-economic characteristics and the likelihood of being HIV infected.
SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2010
We present data from an exploratory case study characterising the social capital in three case vi... more We present data from an exploratory case study characterising the social capital in three case villages situated in areas of varying HIV prevalence in the Kagera region of Tanzania. Focus group discussions and key informant interviews revealed a range of experiences by community members, leaders of organisations and social groups. We found that the formation of social groups during the early 1990s was partly a result of poverty and the many deaths caused by AIDS. They built on a tradition to support those in need and provided social and economic support to members by providing loans. Their strict rules of conduct helped to create new norms, values and trust, important for HIV prevention. Members of different networks ultimately became role models for healthy protective behaviour. Formal organisations also worked together with social groups to facilitate networking and to provide avenues for exchange of information. We conclude that social capital contributed in changing HIV related risk behaviour that supported a decline of HIV infection in the high prevalence zone and maintained a low prevalence in the other zones.
Objective: This study explores violence against women in a low-income setting in relation to resi... more Objective: This study explores violence against women in a low-income setting in relation to residency and literacy. Setting: The study was conducted within the Butajira Rural Health Programme (a Health and Demographic Surveillance Site), which includes rural and semi-urban settings in south-central Ethiopia.
There are reports indicating a worsening of women's health in transitional rural societies in sub... more There are reports indicating a worsening of women's health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of women's status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty. #
This paper is a follow-up of earlier findings by the Kagera AIDS Research Project (KARP), which d... more This paper is a follow-up of earlier findings by the Kagera AIDS Research Project (KARP), which documented declining trends in the prevalence and incidence of HIV infection in the Kagera region of Tanzania. The paper examines socio-cultural and sexual behavioral changes as possible determinants of the observed declining trends in Bukoba, the largest urban area of the region. The study used in-depth interviews, focus group discussions, field observations and ethnographic assessments to collect the required data. The findings suggest that since the initial years of the epidemic there have been significant changes in sexual behaviors, norms, values, and customs that are considered high-risk for HIV transmission. The findings show an increase in condom use, abstinence, zero grazing (sticking to one sexual partner) and uptake of voluntary HIV testing while traditional practices such as polygamy, widow inheritance, excessive alcohol consumption, and sexual networking are declining. We suggest that these changes are partly a result of the severity of the epidemic itself in the study area, and interventions that have been carried out in this area since 1987. The major interventions have included health education, the distribution of condoms, AIDS education in schools, voluntary HIV counseling and testing. These are encouraging findings that give hope and we believe that other places within Tanzania and other countries experiencing a severe AIDS crisis have much to learn from this experience. However, changes in norms and behavior are vulnerable; people in Kagera are still at risk and there is a need for continued intervention together with monitoring of the direction of the epidemic. r
Growing research on social capital and health has fuelled the debate on whether there is a place ... more Growing research on social capital and health has fuelled the debate on whether there is a place effect on health. A central question is whether health inequality between places is due to differences in the composition of people living in these places (compositional effect) or differences in the local social and physical environments (contextual effects). Despite extensive use of multilevel approaches that allows controlling for whether the effects of collective social capital are confounded by access to social capital at the individual level, the picture remains unclear. Recent studies indicate that contextual effects on health may vary for different population subgroups and measuring "average" contextual effects on health for a whole population might therefore be inappropriate. In this study from northern Sweden, we investigated the associations between collective social capital and self-rated health for men and women separately, to understand if health effects of collective social capital are gendered. Two measures of collective social capital were used: one conventional measure (aggregated measures of trust, participation and voting) and one specific place-related (neighbourhood) measure. The results show a positive association between collective social capital and self-rated health for women but not for men. Regardless of the measure used, women who live in very high social capital neighbourhoods are more likely to rate their health as good-fair, compared to women who live in very low social capital neighbourhoods. The health effects of collective social capital might thus be gendered in favour for women. However, a more equal involvement of men and women in the domestic sphere would potentially benefit men in this matter. When controlling for socioeconomic, sociodemographic and social capital attributes at the individual level, the relationship between women's health and collective social capital remained statistically significant when using the neighbourhood-related measure but not when using the conventional measure. Our results support the view that a neighbourhood-related measure provides a clearer picture of the health effects of collective social capital, at least for women.
There is an ongoing debate about the importance of biomedical and sociodemographic risk factors i... more There is an ongoing debate about the importance of biomedical and sociodemographic risk factors in the prediction of self-rated health. To compare the association of sociodemographic and cardiovascular risk factors and self-rated health in Sweden and the US. Data from two population-based cross-sectional health surveys, one in Sweden and one in the US. The surveys included questionnaire and measured data from 5,461 adults in Sweden and 7,643 in the US. Participants were between 35 and 65 years of age. The odds ratios for poor self-rated health for the included cardiovascular risk factors were greater in the US. Low education was significantly more prevalent among those with self-rated poor health in the US, but not in Sweden. Using Swedes with high education as reference group (OR = 1), adults in the US with low education and 2+ risk factors had a greater than threefold risk (OR = 6.3) of self-rated poor health compared with Swedish low-educated adults with the same risk factor burden (OR = 1.9). The better-educated US adults with 2+ risk factors were significantly more likely to report poor health (OR = 3.4) compared with their Swedish counterparts (OR = 2.4). The interaction between risk factors, education, and self-rated health suggests a frightening picture, especially for the US. Public health interventions for reducing cardiovascular risk factors need to include both population and individual measures. Taking people's overall evaluation of their health into account when assessing total health risk is important.
Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the ... more Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the focus of many agricultural safety campaigns. Traditionally efforts have attempted to persuade farmers through education or community awareness interventions. These efforts have lead to marginal change. In response, a social marketing approach was tested as a means for increasing interest in ROPS retrofitting in New York. An initial phone survey was conducted with a random sample of New York farmers to identify a potential target population. Following target selection, in-depth interviews were conducted to isolate barriers and motivators to retrofitting. This information was used to develop message prototypes which were tested in small focus group discussions. Selected and revised messages, as well as various other incentives developed in response to feedback from interviews, were then tested in a prospective, quasi-randomized controlled trial. Small crop and livestock farms were selected as the intervention target since they represent 86% of New York farms with none or only one ROPS protected tractor. Barriers to retrofitting which were identified in interviews were: 1) constant exposures normalize risk, 2) risk is modeled by significant others and 3) safety in general and retrofitting in particular requires too much time and money. The piloting of ROPS incentives led to a marked increase in ROPS sales in New York. Social Marketing provides a promising framework for the design of agricultural injury prevention programs. The potential implications for other health initiatives seeking to promote behaviour change are also discussed.
Objective: to explore women's experiences of a prevention of mother-to-child transmission (PMTCT)... more Objective: to explore women's experiences of a prevention of mother-to-child transmission (PMTCT) programme in rural Malawi. Design, setting and participants: an exploratory, qualitative study using in-depth interviews with 24 purposively selected women infected with human immunodeficiency virus (HIV). The women were in three groups of eight: (1) those who delivered at the hospital and took nevirapine (NVP) before birth and whose babies received NVP within 72 hours of birth; (2) those who birthed at home and took NVP before birth but their babies never received NVP; and (3) those who birthed at home and did not take NVP and whose babies did not receive NVP. Data were analysed using content analysis. Findings: four themes emerged: (1) 'a wish to confirm and protect' refers to women's decisions to take the HIV test, (2) 'a revelation for action' is an illustration of how the testing may be part of an empowering process, (3) 'a dilemma between silence and openness' points to the dilemma that women are facing in their decision to share or not to share their HIV status with spouse, family, friends and community, and (4) 'a desire challenged by circumstances, chance and tradition' refers to the circumstances and actions which prevent these women from actually delivering at the hospital to protect their babies from HIV infection. Conclusions: the PMTCT programme influences women's lives profoundly, and the importance of quality counselling and strengthening male involvement is stressed as the programme is implemented by an increasing number of service providers.
Grounded theory guided the analysis of 30 in-depth interviews with raped women and community memb... more Grounded theory guided the analysis of 30 in-depth interviews with raped women and community members who had supported raped women in their contact with the police and health care services in Tanzania. The aim of this study was to understand and conceptualize the experiences of the informants by creating a theoretical model focusing on barriers, strategies, and responses during the help seeking process. The results illustrate a process of managing in the contemporary world characterized as walking a path of anger and humiliation. The barriers are illustrated by painful experiences of realizing it's all about money, meeting unprofessionalism and irresponsibility, subjected to unreliable Article at Umea University Library on March 31, 2011 jiv.sagepub.com Downloaded from 2 Journal of Interpersonal Violence XX(X) services, and by being caught in a messed-up system. Negotiating truths and knowing what to do capture the informants' coping strategies. The study indicates an urgent need for improvement in the formal procedures of handling rape cases, improved collaboration between the police and the health care system, as well as specific training for professionals to improve their communication and caring skills.
Study objective-To present a formula for equity adjusted years of life saved (EYLS). Design-A mai... more Study objective-To present a formula for equity adjusted years of life saved (EYLS). Design-A mailed questionnaire. The survey participants were given a scenario describing a trade oV between a health maximisation programme and a programme that is less eYcient, but eliminates social inequalities. Setting-Swedish politicians responsible for health care in the county councils. Participants-A sample of 449 Swedish politicians responsible for health care in the county councils. Main results-The principle of health maximisation was rejected. Under certain conditions, the Swedish politicians are prepared to sacrifice 15 of 100 preventable deaths to achieve equity. Based on the results a formula for EYLS is presented. Conclusions-An equity adjusted formula for years of life saved has been proposed, but must be developed and revised according to each country's specific conditions and value premises. In the future, such formulas could serve the purpose of incorporating explicit considerations of equity into cost eVectiveness analyses.
There are few studies on how social workers deal with cases regarding transnational surrogacy. Ou... more There are few studies on how social workers deal with cases regarding transnational surrogacy. Our study intends to contribute to filling this gap. In Sweden, surrogacy as an assisted reproductive technology method is not permitted. As a result, many prospective parents have turned abroad, mainly to India, for surrogacy. There are no laws regulating surrogacy in Sweden, and difficulties have arisen in establishing legal parenthood when the parents return with the child. This qualitative interview study with social workers found that legal uncertainty and ethical issues surrounded their handling. With no guidelines, the constructions of parenthood will continue to depend on individual social workers' conflicting views on how to best meet the surrogate mother's interest and the best interest of the child. Regulation is thus needed to better protect those involved and minimize the contingent aspects of legal handling by individual officials.
Uploads
Papers by Maria Emmelin