Background: Injuries are one of the most common causes of death in the world. Varying types of injuries dominate in different parts of the world, which also have separate influences mortality. In Scandinavia blunt injuries dominates and the majority of those who die do so pre hospital. Over time different injury pattern may vary and by analyzing this we can assess when, where and how preventive work can be reinforced. The aim of this thesis was to study injury epidemiology in Sweden and assess the contribution of different injury patters on mortality. Method: We used the Swedish cause of death and the national patient registries which have a complete national coverage. ICISS was calculated (based on ICD-10) in the in hospital population. We have chosen to do this investigation with a broad perspective using the term injury, which includes trauma but also other diagnoses like suffocation and drowning. Results: During the study period (1999-2012) the number of deaths because of injury was 1213, 25 388, and 18 332 among children, working age and elderly, respectively. Mortality declined in the children and in the working age but inclined in the elderly. Mortality increased with each age group except between the ages of 15–25 and 26–35 years. One thousand two hundred sixty four (97%) of those who died because of penetrating trauma (sharp objects and firearms) were killed by intentional trauma (assault and intentional self-harm). One thousand and seventeen (83%) of the children died prehospital. In the working age 22 211 (80%) of 25 388 died pre hospital. Nine thousand six hundred and eighteen (53%) of 18 332 of the elderly died prehospital. During 2001- 2011 the risk adjusted in hospital mortality decreased in traffic and assault but not in fall related injuries. Discussion: Largely, the anticipated injury mortality picture was found, with blunt injuries (traffic accidents) dominating in the working age and falls in elderly. Further a significant portion of the deaths occurred pre hospital. The intentional injuries are dominated by intentional selfharm. The decrease in child injury mortality is notable as Sweden already has one of the lowest incidences in child injury mortality in the world. The decrease in injury mortality in the working age also implies that preventive work has had an effect. The incline in injury mortality in elderly on the other hand needs to be further studied. Areas of particular importance for future preventive work is the incline in injury mortality in elderly and intentional injuries among children.

<p>Godkänd datum 171026.</p>

<p>Godkänt datum: 2017-10-26.</p>

<p>Godkänd datum: 2017-10-26.</p>

<p>Godkännande datum 2017-11-26.</p>

This project is at the controversial intersection of medicine patent protection and access to medicines at the international level. Advocates for medicine access argue that medicine patent protection may allow prices to become elevated, thereby frustrating medicine access. But advocates for medicine patent protection argue that the patent system incentivized the research and development to make the product possible in the first place. While this ideological debate is valuable, this doctoral project acknowledges the patent system’s existence and seeks to produce research to advance medicine access pragmatically within this context, especially in developing countries and especially for drugs appearing on the World Health Organization’s Model List of Essential Medicines (MLEM). In cooperation with the World Intellectual Property Organization, this project commenced with a legal study to assess the patent status of the entire MLEM (375 medicines) in 137 developing countries. Gathering these patent data and verifying them with global pharmaceutical suppliers was this project’s principal data collection. The patent data were further linked to development indicators of the countries implicated by our study and to economic data detailing medicine procurements made by those working with assistance from international organizations. Building upon the techniques refined during the MLEM study, three supplementary patent studies were performed to investigate very specific questions regarding medicine patenting and medicine access. With these patent data collected, we investigated companies’ medicine patent filing behaviours internationally. Various policy approaches to accelerating access at the international level were compared, including those that disregard patent protection and those are based on cooperation between medicine suppliers. Of the approaches considered, the cooperative approaches appeared to be the most efficient, especially voluntary licensing practices (i.e., originator companies license generic manufacturers to supply the product to developing countries in exchange for royalties). We find that while patents may detour generic competition at times, we also find they may serve as springboards for collaborative endeavours and global medicine access campaigns, like the one for HIV drugs. This thesis concludes by arguing that improved international medicine patent transparency by pharmaceutical suppliers is one of the most powerful ways to foster such collaborations to improve medicine access.

Background: This thesis presents three research papers that evaluate the current tools and methods used to assess the availability of health resources and services during humanitarian emergencies. Methods: A systematic review of peer-reviewed and grey literature was conducted to locate all known health facilities assessment tools currently in use in low- and middle-income countries. The results of this review were used to generate a framework of essential health facilities assessment domains, representative of seven health systems building blocks. Using this framework, a field-based evaluation of tools used to assess the availability of health resources and services in emergencies in Haiti and the Darfur states of Sudan was conducted. The collected assessment tools from these countries were compared against the framework from the systematic review, as well as the Minimum Standards for Health Action in the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response, and the Global Health Cluster’s Set of Core Indicators and Benchmarks by Category. A coding system was developed using all of these frameworks that enabled the comparison of the assessments collected in both countries. Field-based interviews were conducted with key informants using a convergent interviewing methodology, to gain perspectives on data collection and the use of evidence in formulating health systems interventions in emergencies. Results: 10 health facility assessments were located in the systematic review of the literature, generating an assessment framework comprised of 41 assessment domains. Of the included assessments, none contained assessment criteria corresponding to all 41 domains, suggesting a need to standardize these assessments based on a structured health systems framework. In Haiti and Sudan, a total of 9 (Haiti, n=8; Sudan, n=1) different assessment tools were located that corresponded to assessments of the availability of health resources and services. Of these, few collected data that could reasonably have corresponded to the different assessment domains of the health facilities assessment framework or the Sphere Standards, nor could many have provided the necessary inputs for calculating the Global Health Cluster’s indicators or benchmarks. The exception to this was the one tool located in Sudan, which fared reasonably well against these criteria. The interviews with participants revealed that while evidence was viewed as important, systematically-collected data were not routinely being integrated into program planning in emergency settings. This was, in part, due to the absence of reliable information or the perceived weaknesses of the data available, but also due uncertainty as to how to best integrate large amounts of health system data into programs. Conclusions: Greater emphasis is needed to ensure that data on the availability and functionality of health services during major emergencies is collected using methodologically-sound approaches, by field staff with expertise in health systems. There is a need to ensure that baseline data on the health system is available at the outside of emergency response, and that humanitarian health interventions are based on reliable evidence of needs and capacities from within the health system.

No description available.

This ethnographically informed dissertation focuses on the ways rural Yucatec Maya women, midwives and state health care workers participate in the production of childbirth and maternal health care practices. It further addresses how state health programs influence the relationships and interactions between these groups. Although childbirth practices in Yucatan have always been characterized by contestation, negotiation and change, their intensity and speed have significantly increased over the last decade. Drastic changes in the maternal health of rural indigenous communities in Mexico and throughout the world are directly connected to intensified state interventions that favor biomedicine over traditional health systems. In rural Yucatan, state health programs such as Oportunidades and Seguro Popular support a biomedical approach to birth by distributing medical resources to government clinics/hospitals and encouraging program participation of poor women through conditional cash incentives. This dissertation seeks to interrogate changing childbirth practices in a rural indigenous community in Quintana Roo, MX to gain a deeper understanding of the complex politics that shape local understandings and approaches to childbirth. It further explores how shifting social relations and political alliances are created within the context of reproductive health. This ethnography highlights how Yucatec Maya women envision a productive, yet negotiated, relationship with the state that allows them control of their prenatal and maternal health while engaging with state health programs. Focusing on the cultural production of childbirth in a rural community in southwestern Quintana Roo, this research seeks to explore the dynamic ways in which indigenous communities are reproduced over time through moments of engagement and contestation with the state. The Maya women in this dissertation exist at the margins of the Mexican government’s concerns, policies, and resources. Yet, even at the margins the influence and power of state ideology and policies intimately affect the lives of rural indigenous women. The core argument of this dissertation is that these women, who rely on traditional and historical experience, create strategies for survival and social reproduction despite their marginalized position within the Mexican state. This research draws from over a decade of fieldwork. Predissertation fieldwork took place during the summer months of 2002, 2003, 2004, 2007, 2008, and 2010. I completed my dissertation fieldwork from January to October of 2013. During that time, I conducted 60 formal and informal interviews and a small survey. Additionally, a large portion of my research took place with a local family that consisted of female healers and health educators, whom I extensively interviewed and conducted hundreds of hours of participant observation. The family was the locus of authoritative knowledge in the community and they provided vital insights into community life and local understandings and approaches to reproductive health. This dissertation follows the Latin American tradition of using testimonios to articulate—and reflexively examine—the layered meanings and intersecting politics that shape changing childbirth practices in rural Yucatan.

Background It is stated that vital exhaustion (VE) increases the risk of getting cardiovascular disease (CVD) (1), at the moment the leading cause of death globally (2). A factor in life that may be protective against the harmful effect of VE is social support (3) which is also associated with CVD (4). This thesis will investigate if social support can moderate the relationship between VE and CVD outcomes and have a protective effect. It will also exploratively investigate if comorbid depression or self-rated health confound the relationship. Method This thesis uses secondary data from 935 myocardial infarction patients that were included in the Uppsala University Psychosocial Care Programme (U-CARE) Heart Trial conducted in Sweden. To estimate the hazard ratio (HR) for developing CVD outcomes and investigate if the relationship between VE and CVD could be explained by different confounders and moderated by social support, stratified and interaction analyses were conducted, as well as Cox proportional hazard regression model. Results Social support did not moderate the relationship between VE and CVD. No protective effect on the hazard of developing CVD was shown in those with high social support. The effect of VE on CVD was not affected by depression but when self-rated health was included in the model VE lost its unique effect on CVD. Conclusion Social support did not have a protective effect on VE that impacted CVD. Globally, the main focus should be on preventing individuals from getting VE to prevent and reduce the prevalence of CVD.