Thèses sur le sujet « Equality – Health aspects – Sweden »

Canada's health system is based on the firmly-held belief that the receipt of care should be based on need and not ability to pay. This thesis examines three aspects of this equity goal: provincial variations in equity in the receipt of care; the role of private prescription drug insurance in explaining inequity in the use of physician services; and the equity implications of subjective unmet need. Canada's provinces are responsible for planning and funding most publicly insured health services, hence there is variation in health system characteristics across the country. In the context of such variation, the first empirical analysis examines equity in the use of health services across the provinces. The analysis reveals some evidence of inequity in the likelihood of a GP visit, and the likelihood and number of specialist and dentist visits; some variations can also be found across the provinces. The second empirical analysis investigates the role of complementary insurance for prescription drugs in explaining inequity in the use of publicly-funded physician services. Due to the complementary relationship between prescription drugs and physician services, and the unequal distribution of private insurance coverage across income groups, inequity in physician utilisation partly can be explained by the interaction with insurance. The third empirical analysis assesses the equity implications of subjective unmet need. It finds that there are different utilisation patterns among the different types of unmet need, which raises methodological and conceptual challenges. The concluding chapter positions the three empirical studies within the broader policy context, offers an in-depth discussion of their methodological and policy implications, and proposes areas for future research.

The epidemiology of urinary tract infection (UTI) in the population of Vännäs (8 000 inhabitants) was studied during one year. The annual incidence increased from 0.5% in the first decade of life to more than 10% in the age group 90-100 years. Male UTI comprised only 13% of the episodes, increased after middle age and contributed 4 0% by > 80 years of age. At 17 PHC centres (PHCCs) a prevalence study (McPHC) of mainly uncomplicated UTI was performed. Most episodes were acutely symptomatic (lower 75%, upper 5%). Microscopy of wet-stained urinary sediment with a minimum of moderate amount of bacteria and/or 5 leukocytes per high power field (4 00 x) as breakpoint resulted in a desired high sensitivity (97%) and 86% efficacy in acutely symptomatic patients. Diagnosis of bacteriuria using Uricult dipslides yielded acceptable results with an overall efficacy of 88%. Nitrite test and Uriglox showed an unacceptable low mean sensitivity ofR56 and 69%, respectively. A positive nitrite, sediment or Uricult , when used in combination, was optimal in diagnosing UTI with a sensitivity of 98% in acutely symptomatic patients during their office visits. The average risk of drug resistance was 17% in the Vännäs study. Sensicult satisfactorily predicted drug sensitivity (93%) but not bacterial drug resistance (50%). Using Uricult with classification of bacteriuria by Gram-grouping, lactose and catalase reactions for targeting UTI therapy, according to local guidelines, resulted in a similar low risk (6 %) of prescribing drugs to which the organisms were resistagt as when using Sensicult (7%). This development of the Uricult method is simple and can be recommended for office practice in PHC. The spectrum of bacteria causing UTI and their drug resistance was more associated with the selection of patients, sex and age than with symptoms. The pattern of drug resistance was little influenced by UTI history and the mean pretherapy resistance for the seven drugs tested in McPHC was low (7%). Drug resistance was increased in failure (mean 24%) but not in early or repeated recurrence. In McPHC therapy resulted in 8% bacteriological failure and 12% early recurrence, irrespective of whether the bacteria were classified as sensitive or resistant in vitro to the drug given. Thus, in order to be of prognostic value for therapy of uncomplicated UTI, high-level breakpoints focusing more on peak urinary drug concentrations need to be studied. UTI symptoms in McPHC were eradicated in only 2/3 of the bacterio- logically cured episodes and in 1/3 of the failures at control 1-3 days posttherapy showing that symptoms are an unreliable indicator of UTI. From current literature, it seems unlikely that asymptomatic bacteriuria (ABU) plays a major role in the development of uremia due to chronic pyelonephritis. With the exception of ABU in pregnancy, therapy seems to yield no benefit. Omitting posttherapy bacteriuria controls in patients with symptoms eradicated, at least in women with uncomplicated UTI, would lead to considerable savings both for patients and the health care system.

Diss. (sammanfattning) Umeå : Umeå universitet, 1988, härtill 6 uppsatser.

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Father involvement benefits children, mothers, and themselves in a number of ways. Swedish legislation and Swedish society have promoted father involvement. At the same time, the Swedish child health field has also unequivocally states that both parents should feel welcomed and supported within that sphere. Despite these statements and policies, fathers feel neglected and invisible within and throughout the Swedish child health field, which includes prenatal clinics, birth and labor wards, postnatal clinics, child health centers, and parent support programs. Less is known however about the factors that influence father involvement in the child health centers, especially from the child health nurses’ perspective and the influence of the built environment. Additionally, parent support programs are another way through which parents receive support regarding their young child’s mental health, but very little research has focused on why fathers participate or the thoughts parents have regarding their participation, especially within a Swedish context. The overall aim of this dissertation was to better understand some of the barriers fathers have when trying to participate in the female-dominated world of the Swedish child health field, especially during the child’s preschool years. In Study I, 17 child health nurses were interviewed regarding their thoughts on fathers, and in Study II, 31 child health centers’ built environments were assessed to see how inclusive they were of fathers. In Study III, a parent support program was assessed to see if mothers and fathers had different background characteristics for participating, and Study IV sought to understand the extent to which parents appreciated and used the information from the program. These studies showed that child health nurses welcomed fathers, but did not actively invite them to participate. In addition, 75% of the child health centers did not have representations of fathers, but most child health centers had representations of mothers and/or children. Paternal behaviors positively changed if they were in an environment with either explicit paternal representations or only child representations. Mothers participated in the parent support program for several reasons, including if their child had perceived behavior problems, while fathers participated if they were stressed and perceived their child as having emotional problems. Parents believed the information they learned in the parent support program was valuable, and they continued using some strategies a year after the intervention. Swedish family policies can affect parental involvement within the child health field, but the child health field is less inclusive of fathers than mothers, and it fails to meet the needs of fathers, which can then, in turn, negatively affect maternal, paternal, and child outcomes. Therefore, the Swedish child health field needs to continue working on improving their practices of treating both parents equally.

The European health care is facing challenges with an increasing ageing population, with a higher frequency of chronic diseases, which have resulted in rising health care costs. Meanwhile, the trend shows how patients and citizens are becoming more active in their personal health care, with the number of existing doctors and nurses subsiding furthermore entailing problems. The area of eHealth, which involves information and communication technologies with health care, is hence seen as a partial long-term solution and is considered being a rapidly growing market both in Sweden, but also in Europe. eHealth services further consider to promote increased access, mobility and interoperability in the health care, but the lack of wholehearted commitment, financial support and complex EHR-systems in Sweden's municipalities and county councils might partially impeding down the development. The purpose of this report is therefore targeting to explore, identify and analyze prominent aspects for the continued development of the Swedish health care and eHealth services. The study also examines what subsequent benefits an implementation of an eHealth service entails, which also has been related to the identified prominent aspects. This master thesis is based on a thorough literature review extracted from a theoretical framework including an interoperability-, security-, mobility- and business-modeling perspective, which are used as a foundation for the building of a set of hypotheses, which are subsequently verified with the aid of gathered empirics. The empirics are obtained from 10 semi-structured qualitative interviews, as well as two case studies, which together resulted in key-findings and conclusions. Firstly, in relation to the interoperability perspective, it became clear how there should exist both a technical and social interoperability that communicate with each other. The EHR-systems of today are often considered difficult to learn, non-intuitive and lacking interfaces that are user-friendly designed for the end-user. Increased interoperability was also seen as enabling and simplifying the access to the patient’s medical history, which the EHR-system TakeCare evidently demonstrated. Furthermore, it was acknowledged how there is no correlation between the increased time spent by health care professionals with administrative tasks and documentation with an increased interoperability. It also emerged that patients and the dominant part of the population had either no or very limited knowledge regarding the underlying security and overall management of personal health information in health care. Patients instead often blindly trust the Swedish health care system being secure, and prioritizing other things during medical appointments. The knowledge of security issues in the health care is predicted to increase among patients if they in the future would obtain full access to their own medical records. There is also a general opinion among health care professionals and related instances how new security risks will arise alongside the eHealth wave, with a particular concern for the increasing involvement of mobile devices. Relationships between an increased interoperability also seem to favor increased mobility in health care, but security aspects often prevent the mobility development. Finally, it was unanimously espoused how non-financial values must not be ignored, where the on-going debate argues whether what real impact these non-financial values have, where inter alia strict budgets and large gaps between the decision-makers and end-users appeared as issues. Similar arguments were encountered regarding the actual impact of the opinions of patients in relation to business modeling, where a tripartite-problem and the patients’ limited access to their medical records was partly seen as a primary issue. Secondly, the case studies demonstrated how a transition to the EHR-system TakeCare generally did result in cost- and resource savings in terms of local servers, IT-maintenance and inventory management. The TakeCare implementation also led to an increased visibility among health care centers by enabling and simplifying the access to patient medical history. Increased communication, awareness, and more effective internal processes due to integrated modules and direct connections to ePrescriptions could also be accessed from the TakeCare transition. Finally, it emerged that relations existed between simplified access to the patient’s medical history and how it subsequently resulted in an increased interoperability. A correlation was also seen as the health care become generally more mobile due to increased interoperability.
Hälso- och sjukvården i Europa står inför utmaningar i och med en stigande åldersgrupp med en större andel kroniska sjukdomar, vilket resulterat i stegrande sjukvårdskostnader. Samtidigt ses en trend i hur patienter och medborgare börjar bli mer aktiva i sin egen vård och efterfrågan på sjukvårdspersonal ökar, med ökande utmaningar som följd. eHälsa-området, vilket involverar informations- och kommunikationsteknik inom sjukvården, ses därför som en potentiell långsiktig del-lösning och anses samtidigt vara ett starkt växande område i Sverige, men också på den övriga europeiska marknaden. eHälsa betraktas vidare främja en ökad åtkomst, mobilitet och interoperabilitet inom sjukvården, men bristen på helhjärtat engagemang, finansiellt stöd och det stora antal komplexa journalsystem i Sveriges olika kommuner och landsting ses delvis ligga till grund för en bromsad utveckling. Syftet med denna rapport är därför att undersöka, kartlägga och analysera de mest centrala aspekterna för den fortsatta utvecklingen av svensk sjukvård och eHälso-tjänster. Studien undersöker även vad implement av en eHälso-tjänst praktiskt har medfört, med ett fokus på journalsystem där de enskilda förändringarna även har relaterats till de identifierade centrala aspekterna. Examensarbetet är baserat på en gedigen litteraturstudie som utifrån ett teoretiskt ramverk inkluderande ett interoperabilitets-, säkerhets-, mobilitets- och affärsmoduleringsperspektiv ligger till grund för framtagandet av hypoteser som sedan verifierats med hjälp av empiriskt insamlad information. Empirin är erhållen från tio semi-strukturerande kvalitativa intervjuer, samt två fallstudier, vilka tillsammans har resulterat i ett flertal slutsatser. Utifrån ett interoperabilitetsperspektiv framgick det hur det bör finnas både en teknisk och social interoperabilitet som kommunicerar med varandra, då journalsystem idag anses vara svåra att lära sig, icke intuitiva och ej användarvänligt utformade för slutanvändaren. Ökad interoperabilitet ses även möjliggöra och förenkla åtkomsten av patienthistorik, vilket journalsystemet TakeCare tydligt påvisat. Vidare kunde det konstateras att det inte finns en korrelation mellan den progressivt ökande avsatta tiden som sjukvårdspersonal idag tillbringar med administrativa uppgifter och dokumentation med en förhöjd interoperabilitet. Det framkom även att patienter har väldigt liten eller obefintlig kunskap rörande den underliggande säkerheten och hanteringen av personlig information i sjukvården, då de ofta blint litar på att svensk sjukvård anses vara säker samt att patienter prioriterar annat vid läkarbesök. Kunskaper om säkerheten i sjukvården bland patienterna anses dock öka ifall de i framtiden får tillgång till sin journal. Det finns även en allmän oro bland sjukvårdspersonal och närbesläktade instanser för att nya säkerhetsrisker kommer att uppstå i och med eHälsa-vågen, med ett särskilt orosmoln för den ökande användningen av mobila enheter. Relationer mellan hur ökad interoperabilitet även gynnar förhöjd mobilitet sågs även förekomma, men att det ofta samtidigt är säkerhetsaspekter som hindrar den mobila utvecklingen. Avslutningsvis förespråkades det hur icke-finansiella värden inte får bli ignorerade, men problemet kring hur verkningsfull dess faktiska påverkan är, relateras bland annat till strikta budgetar samt stora avstånd mellan beslutstagare och slutanvändare. Liknande argument påträffades angående den faktiska inverkan av åsikter från patienter vid affärsmodulering, där ett trepartsproblem och patienternas begränsade åtkomst till sina journaler delvis sågs ligga till grund. Fallstudierna påvisade hur övergången till journalsystemet TakeCare generellt har lett till resursbesparingar i form av lokala servrars underhåll och lageranvändning, samt en ökad synlighet i vården med förbättrad tillgång till patienthistorik jämfört med tidigare journalsystem. En ökad kommunikation och medvetenhet samt effektivare interna processer på grund av integrerade moduler och direktkoppling till eRecept kunde även påvisas. Slutligen framgick det att relationer förekom mellan den ökande åtkomsten av patienthistorik och andra journaler, och hur förhöjd interoperabilitet medfört detta. Samband kunde även ses hur ökad interoperabilitet positivt gynnar mobiliteten i sjukvården.

The main research questions examined in this thesis concern the extent to which social class influence individuals' health, and how and whether individuals' occupation, education and lifestyles mediate between class and health. The conclusions drawn from the analysis of these empirical questions cast further light on the widening health inequalities seen in developed societies in recent decades. In particular, this research suggests that, employment conditions as well as educational levels are variables that need to be taken into account when planning policies aimed at tackling differences in health outcomes. Lifestyle variables, on the other hand, would appear to be almost irrelevant when explaining why the members of the more privileged social classes not only live longer than those in other classes, but also enjoy significantly better health over the course of their lives. In trying to understand the association between class and health, I define a theoretical framework that specifies the mechanisms through which class is linked to health. Social structure influences health by distributing certain factors such as material resources or some health-related behaviour that ultimately result in individuals having different living conditions. Educational attainment also affects the way these resources are employed and, therefore, lifestyles. A fundamental element of a social class is occupation: individuals' employment and working conditions also affect their health. Furthermore, the nature of a social structure has an effect on health at the aggregate level of analysis since social policies are partly the result of the structure of class interests. Four mechanisms are specified in order to systematically test this theoretical framework. Mechanisms (2) and (3), those that relate class and health through education and lifestyle lie at the heart of the empirical analysis. This analysis employs individual-level data drawn from health surveys carried out during the first half of the 1990s in the two countries selected for the analysis, United Kingdom and Spain. These countries are treated as contexts in which to test the theoretical explanation. The main results of the analysis reveal the importance of social class in determining health outcomes. Indeed, individuals from different classes enjoy distinct degrees of health. Specifically, individuals in the most privileged class categories have persistently better health than those in the other class categories. Differences exist in terms of both objective and subjective or self-perceived health. Moving on from observation to explanation, the analysis suggests that the distribution of certain resources across classes accounts for some of the variance in health outcomes. Hence, education is identified as a significant variable to comprehend part of the health inequalities in developed societies. Lifestyle, on the other hand, does not appear relevant in accounting for health outcomes. The small differences found between the United Kingdom and Spain in the mechanisms that link class and health suggest that the process through which class affects health is essentially similar in developed societies.

This thesis explores the stigmas and taboos surrounding youth health centers in Sweden and how this might be hindering young people to visit the youth health centers. It’s exploring how this can be challenged and how the threshold can be lowered by involving the informal support system and bringing the youth health center to the youth arena which allows for a more informal type of support and guidance. The youth health centers in Sweden have been around since 1970 and are a well known and established form of healthcare, yet the majority of the visitors are young women. How come? I’ve been working from the hypothesis that there is a need for more youth to seek help but that they for various reasons don’t manage to make it all the way there. There are many stigmas surrounding topics that the youth health center is dealing with, such as sex, depression, or domestic violence. This is especially true for young people on the edge between childhood and adulthood. Using a human-centered design approach this project has through the involvement of adolescents, midwives and youth workers among others, been exploring challenges and finding opportunities where interaction design can be used to improve the situation for the youth that do not make it to the youth health centers but that want and would benefit from their services. The final design proposal is an ambassadorship, aimed towards adults already part of the informal support system, that will enable youth to feel more empowered to seek help. It is set up to reach the youth in new ways, in an informal manner to bring the solution to the youth and to create a more comfortable space for them to open up within. Part of this is also a service for youth to effortlessly get in contact with the youth health center and to create personal connections to its personnel through link cards and video presentations. These connections are there to prepare the youth and to lower the bar of contact by building trust and humanize the help-seeking process. To make it clear that they are not trying to contact an institution but a person.

A number of theoretical explanations seek to describe the factors that have led to the position of the United States as the last industrialized Western nation without a universal health care program. Theories focus on institutional arrangement, historic precedent, and the influence of the private sector and market forces. This study explores another factor: the role of underlying social values. The research examines differences in values among ten European countries, the United States and Canada, and analyzes the associations between the values that have been seen to contribute the individualism-collectivism dynamic in the United States. The hypothesis that equality and generalized trust are positively associated with universalism is only partially true. Equality is positively associated (B = .301, p < .001), while generalized trust is negatively associated with universalism (B = -.052, p < .001). Not only do Americans show lower levels of support for income equality and universalism than Europeans, but the effect of being American holds even after controlling for socio-demographic and religious variables (B = .044, p < .01). When the model tests the association of equality and trust on universalism in each region, it explains approximately 17 percent of the variance of universalism for the United States, and approximately 13 percent in Europe and Canada.

Socioeconomic positions of individuals are clearly associated with the chances of living a healthy long life. In four empirical studies based on Swedish population registers, two topics are examined in this thesis: The relationships between different indicators of social position and mortality, and the importance of family members’ socioeconomic resources for the survival of the individual. The overall conclusion from the separate studies is that no single individual socioeconomic factor gives a complete picture of mortality inequalities. Further, the socioeconomic resources of partners and adult children are important in addition to the individual ones. The specific results from each study include that: I education, social class, social status and income are, to various extent, independently associated with mortality risk. Education and social status are related to women’s mortality, and education, social class, and income to men’s mortality. II one partner’s social position is related to the other partner’s survival, also when individual socioeconomic factors are statistically controlled for. In particular, men’s mortality is linked to their wives’ education and women’s mortality to their husbands’ social class. III adult children’s education is related to their parents’ risk of dying, also when both parents’ socioeconomic resources are taken into consideration. Further, the association between the offspring’s level of education and parental mortality cannot be explained by charac­teristics that parents share with their siblings. IV children’s social class and income are related to parental mortality, but not as strongly as the education of the children. There is no relationship between a mother’s own education and breast cancer mortality, while mothers seem to have better chances of surviving breast cancer if they have well-educated children.

At the time of doctoral defence the following paper was unpublished and had a status as follows: Paper 4: Manuscript

This thesis explores alcohol use during pregnancy in relation to guidance, attitudes and social norms. The research was conducted in England, where at the time of the study pregnant women were advised to abstain but limit their intake if they chose to drink, and Sweden, where complete abstinence was endorsed. Alcohol use during pregnancy can have harmful effects on the developing foetus, yet there is an unsettled debate as to whether a safe limit exists. In some countries more than half of pregnant women report drinking and while factors such as age, socio-economic status, and pre-pregnancy drinking habits may influence continued drinking, there is a lack of research addressing wider socio-cultural factors, drinking occasions, and partner drinking. A greater understanding of why women drink during pregnancy can inform policy and practice to prevent alcohol-related birth defects. A mixed methods research study was undertaken, comprised of a survey, completed by 347 parents, and interviews with 44 parents and 16 midwives, aimed at exploring cross-cultural differences in prenatal alcohol use from a socio-ecological perspective. Data from the three strands were synthesised and contrasted using triangulation and mapped into meta-themes. The findings showed that English women were significantly more likely to drink during pregnancy than Swedish women. Partner drinking did not appear to influence women’s decisions around alcohol. Moral values underpinned the discourses of whether prenatal alcohol is acceptable; Swedish parents advocated for the rights of the foetus whilst English parents weighed that right against the woman’s right to autonomy. Consistent communication of an abstinence message was evident in Sweden, whereas English parents’ experiences varied, some even reported conflicting advice. In contrast, all midwives advised pregnant women to abstain. The findings suggest that clear communication of an abstinence message may contribute to shared social norms against drinking during pregnancy. However, a lack of clear evidence as to the effects of low level drinking was interpreted differently in the two countries.

Public health aspects of pharmaceutical prescription patterns: Exemplified by treatments for prevention of cardiovascular disease. Louise Silwer. ISBN: 978-91-85721-18-4 ISSN: 0283-1961Main aim:To study patterns and trends of dispensed prescriptions, to explore what proportion of the population is exposed to some of the more prevalently prescribed pharmaceuticals, and to find possible ways of measuring drug-induced adverse symptoms in the population. Further, to illuminate conditions surrounding prescribing in primary prevention of cardiovascular disease. Methods: In three descriptive studies of prescription patterns, prescription data at aggregate level from a Swedish county were analysed retrospectively, and proportions were calculated. Data from the first ten years of the studies were obtained from a local prescription study, and data from another five years were local data from a national prescription survey. Data from a Danish database (OPED), with data at the individual level, were used for a prescription sequence symmetry analysis, and when Swedish national prescription data at the individual level became accessible, they were used for calculations of drug prevalence in the entire Swedish population. In a qualitative analysis of interview data, a phenomenographic approach was used. Main results: The purchase of pharmaceuticals on prescription almost doubled in the studied county in the period 1988-2002. Some common pharmaceuticals that increased to a great extent among the older part of the population were cardiovascular preventive drugs, such as antihypertensive and lipid modifying agents, and also hormone replacement therapy for women. In 2005, over half of all Swedish citizens, aged 60 or over, purchased antihypertensive or lipid modifying preparations during a six-month period. The different views that were found among GPs, regarding beliefs and practical management of primary prevention of CVD, could be interpreted as a reflection of the complexity of patient counselling in primary prevention in practice. Conclusion: The increase in dispensed prescriptions over the 15 years and the magnitude of the prevalence of the studied pharmaceuticals, such as antihypertensive, lipid modifying and hormonal treatments, which to a great extent are used by ‘healthy’ people, point to the need of following-up both beneficial and harmful consequences on public health. The prevalence of preventive treatments together with the variation in views of administration of primary prevention of cardiovascular disease, also point to the need of clarification of guidelines regarding pharmaceutical primary prevention and encouragement of therapy discussions among GPs.

This thesis presents an instrumental case study of a National Health Service (NHS) mental healthcare trust in relation to race related equality policy in the delivery of secondary mental healthcare in England. The study takes a constructionist ontological position, and an interpretivist epistemology. Semi-structured interviews were conducted with the 20 participants working at three different levels of the organisation. These include strategic leaders: Chief Executive Officer, Operational Director, Director of Nursing Quality and Patient Experiences, Director of Learning and Development, Head of Human Resources, Equality and Diversity Lead; service level middle managers: General Manager, Modern Matron, Team leader, Manager of the Recovery College; and frontline practitioners: clinical directors, psychiatrist, occupational therapist, staff nurses, community psychiatrist nurse, Recovery College instructor, all working in an adult mental healthcare setting of the organisation. Narrative interviews were also conducted with eight members of the Pakistani community living in the local service area to gain their perspectives on mental illnesses and mental health services. The study was conducted because national race equality policy expects NHS mental healthcare organisations to change their culture and deliver equitable, culturally appropriate and satisfactory mental health services to all members of society, including those who identify themselves as ‘BME’ groups. However, there is evidence in the policy and research literature of inequalities in mental healthcare experienced by service users who identify themselves as being from ‘BME’ groups in England. This study, therefore, explores how a NHS mental healthcare Trust is trying to bring about cultural changes in order to meet the expectations of policy as well as meeting the needs of service users of ethnic background. For example, on the organisational side, the study explored vision and strategy as well as interventions for bringing about organisational change and the views of the participants on this change. The views from the members of the Pakistani ethnic group highlight how mental illnesses are perceived and responded to within this ethnic group. Data obtained from the staff group were analysed using a thematic framework approach. Resultant themes include: interpretation of racial equality policy in the organisation; organisational vision and strategy for change; and the challenges, barriers and facilitators to achieving the stated vision on racial equality in the service provision, especially for people of Pakistani ethnic group. The analysis benefited from the organisational development literature in analysing the data. Data obtained from the members of the Pakistani community were analysed using a thematic narrative approach. This data reflected ways in which mental health/illness is perceived and responded to within this group including: the social identity claims that people of Pakistani ethnicity make when perceiving and responding to mental illnesses; the extent to which they associate themselves with western and/or eastern models of mental illnesses; and their identification as an ethnic group with diverse and multiple social identities. Social identity literature is used to analyse and interpret this data. The relationship between the organisational data and the ethnic group data is discussed, and a way forward is suggested for bringing about the expected cultural change to the organisation in order to meet the mental health needs of ‘BME’ groups in England. The instrumental organisational case study, along with perspectives of the service users, have served to underline the challenges for the organisation on a day-to-day basis as they attempt to meet the expectations of policy, as well as the views and expectations of people of Pakistani ethnicity.

Background Indigenous peoples with traditional lifestyles worldwide are considered particularly vulnerable to climate change effects. Large climate change impacts on the spread of infectious vector-borne diseases are expected as a health outcome. The most rapid climate changes are occurring in the Arctic regions, and as a part of this region northernmost Sweden might experience early effects. In this thesis, climate change effects on the lives of Sami reindeer herders are described and 30 years of weather changes are quantified. Epidemiology of the climate sensitive human infection tularemia is assessed, baseline serologic prevalence of tularemia is investigated and the disease burden is quantified across inhabitants in the region. Methods Perceptions and experiences of climate change effects among the indigenous Sami reindeer herders of northern Sweden were investigated through qualitative analyses of fourteen interviews. The results were then combined with instrumental weather data from ten meteorological stations in a mixed-methods design to further illustrate climate change effects in this region. In two following studies, tularemia ecology and epidemiology were investigated. A total of 4,792 reported cases of tularemia between 1984 and 2012 were analysed and correlated to ecological regions and presence of inland water using geographical mapping. The status of tularemia in the Swedish Arctic region was further investigated through risk factor analyses of a 2012 regional outbreak and a cross-sectional serological survey to estimate the burden of disease including unreported cases. Results The reindeer herders described how the winters of northern Sweden have changed since the 1970s – warmer winters with shorter snow season and cold periods, and earlier spring. The adverse effects on the reindeer herders through the obstruction of their work, the stress induced and the threat to their lifestyle was demonstrated, forcing the reindeer herders towards the limit of resilience. Weather data supported the observations of winter changes; some stations displayed a more than two full months shorter snow cover season and winter temperatures increased significantly, most pronounced in the lowest temperatures. During the same time period a near tenfold increase in national incidence of tularemia was observed in Sweden (from 0.26 to 2.47/100,000 p<0.001) with a clear overrepresentation of cases in the north versus the south (4.52 vs. 0.56/100,000 p<0.001). The incidence was positively correlated with the presence of inland water (p<0.001) and higher than expected in the alpine and boreal ecologic regions (p<0.001). In the outbreak investigation a dose-response relationship to water was identified; distance from residence to water – less than 100 m, mOR 2.86 (95% CI 1.79–4.57) and 100 to 500 m, mOR 1.63 (95% CI 1.08–2.46). The prevalence of tularemia antibodies in the two northernmost counties was 2.9% corresponding to a 16 times higher number of cases than reported indicating that the reported numbers represent only a minute fraction of the true tularemia. Conclusions The extensive winter changes pose a threat to reindeer herding in this region. Tularemia is increasing in Sweden, it has a strong correlation to water and northern ecoregions, and unreported tularemia cases are quite common.

The objective of this study was to examine if intra-racial income inequality contributes to higher infant mortality rates (IMRs) for African-Americans. The conceptual framework for this study is derived from Richard Wilkinson's psychosocial environment interpretation of the income inequality and health link. The hypotheses examined were that race/ethnicity-specific IMRs are influenced by intra-race/ethnicity income inequality, and that these effects of income inequality on health are mediated by level of social mistrust and/or risk profile of the mother. Using state-level data from several sources, the 2000 National Center for Health Statistics Linked Birth Infant Death database, 2000 U.S. Census, and 2000 General Social Survey, a number of regression equations were estimated. Results indicated that the level of intra-racial/ethnic income inequality is a significant predictor of non-Hispanic Black IMRs, but not the IMRs of non-Hispanic Whites or Hispanics. Additionally, among Blacks, the effect of their intra-racial income inequality on their IMRs was found to be mediated by the risk profile of the mother, namely, the increased likelihood of smoking and/or drinking and/or less prenatal care by Black women during pregnancy. Implications of the findings are discussed.

Research has shown that gender equality gaps are prominent and experienced when it comes to strength training and gym use. The health benefits of strength training are many, and it is of importance to public health science that any gender inequalities are exterminated so that both men and women can benefit from these. The gym is a common area for practising strength training, but the research done about gender equality from a gym perspective does however seem to be limited, particularly regarding from a gym enterprises point of view. The purpose of this study was hence to explore how different gym enterprises in a medium-sized Swedish city integrated gender equality in their business operation. This was carried out through a total of four individual interviews with a voluntary representative from each different gym. The results displayed five main themes with different aspects, wich all somehow connected to integration of gender equality at the gym. The most characteristic of these themes turned out to be ambiguity, wich could be observed in several of the five main themes and noticed through all four interviews. The conclusions came to be that the gyms did not see gender equality as one of their specific fields of work, and also that gender equality was not something established or recognized by them. They did however work for inclusion and affinity wich could be seen as some kind of contribution to gender equality. It was shown that the gyms did not seem to consciously integrate gender equality in their business operation.

This thesis undertakes an in-depth examination of the power of human rights advocacy in combating women's vulnerability to HIV/AIDS. Focusing on sub-Saharan Africa, the thesis explores the gender discrimination that lies at the core of women's susceptibility to the virus. Culturally-imposed social roles are depicted as the fundamental cause of the violation of women's human rights, including their right to health. The objective of the thesis is to analyze the potential of using a human rights approach to address this issue. It adopts the assumption that "the mobilization of shame" triggered by civil society's actors can alter states' human rights practices. Looking at a specific type of actors, namely the transnational advocacy networks, the thesis concludes that "the human rights approach to HIV/AIDS" can be an efficient and effective strategy to pressurize governments to implement their international human rights obligations.

Les questions de genre, de santé et droits sexuels et reproductifs et de développement ont depuis plus de deux décennies pris une place grandissante à la fois chez les théoriciens et les praticiens du développement, chercheurs, institutions nationales et internationales, organisations non gouvernementales et experts des agences de développement. La Suède a joué un rôle déterminant dans l'évolution de cet agenda global. Parmi les plus grands contributeurs d'Aide Publique au Développement, la Suède est le pays qui a le plus intégré les perspectives de genre et de droits au coeur de son dispositif d'aide internationale. Le cycle des grandes conférences onusiennes des années 1990, qui font de l'égalité femmes- hommes à la fois une condition et un moyen pour atteindre un développement humain durable a été l'occasion pour la Suède de s'affirmer comme une puissance d'influence de premier ordre. L'examen des facteurs déterminants dans l'histoire suédoise (références culturelles, politiques, sociales) ainsi qu'une lecture critique des textes fondateurs depuis 1994 (déclarations politiques, lois, documents stratégiques et de communication, évaluations programmatiques) mettent en valeur l'apport original de l'aide publique suédoise qui, au-delà de la dimension massive de son volume, révèle le caractère fondamentalement anthropologique et politique du développement et rappelle que la mondialisation ne saurait ignorer le questionnement croissant autour des inégalités, en particulier genrées
For the last twenty years, Gender, Sexual and Reproductive Health and Rights and Development issues have been at the heart of a growing trend of interest from both development thinkers and practitioners, researchers, international and national institutions, non governmental organisations, and experts from development agencies. Sweden has played a key role in the evolution of this global agenda. Among the major Overseas Development Assistance contributors, Sweden has proven to be one of the "like-minded" countries, which has integrated the gender perspective and the rights perspective at the very heart of its ODA mechanisms. The cycle of 1990's UN conferences, which has promoted gender equality as both a condition and a mean to achieve a sustainable human development was the occasion for Sweden to take a clear leadership as an influential "soft power". The analysis of decisive factors in the Swedish history (cultural, political and social references) as well as a critical reading of founding documents since 1994 (political statements, bills and laws, strategic/planning and communication papers, program evaluations) shows the original contribution of Swedish ODA, which beyond its remarkable amount, reveals the anthropological and political fundamentals of development and recalls that globalisation should not ignore the growing demands around inequalities, in particular gender inequalities

Defence date: 4 May 2017
Examining Board: Professor Hans-Peter Blossfled, European University Institute (Supervisor); Professor Fabrizio Bernardi, European University Institute; Professor Johan Mackenback, Erasmus Medical Centre, University of Rotterdam; Professor Johan Fritzell, CHESS, University of Stockholm
According to the cumulative (dis)advantage hypothesis, social disparities in health increase over the life course. Evidence on this hypothesis is largely limited to the U.S. context. The present dissertation draws on recent theoretical and methodological advances to test the cumulative (dis)advantage hypothesis in two other contexts – Sweden and West Germany. Three empirical studies examine the core association between socioeconomic position and health (a) from a life-course perspective considering individual change, (b) from a cohort perspective considering socio-historical change, and (c) from a comparative perspective considering cross-national differences. The analyses are based on large-scale longitudinal data from the Swedish Level of Living Survey, the German Socio-economic Panel Study, the Health and Retirement Study, and the Survey of Health, Ageing and Retirement in Europe. The key analytical constructs are education as a measure of socioeconomic position and self-rated health, mobility limitations, and chronic conditions as measures of health. The results show large differences within countries and between countries in the age patterns and cohort patterns of change in health inequality. In the U.S., educational gaps in health widen strongly over the life course, and this divergence intensifies across cohorts. In Sweden, health gaps are much smaller, widen only moderately with age, and remain stable across cohorts. In Germany, health gaps widen with age and across cohorts, but these patterns pertain only to men. Taken together, these findings show that health inequality across lives and cohorts is mitigated in Western European welfare states, which target social inequality in health-related resources. In the U.S. context, which is characterized by a lack of social security, unequal access to health care, and large social disparities in quality of living, health inequality increases across lives and cohorts.
Chapter 2 ‘Cumulative disadvantage in an egalitarian country? Socioeconomic Health Disparities over the Life Course in Sweden' of the PhD thesis draws upon an earlier version published as an article 'Cumulative advantage in an egalitarian country? : socioeconomic health disparities over the life course in Sweden' (2016) in the journal ‘Journal of health and social behavior’

Text in English
South Africa is currently in the process health care reform as the Government has undertaken the task of providing universal health care to all South Africans through the implementation of the National Health Insurance Scheme (NHI). This study took an in-depth look at the history and progression of the post-1994 South African health care policy, and applied the Power Resources Theory to the political economy of the current health care reform process in South Africa. Through a comparative study of the pivotal elements in the phases of health reform in Canada and Sweden this study drew lessons for the design and implementation of universal public health care provision in South Africa. This study found that a strong culture of care, strong political will, active civil society participation and a focus on equality as opposed to poverty in the creation of policy is essential to a successful implementation of universal health care.
Sociology
M.A. (Sociology)

Text in English
South Africa is currently in the process health care reform as the Government has undertaken the task of providing universal health care to all South Africans through the implementation of the National Health Insurance Scheme (NHI). This study took an in-depth look at the history and progression of the post-1994 South African health care policy, and applied the Power Resources Theory to the political economy of the current health care reform process in South Africa. Through a comparative study of the pivotal elements in the phases of health reform in Canada and Sweden this study drew lessons for the design and implementation of universal public health care provision in South Africa. This study found that a strong culture of care, strong political will, active civil society participation and a focus on equality as opposed to poverty in the creation of policy is essential to a successful implementation of universal health care.
Sociology
M.A. (Sociology)

Luo, Weixiang.
Thesis (Ph.D.)--Chinese University of Hong Kong, 2013.
Includes bibliographical references (leaves 90-105).
Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
Abstracts also in Chinese.

Public health and social policies are often debated, designed, and adopted without implementation, sustainability, or equity in mind, which can generate profound uncertainty about how to equitably deliver them initially and over time. Although sustainability and equity considerations are sometimes considered in post-hoc policy analysis and evaluation, little is known about how to plan for and track planned and unplanned adaptations to policy implementation, as well as the ways that key sustainability factors and strategies can relate to the equitable delivery or relative effectiveness of policies on the ground and in community settings. The purpose of this dissertation was to explore the long-term sustainability and equity of tobacco control policies and programs in New York City to understand and contextualize their limited reach and impact on persistent smoking and tobacco-related health disparities in underserved Asian American communities. The specific aims were to: 1) conceptually specify an operational definition of policy sustainability and its key dimensions, including health equity, and to refine this using a mixed methods single case study of tobacco policies in New York City; 2) use the case study approach to describe the extent to which tobacco policies have been sustained and adapted in New York City; and 3) to use the case study to identify key multi-level factors that influence the long-term sustainability and equity of tobacco policies in New York City. Using a single, in-depth, convergent-parallel mixed methods case study design, data were collected, analyzed, and integrated across five key primary and secondary sources: 1) Policymaking documents – text of key tobacco bills and statutes, as well as transcripts from when they were first proposed, amended, debated, and adopted; 2) Local newspaper coverage – articles from a database of 29 major newspapers in New York State on the policies and their impacts on communities and businesses over time; 3) Key informant interviews – conducted with community members and community leaders at local health and advocacy organizations in New York City that primarily serve Asian American and immigrant communities (n = 21); 4) Direct observation periods – conducted within and around the health and advocacy organizations, as well as in majority Asian neighborhoods and Asian ethnic enclaves (n = 15); and 5) the New York City Community Health Survey (2012-2017) – conducted annually by the New York City Department of Health and Mental Hygiene. The integrated study findings point to the importance of understanding policy sustainability not as a static end goal, but rather as a dynamic set of processes and outcomes that impact health and health equity. Findings from this case study clustered across three key themes: 1) since the initial adoption of comprehensive local tobacco control measures in New York City in 2002, broad “one-size-fits-all” approaches to policy implementation and monitoring have been sustained, which have had and continue to have limited reach and impact within underserved Asian American and immigrant communities; 2) two delayed adaptation efforts were made by policymakers during the sustainability phase, one in 2012 and another in 2018, were intended to improve on prior uneven implementation to better reach Chinese-speaking communities, with the 2018 adaptation demonstrating significant improvements from the 2012 effort; and 3) community-based organizations have played a direct role in functioning not just as key stakeholders but also as key implementers to ensure that tobacco and other health policies are reaching communities that the designated or official implementers cannot reach. This suggests the need for further study of unofficial implementers in implementation science – those who have not been formally designated as the ones responsible for ensuring that implementation takes place, but are still delivering implementation strategies to ensure adoption, integration, and sustainment. Overall, this case study points to the potential for policy sustainability research to advance health equity by identifying factors and mechanisms that can be improved to maximize and sustain the equitable reach and impact of social and public health policies. By focusing on dynamic contextual factors and sustainability as a set of processes and outcomes, the findings from this case study raise critical questions about the criteria typically used to evaluate whether policy interventions are deemed evidence-based and effective by asking: 1) effective for whom?; 2) based on what evidence?; and 3) what happens as dynamic populations and contexts change over time? These questions highlight how the tobacco control success story was largely constructed around broad population-wide implementation and benefits, while overlooking underserved Asian American communities who continue to disproportionately bear the brunt of smoking and tobacco-related health disparities in New York City.

Socioeconomic inequalities are a substantial problem in relation to Australia's biggest killer and area of health expenditure, coronary heart disease (CHD). They have been well documented for mortality, but little is known about whether they are due to differing chances of having a major coronary event (the event rate) or of dying when one occurs (the case-fatality rate). Nor does very much detail exist on whether these inequalities have changed over time. This study aims to fill these gaps, and also to examine the role the health care system plays in generating inequalities by analysing inequalities in the use of relevant services, and whether levels of use match levels of need for these services. A large, national dataset was constructed. It contains information on all major coronary events (essentially heart attacks) in Australia over a period of 10 years, 1996-2005, both fatal and non-fatal. Similarly, all 'services' provided for up to 10 years in the form of cholesterol-lowering medications (statins), a diagnostic procedure (angiography) and two types of revascularisation (coronary artery bypass grafts (CABGs) and percutaneous coronary interventions (PCls)) are included. In addition, a measure of need for services was developed. The dataset was then linked to census information on the socioeconomic characteristics of small areas to enable analysis of differences in outcomes and services across socioeconomic groups. The majority of the analysis was carried out using negative binomial regression to derive relative and absolute measures of inequality, including in particular the relative index of inequality and the slope index of inequality. The study clearly shows that nearly all of the socioeconomic inequality in CHD mortality in Australia comes from event rates rather than case-fatality rates. This indicates that the health care system's efforts to reduce these inequalities need to focus on preventing major coronary events, including by encouraging improvements in behavioural risk factors for them and treating risk factors when present (such as with medications), diagnosing problems early, and using surgery and other procedures (such as CABGs and PCls). Differential access to emergency care appears not to contribute to these inequalities. Time series analysis shows that inequalities in event rates have been increasing in relative terms, and even in absolute terms for males. Analysis of the use of statins, angiography and revascularisations shows substantial inequity -that is, use relative to need is much higher among the most well-off compared with the least well-off. The former are over twice as likely as the latter to receive these services for a given level of need. The largest inequities were found for the newer service (PCl rather than CABG) and for care provided earlier in the disease process (through medications and angiography). The study also shows that differential use of private health care plays a significant role in this inequity, and rural or remote locations play a smaller role. This study clearly demonstrates that socioeconomic inequalities in CHD are a major problem in Australia, and the gap is widening-improvements over time are benefiting the most well-off more than the least well-off. Inequalities largely derive from differential chances of having a major coronary event, rather than of dying when one occurs. The health care system appears to also contribute to the inequalities, and therefore has the potential to help reduce them by becoming more equitable.

Prior 1994 South Africa had a fragmented health system designed along racial lines. One system was highly resourced and benefitted the few and the other was under-resourced and was for the black majority. Attempts to deal with these disparities did not fully address the inequities. The objective of the NHI is to address the inequalities by ensuring that all South African have access to affordable, quality healthcare services regardless of their socio-economic status. The majority of the participants do not understand the meaning and the implications of the national health insurance. Among the health professionals that were interviewed, there were no consultations before the implementation of the NHI. The health economists verbalized that it will be too expensive as the majority of citizens do not pay taxes. More roadshows need to be done to make communities aware of the planned strategy which will benefit all.
Health Studies

Bibliography: leaves 203-219.
219 leaves : ill. ; 30 cm.
Title page, contents and abstract only. The complete thesis in print form is available from the University Library.
Concerned with the contribution of commonsense understandings of disease to social differentials in health outcomes. Argues that understandings in part reflect the social circumstances of an individual and mediate preventive activities and use of services, thereby influencing health outcomes. These are examined using the specific health outcomes of tooth loss and tooth decay.
Thesis (Ph.D.)--University of Adelaide, Dept. of Public Health, 2000

Bibliography: leaves 203-219.
219 leaves : ill. ; 30 cm.
Concerned with the contribution of commonsense understandings of disease to social differentials in health outcomes. Argues that understandings in part reflect the social circumstances of an individual and mediate preventive activities and use of services, thereby influencing health outcomes. These are examined using the specific health outcomes of tooth loss and tooth decay.
Thesis (Ph.D.)--University of Adelaide, Dept. of Public Health, 2000

In recent years, studies have linked various structural and environmental factors to disproportionately increased rates of morbidity, mortality, and adverse health outcomes in low-income racial and ethnic minority neighborhoods. Among the adverse health outcomes, is the constraint on the ability to access and afford a healthy diet. While local food systems play a significant role in influencing urban health and well-being outcomes, they also present an opportunity to develop community-based assets and resilience. By identifying limitations and successes in current food system literature and practice, this report examines how a more comprehensive approach to equitable community health and wellness can be achieved and sustained. Effective disparity reduction relies on cross-sectoral partnerships that not only promote food equity, but also provide participatory social, economic, and educational opportunities to marginalized communities.
text

Inequalities in levels of health between regions within a country are frequently regarded as a problem. Zimbabwe is characterised by poor and unequal conditions of health (both the state of people’s health and health services). The health system of the country shows severe spatial inequalities that are manifested at provincial, district and even local levels. This research therefore examines and analyses the spatial inequalities and temporal variation of health conditions in Zimbabwe. Composite indices were used to determine the people’s state of health in Zimbabwe. Administrative districts were ranked according to the level of people’s state of health. Cluster analysis was also performed to demarcate administrative districts according the level of health service provision. Districts with minimum difference were demarcated in a single cluster. Clusters were delineated using data on patterns of diseases and health and such clusters were used to demarcate the country’s spatial health system according to the Adapted Epidemiological Transition Model. This was used to evaluate the applicability of the model to Zimbabwe. It emerged from the research that generally the country’s health conditions are poor and the health system is characterised by severe spatial inequalities. Some districts are experiencing poor health service provision and serious health challenges and are still in the age of pestilence and famine but others have good health service provision as well as highly developed health conditions and are in the age degenerative diseases of the epidemiological transition model. It further emerged that the country’s health has been evolving with signs of improvement since the 1990s. Recommendations were made regarding possible adjustment to previous strategies and policies used in Zimbabwe, for the development of the health system of the country. New strategies were also recommended for the improvement of the health system of the country. Some proposals are made for further research on the spatial development of health in the country.
Geography
D. Litt et. Phil. (Geography)

Univerzita Karlova v Praze Fakulta humanitních studií Název oboru Filozofie Disertační práce (obor Aplikovaná etika) Uplatňování etického principu při tvorbě zdravotnického systému The Application of Ethical Principles in the Development of the Health System Mgr. Monika Válková Vedoucí práce: Doc. prim. MUDr. Iva Holmerová, Ph.D. Praha 2013 2 Anotace Disertační práce na téma Uplatňování etického principu při tvorbě zdravotnického systému je zaměřena na etické principy, které se promítaly ve vývoji zdravotnického systému v České republice. Solidarita, spravedlnost , rovnost a právo na zdraví jsou základní etické principy uplatňované ve zdravotnických systémech Z historického hlediska je solidarita nejstarším etickým principem , která měla vliv na utváření jednotlivých typů sociálních států v Evropě. Solidarita je zkoumána z pohledu vývoje sociálního zabezpečení v době nemoci a chudoby. Zdravotnický systém v České republice je hodnocen z hlediska uplatňování etických principů v různých etapách společenského uspořádání země od Rakouska Uherska a ž do současnosti. V praktické části disertační práce byly srovnávány s Českou republikou zdravotnické systémy Švédska a Francie dle etických principů solidarita, spravedlnost, rovnost a právo na zdraví Hlavním cílem disertační práce bylo prokázat na základě vybraných...