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The 2015 global adoption of the United Nations 2030 Agenda for Sustainable Development places the achievement of health equity as a global priority for health and development. Due to the normative nature of the concept of health equity and the multi-level, multi-sectoral approaches required to advance it, interdisciplinary investigations are warranted to demonstrate how health equity as a policy objective is understood and operationalized. This dissertation is a case study of health equity in maternal, newborn and child health (MNCH) in Ethiopia, using qualitative methods to explore how health equity is conceptualized and pursued by stakeholders across levels of the health system. Ethiopia, a low-income country in East Africa, reported improvements in MNCH during the Millennium Development Goal period (1990-2015), largely attributed to the expansion of health services into rural areas; however, achievements were not realized across all geographies and population groups. Health equity is a stated policy objective for the country. Through a series of four articles, this dissertation addresses: community members’ perceptions and experiences related to health inequity and MNCH; barriers and enablers encountered by community-level health workers in implementing an equity-oriented MNCH intervention; subnational health managers’ understandings of health equity, and their roles in promoting it; and the characterization of health equity as a policy problem in national-level health discourses. This work deconstructs health equity into three components (health, distribution of health and characterization of the distribution of health) and compares how stakeholders across levels of the health system attribute meaning to each component and imply responsibility and accountability for health equity. The findings detail how diverse experiences related to health equity in MNCH across community, subnational and national contexts are driven by high-level technocratic framings of health equity, which tend to emphasize the delivery of a narrow package of health services to under-served geographical areas. Providing support and recognition for the role of subnational stakeholders in mediating the adaption of national health equity policies to local contexts, and making prominent the social justice underpinnings of health equity in the implementation of national policies are opportunities to strengthen the advancement of health equity in Ethiopia.

The introduction of welfare markets in publicly financed healthcare system has together with digital innovation of healthcare delivery led to a rapid growth of direct-to-consumer telemedicine services. In Sweden, the rise of such digital doctors has sparked a debate and there are indications that these developments might affect the overreaching goals of Swedish healthcare delivery on equal terms and according to need. This thesis examines the emergence of the new digital healthcare market and the political debate surrounding these developments, in order to answer the overreaching question of what these developments mean for equity in health in the Swedish healthcare system. This is done by describing developments on the digital healthcare market in Sweden and by conducting an idea analysis of the political parties’ views on these developments. Findings indicate that healthcare providers have great influence on the digital healthcare market in Sweden at the expense of public actors. Results from the idea analysis shows that political parties mainly discuss health equity in relation to the digital healthcare market in line with social or liberal egalitarian ideas of health equity.

The goal of this dissertation was to explore aging lesbian and gay individuals living in rural communities, in terms of their social networks and the relationships between these networks, identity, health, and quality of life. Guiding the study were three overarching questions. Using a multi-method design, the research was grounded within a socio-ecological context and focused on how structural systems create pathways for health and are affected by social position (intersectionality). Participants (n=25) were recruited from Kentucky (n=20), West Virginia (n=3), and Tennessee (n=2). Thirteen participants self-identified as gay and twelve as lesbian. Findings highlight the complexity of the aging experience and the difficulty in parsing out the influence of a rural location, the aging process, and being a lesbian or gay male, on social network development, identity, health, and quality of life. Findings indicate that rural gay and lesbian individuals develop networks based on need with limited consideration for network members’ acceptance of their identity. The findings also indicate that networks are primarily composed of heterosexual members. Social isolation and loneliness remain a pervasive issue in the rural gay and lesbian aging community. Finally, network size does not affect the overall health and quality of life for rural aging lesbian and gay individuals, but identity congruence does. Conclusions point to the greater need for research to understand the factors affecting aging lesbian and gay individuals in rural environments. Opportunities abound for developing further research addressing social isolation among this population and exploring the positive relationship between identity congruence and quality of life. The findings highlight the collective need to continue research into sexual minority aging and rural sexual minority aging.

Background: Digital primary care is expanding rapidly in Sweden and access is unevenly distributed and affected by socioeconomic status (SES) and digital exclusion. The COVID-19 pandemic further highlighted this problem as digital care removes risk of infection. Research is lacking on digital visits by traditional health care providers (HCP) during the COVID-19 pandemic and a risk exists that socially vulnerable groups are multiple afflicted by the current situation and that health policy goals are not achieved. Objectives: To investigate the effect of the COVID-19 pandemic on digital visits by traditional HCP, the distribution of visits and correlations to SES in Malmö municipality. Method: Ecological retrospective observational cross-sectional study with comparisons between the years 2020 and 2021. Descriptive analysis of changes between the years and distribution of visits and logistic regression for the correlation to Care Need Index (CNI) as a proxy for SES. Results: Physical visits decreased more than digital visits increased. Privately operated HCP and HCP in areas with higher income better compensated the decrease of physical visits with digital visits. There were major differences between HCP in use of digital visits and high CNI and private operation negatively affected this. Conclusion: Among traditional HCP in Malmö municipality the COVID-19 pandemic may have increased digital visits and the access was unevenly distributed. This risks increased inequality in health and not achieving set health policy goals. Further studies and efforts are needed to achieve a digital primary care with equal access and patient’s autonomy, participation, and empowerment in focus. / <p>Betyg i Ladok 220617.</p>

Os povos indígenas vivem há mais de 500 anos na luta pela superação do colonialismo interno. Com a homogeneização das formas de vida, estes povos são sistematicamente produzidos como não existentes nas políticas integracionistas. A Constituição Federal de 1988 rompe com esta prática garantindo o direito do reconhecimento de suas identidades e modos de vida, expressos pela sua cultura, e o direito à saúde. O direito dos povos originários à saúde pautou três Conferências de Saúde Indígena que estabeleceram as diretrizes para a criação do Subsistema de Atenção à Saúde Indígena em 1999. Desde o início de sua estruturação nos 34 Distritos Sanitários Especiais Indígenas (DSEI), foram organizados os Conselhos Distritais de Saúde Indígena (CONDISI) e o Fórum de Presidentes de CONDISI no nível central. Este estudo tem como objetivo analisar a participação e o protagonismo dos povos indígenas no processo de construção e implementação da Política Nacional de Saúde Indígena, após a Constituição Federal de 1988, a partir das Epistemologias do Sul. Foi utilizada a metodologia qualitativa com diversas fontes e materiais: análise documental das atas de reuniões, legislações, relatórios das cinco Conferências Nacionais de Saúde Indígena e 24 entrevistas em profundidade com indígenas, gestores, indigenistas e representante do MPF. A análise das legislações reconhecidas como pertinentes ao tema indicam uma grande quantidade e diversidade de normas que tratam de forma segregada as temáticas indígenas e as normas do Sistema Único de Saúde. Demonstram, para além da fragmentação legal e normativa, algumas iniciativas que avançam na integralidade da assistência, bastante pontuais, como a criação de incentivos financeiros específicos. Destaca-se a complexidade e a fragilidade da articulação interfederativa, que se torna mais complexa com a gestão federal e a territorialização dos DSEI, que não coincidem com os territórios de estados e municípios. No que tange à participação, pode-se afirmar que a maioria dos entrevistados reconhecem o CONDISI como espaço legítimo de diálogo entre indígenas e governo para debater a política de saúde e sua execução nas aldeias indígenas. Contudo, é evidente o predomínio das pautas de interesse da gestão e a repercussão nas reuniões de CONDISI de temas já discutidos no Fórum de Presidentes. Nas pautas do CONDISI Litoral Sul, que foram objeto deste estudo, por exemplo, a discussão da divisão territorial do DSEI, de interesse dos indígenas, não ganhou espaço e reconhecimento pela gestão. Chama a atenção à ausência de discussão nos espaços formais de temas que predominam nas entrevistas com os indígenas, como a valorização da medicina tradicional e a atenção diferenciada. Esta última é a justificativa central para existência do Subsistema e pauta-se nas desigualdades em saúde, na necessidade de modos de produção de cuidado que articulem as medicinas indígenas e a biomedicina e na diversidade cultural dos mais de 300 povos. O predomínio da biomedicina como forma científica e legítima do saber sobre a saúde acaba por interditar as pautas referentes às medicinas indígenas. Esta lógica perpetua a relação colonial do governo com os povos originários, principalmente sobre o saber, comprometendo a efetivação da atenção diferenciada, e, por consequência, do direito à saúde. Esta política, para ser efetiva, deveria se organizar na perspectiva da Ecologia de Saberes, considerando os modos de existência destes povos, principalmente sua relação com a terra, e sua construção como sujeitos coletivos. / Indigenous Peoples have been living for more than 500 years in the struggle to overcome internal colonialism. With the homogenization of the way of life, these peoples are systematically considered as non-existent in integrationist policies. The Federal Constitution of 1988 breaks with this logic assuring them the right to their identities and their ways of life, expressed by their culture, and also their right to health. The Indigenous Peoples\' right to health established three Indigenous Health Conferences that set the guidelines for the creation of the Indigenous Health Care Subsystem, in 1999. Since its beginning, along with the establishiment of the 34 Special Indigenous Sanitary Districts (DSEI), participatory Councils were organized (CONDISI), and also the CONDISI Presidents\' Forum at the central level. Based on Epistemologies of the South, this study aims to analyze the participation and the protagonism of Indigenous Peoples in the construction and implementation processes of the National Indigenous Health Policy, after the Federal Constitution of 1988. The qualitative methodology used with several sources and materials: documenta analysis of minutes of meetings, legislations, reports of the five National Indigenous Health Conferences and 24 in-depth interviews with Indigenous Peoples, managers, indigenists and Federal Prosecution Service. Relevant legislation analyzed showed great quantity and diversity of norms that separate the indigenous themes and the norms of the Unified Health System. They demonstrate, in addition to legal and normative fragmentation, some initiatives towards care integrality quite specific ones, such as the creation of financial incentives. We highlight the complexity and fragility of the interfederative articulation, which becomes more complex with federal management and territorialisation of the DSEI, which do not match with the limits of states and municipalities territories. Regarding participation, it can be said that most interviewees recognize the CONDISI as a legitimate space for dialogue between Indigenous Peoples and the government to discuss the health policy and its implementation in indigenous communities. However, there is a clear predominance of agendas in the interest of the management representatives and the repercussions on the CONDISI meetings of topics already discussed in the Presidents\' Forum. For example, on the agenda of the CONDISI Litoral Sul, object of this study, the discussion of the territorial division of the DSEI, on the interest of the indigenous representatives, did not gain space and recognition by the management representatives. What also draws attention is the absence of discussions of topics that were predominant on the interviews with Indigenous Peoples on formal spaces, such as traditional medicine and differentiated care. This last one is central to the existence of the Subsystem and it is based on inequalities in health, the need for care production methods that articulate traditional indigenous medicine and biomedicine, and the cultural diversity of more than 300 tribes. The predominance of biomedicine as a scientific and legitimate way of health knowledge inhibits the agenda related to traditional indigenous medicine. This logic perpetuates the colonial relationship of the government upon the Indigenous Peoples, especially regarding knowledge, compromising the effectiveness of differentiated care and, consequently, the right to health. This policy, in order to be effective, should be organized in the perspective of the Ecology of Knowledges, considering the ways of existence of these peoples, especially their relationship with the land, and their construction as collective subjects.

Submitted by Gentil Jeorgina (jeorgina@icict.fiocruz.br) on 2013-10-09T16:15:12Z No. of bitstreams: 1 Valéria Hartt.pdf: 1919843 bytes, checksum: 68a6cd38069d53b02f4eb969f570af19 (MD5) / Made available in DSpace on 2013-10-09T16:15:12Z (GMT). No. of bitstreams: 1 Valéria Hartt.pdf: 1919843 bytes, checksum: 68a6cd38069d53b02f4eb969f570af19 (MD5) Previous issue date: 2013 / Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. Rio de Janeiro, RJ, Brasil / Nesse recorte de pesquisa, o conceito de conhecimento leigo é ponto de partida e fio condutor para compreender as práticas de participação e ativismo de uma organização de pacientes de câncer, aqui na experiência da International Myeloma Foundation no Brasil (IMF). É a perspectiva informacional que ancora a meta de identificar os contornos do conhecimento leigo da representação brasileira da IMF para dar relevo aos sentidos de equidade em saúde na atenção oncológica. Os resultados apontam para uma forma de mobilização cidadã capaz de abrigar a produção social do conhecimento científico, mas mostram que a prática de advocacia em saúde ainda precisa avançar no Brasil como reflexo dessa nova forma de construção do conhecimento. / In this research outline, the concept of lay knowledge is a starting point and guideline for understanding the practices of participation and activism of a cancer patients organization, here through the experience of the International Myeloma Foundation (IMF) in Brazil. It is the informational perspective that anchors the goal of identifying the contours of lay knowledge of Brazilian representation of the IMF to emphasize the senses of equity in health in cancer care. The results point to a form of citizen mobilization able to shelter the social production of scientific knowledge, but show that the practice of health advocacy still needs to advance in Brazil as a result of this new form of knowledge construction.

OBJETIVOS: Determinar la desigualdad de la prevalencia de desnutrición crónica infantil en función a algunos determinantes sociales en países de América Latina y el Caribe (ALC)  MÉTODOS: Se realizó un estudio ecológico con los indicadores de desarrollo de la base de datos del Banco Mundial. Se analizaron los indicadores de 19 países (acceso a electricidad y servicios básicos de agua en población rural, PBI per cápita, gasto en salud per cápita). La desigualdad absoluta y relativa se determinó mediante el Índice de Kuznets absoluto, y relativo, la gradiente de la desigualdad a través de índice de las gradientes de la desigualdad, y para la desigualdad proporcional se usó el (índice de concentración de salud) ICS y la curva de concentración. RESULTADOS: la brecha de las desigualdades en la prevalencia de desnutrición crónica infantil entre los países de ALC se mantuvo prácticamente sin cambios significativos a lo largo del periodo estudiado. El 20% de los países con mayor desventaja concentran el 40% de la prevalencia de desnutrición crónica mientras que el 20% de los países con mayor ventaja solo el 7-8%, medido a través del ICS. CONCLUSIONES: A pesar de que en los Objetivos de Desarrollo del Milenio se encontraban eliminar la desnutrición, ésta permanece. La brecha de desigualdad ha disminuido respecto a la gradiente de desigualdad (desigualdad absoluta), sin embargo, la desigualdad proporcional se ha mantenido igual. Para eliminar esta brecha en ALC se deben generar políticas para distribuir de forma más eficiente y equitativa los recursos destinados al gasto en salud y los sectores relacionados, para de esa forma enfocarse en los determinantes sociales debidos. / OBJECTIVES: determinate the inequality of the prevalence of chronic childhood malnutrition according to some social stratifiers in the countries of Latin America and the Caribbean (LAC) METHODS: An ecological study was carried out at the country level with the development indicators of the World Bank database. The indicators of 19 countries will be analyzed (access to electricity and basic water services in rural areas, GDP per capita, health expenditure per capita). The absolute and relative inequality was determined by the absolute and relative Kuznets index, gradient of the inequality through the graduation index of the inequality, in addition, the proportional inequality was calculated through the index of concentration in health and the curve of concentration. RESULTS: the gap of inequalities in the prevalence of chronic child malnutrition in the LAC countries, remained practically without significant changes throughout the period studied. In addition, 20% of the countries with the greatest disadvantage accounted for 40% of the prevalence of chronic malnutrition compared to 20% of the countries with the greatest advantage, which presented 7-8% of the prevalence through the index of concentration on health. CONCLUSIONS: Although the Millennium Development Goals were to eliminate malnutrition, it was not possible to do so. However, the inequality gap has partially decreased. To eliminate it In LAC, wealth should be distributed more efficiently, and equitable resources allocated to health spending and related sectors. As well as generating Policies to address inequalities in and between countries. / Tesis

Bakgrund: Narkotikamissbruk har sedan 1960-talet ansetts vara ett allvarligt samhällsproblem som ökar risken för sjukdom och social utsatthet. Varje år dör omkring 900 personer i Sverige av läkemedels- och narkotikaförgiftningar. Personer som utvecklat ett narkotikamissbruk kan hamna i en ond spiral där de negativa konsekvenserna ökar och medför en risk att förlora allt så som jobb, hem och familj. Detta kan i sig öka de socioekonomiska skillnaderna i befolkningen. När en person bryter sitt missbruk sker en process som i denna studie förklarats utifrån modellen Stages of change. Syfte: Syftet med studien är att skildra betydelsefulla faktorer i förändringsprocessen för individer som tagit sig ur narkotikamissbruk. Metod: Studien var av kvalitativ karaktär och genomfördes med semistrukturerade intervjuer. I studien kombinerades induktiv och deduktiv ansats. Resultat: Resultatet visade att socialt stöd var en viktig faktor genom förändringsprocessen, framförallt under faserna action och maintenance. Olika strategier som att bryta gamla beteenden och mönster var betydande. Den egna viljan ansågs vara essentiell för att inleda och genomföra en förändring. Genom behandling fick informanterna verktyg att hantera sin vardag. De jobbade hårt med sig själva genom de olika förändringsfaserna i Stages of change för att uppnå ett vidmakthållande och minimera risken för återfall. Konklusion: Studiens resultat visar att när en person är i behov av hjälp, och uttrycker detta, då behöver familj och samhälle erbjuda stöd. För de individer som inte har det sociala nätverket bakom sig, där synliggörs ett större behov av att samhällsinsatser måste finnas tillgängliga för att bidra till jämlik hälsa. / Background: Since the 1960s, drug abuse has been considered a serious societal issue that increases the risk of illness and social exclusion. In Sweden approximately 900 people die from drug intoxication annually. People who develop a drug addiction can end up in a negative spiral with consequences such as loss of work, home and family. Consequences that can increase the socio-economic differences within the population. When a person decides to end their addiction a process of change takes place, in this study explained using the Stage of change model. Purpose: The purpose of the study is to describe significant factors during the process of change within individuals who have recovered from drug abuse. Method: The study design was qualitative and was conducted using a semi-structured interview guide. The study combined inductive and deductive analysis. Results: The results indicated that social support was an important factor throughout the process of change, especially during the phases action and maintenance. Various strategies such as breaking old habits and patterns were also significant. Self-determination was considered essential to initiate and implement change. During treatment, the informants were given coping strategies to handle their everyday lives. They worked hard with themselves throughout the various stages in Stages of change to achieve sustainability and minimize the risk of relapse. Conclusion: The study's result implies that when a person is in need of help, and expresses this, family and community need to offer support. Individuals who do not have the social network requires more interventions from the community to enable a healthy life.

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