<p>The aim of this study was to examine how Tanzanian HIV-positive women experience their socioeconomic situation. Semistructured interviews were carried out and the number of interviewees was 15. Collected data was analysed according to a qualitative content analysis and resulted in an overarching theme; Struggle for survival and tolerable life. Important in the lives of the informants was the access to economic and social resources. The informants described access to economic resources as important because of the possibilty to support oneself and the possibility of a lower level of physical strain. Social resources gave the informants knowledge for a healthy lifestyle and mental support for inner strength. Further research is ought to examine how economic and social support is being comprehend and used, and with a particular weight on the social support because of lack of knowledge in this field. Research which is considering the men´s view of their situation is also important, since a change of the men´s situation could involve a change of the women´s situation.</p>

The aim of this study was to examine how Tanzanian HIV-positive women experience their socioeconomic situation. Semistructured interviews were carried out and the number of interviewees was 15. Collected data was analysed according to a qualitative content analysis and resulted in an overarching theme; Struggle for survival and tolerable life. Important in the lives of the informants was the access to economic and social resources. The informants described access to economic resources as important because of the possibilty to support oneself and the possibility of a lower level of physical strain. Social resources gave the informants knowledge for a healthy lifestyle and mental support for inner strength. Further research is ought to examine how economic and social support is being comprehend and used, and with a particular weight on the social support because of lack of knowledge in this field. Research which is considering the men´s view of their situation is also important, since a change of the men´s situation could involve a change of the women´s situation.

This study addresses health policy and public health in the field of cardiovascular disease (CVD) on the local level in Sweden. The overall aim is to contribute to the assessment of structural and social conditions within public health by analysing participation processes and outcome patterns in a local health programme. The northern Swedish MONICA study served as a reference area. The research strategy has been to integrate quantitative and  qualitative methodologies and, thereby, focus on different aspects of the health programme under study. The mortality rate was excessive in the study area of Norsjö relative to both provincial and national figures over a period of more than 10 years. This finding formed the basis for a tenyear comprehensive and community-based health programme towards the prevention of CVD and diabetes. Even in this seemingly homogeneous area it was found that socio-economic circumstances were associated with the public health. Almost half of the study population had hypercholesterolaemia (;&gt;6.5 mmol/1), 19% of men and 25% of women were smokers and 30% and 29%, respectively, had high blood pressure. Age had a strong impact on all outcome measures. After adjustments for age and social factors it was found that the relative risk of having hypercholesterolaemia dropped significantly in both sexes during the six years of intervention. The probability of being a smoker was significantly reduced only in highly educated groups. No statistically significant change over time could be found for the risk of suffering high blood pressure. In the reference area of northern Sweden there were no changes over time for any of the selected risk factors. The likelihood of self-assessed good health decreased with increasing risk factor load, with the exception of hypercholesterolaemia , in all social strata. The authorities, including the health and medical staff, were the main actors on the mediastage. Men in manual occupations were least affected by the media coverage. The actors and the public as well as the media viewed the health programme as orientated towards individual lifestyles. Community participation was mainly defined by the actors based on the medical and health planning approach. Differences in interpretations, social interests, personal conflicts and ideological constraints among the actors at local level were observed. Some critical attitudes towards the organization and management of the health programme were also noted among the citizens. However, a majority of the public wanted the health programme to continue. The present study underlines the importance of considering age, gender and social differences in the planning and evaluation of CVD preventive programmes. / digitalisering@umu

Purpose: I examined two labour force disparities – unemployment and underemployment, among working-aged individuals (20-64 years) with self-reported disabilities using the 2006 Participation and Activity Limitation Survey (PALS). As disability type was the predictor of interest, two groups were compared: individuals with one or more physical disabilities (e.g. mobility, agility, pain) exclusively vs. those with one or more physical disabilities and a co-morbid mental disability (including depression, phobias or substance use). Methods: This study was a secondary analysis of the 2006 PALS, a cross-sectional survey conducted by Statistics Canada to gather information about individuals whose everyday activities are limited due to a physical or mental condition that used the 2006 census as a sampling frame. I estimated the prevalence of unemployment (last week) and underemployment (last five years) and used multiple logistic regression to measure the association between disability type and each outcome, while considering other relevant covariates. Results: Disability type was significantly associated with both unemployment and underemployment. Other significant effects were age, education level and family income quintile (in addition to current labour force status and frequency of health services access in underemployment), in both the bivariate and multivariate analyses. Those with a mental co-morbidity had approximately double the odds of being unemployed, relative to those with exclusively physical disabilities and the effect continued to be significant when disability severity was included in the model. Individuals with a mental co-morbidity also experienced greater odds (OR: 2.92) of reporting underemployment, compared to those with exclusively physical disabilities, though when disability severity was accounted for, the effect was reduced (OR: 1.52) and no longer significant. Conclusion: To my knowledge, this is the first large-scale investigation using Canadian data to explore the association of disability type and two labour force disparities. In support of my hypothesis, individuals with a mental co-morbidity were found to be more disadvantaged in terms of both accessing employment and probability of encountering stigmatizing experiences in the workplace. More research is needed to gain a better understanding of the nature of these outcomes in order to progress toward the removal of significant barriers that persist in this population. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2011-01-30 20:02:56.55

Objectives: The overall aim of this research was to describe the health-seeking behaviours (HSBs) of people in rural Makwanpur, Nepal, and to analyse the patient, household, community, health-system, knowledge and illness factors, and the psychological, social and cultural processes which explain these behaviours. Background: Much about the health status of populations and individuals can be understood by studying how people utilise their health services and the factors associated with this utilisation. HSB studies act as a starting point for the planning of health programmes and the structuring of health systems. Nepal, with its shortage of health providers and funding, its low service usage and its pluralistic medical landscape provides an interesting setting in which to examine HSBs. Most health policies in this context have been devised without taking into account the perspectives of the system users. Moreover, limited formal research on this topic has been carried out in this context. Methods: This study involved a mixed-methods, explanatory sequential design consisting of two phases – quantitative data collection followed by qualitative data collection. Quantitative data was collected using a cross-sectional household survey carried out in 2,334 households across ten VDCs in Makwanpur district between April 2011 and August 2011. Households were selected using a random sampling method. The survey asked about care-seeking in response to an acute episode of illness in the previous one month. Qualitative data was collected after the quantitative data using semi-structured household interviews (n=90) in three VDCs between November and December 2012. The Qualitative interviews were designed to compliment the quantitative findings and to determine the explicit factors associated with care decisions. Results: Of the 2,334 households surveyed,46% had at least one episode of illness in the month prior. The majority of illnesses were infectious or parasitic diseases (42%). Of those households experiencing illnesses, 69% chose to seek care outside of the home; 22% used traditional healers, 37% used allopathic providers and 12% opted for pharmacies as a first option. Sixteen did nothing to address their illnesses, sighting geography, finances, workload and lack of severity as the reasons. Regression models revealed that a host of different patient, household, community, illness, health facility and knowledge factors were associated with care decisions depending on the decision, but illness factors had the greatest impact overall on whether or not a household sought some care or care outside of the home, while household level factors had the greatest impact on the type of care sought outside of the home and the length of delays before seeking care. Patient gender had an impact on whether or not allopathic care was used at least once. Qualitative results revealed that health facility factors were also equally important in determining households’ conscious decision-making about specific providers. Conclusions: Overall it appears that people in Makwanpur are not underutilising health services as suspected. Households use certified government providers most frequently to address their illnesses, and do not rely too heavily on traditional healers or informal providers exclusively. The results indicate that while illness and household factors are important, in order to improve HSBs and increase allopathic care utilisation, a focus should be on improving health service delivery rather than on changing HSBs. However, in order to decrease delays in care-seeking, a focus should be made to reduce household-level barriers to care as well.

nÃo hà / FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / Este trabalho objetivou analisar o processo de construÃÃo do territÃrio de Fortaleza, estado do CearÃ, Brasil e sua relaÃÃo com a saÃde da populaÃÃo da cidade. Para tanto, foi necessÃrio descrever a evoluÃÃo de sua ocupaÃÃo com base na variaÃÃo da densidade demogrÃfica e na caracterizaÃÃo socioocupacional dos bairros no perÃodo de 1970 a 2010 e nos movimentos (ondas) de ocupaÃÃo territorial e sua relaÃÃo com o perfil socioeconÃmico em 2010, caracterizar o perfil socioeconÃmico e de mortalidade segundo sexo da populaÃÃo de Fortaleza em 2010 e identificar as relaÃÃes entre os perfis socioeconÃmicos e de mortalidade com os determinantes sociais da populaÃÃo de Fortaleza segundo sexo em 2010. Este foi um estudo ecolÃgico, utilizando coleta de dados secundÃrios, a partir do Sistema de InformaÃÃo de Mortalidade (SIM) de Fortaleza-CE, em 2010, pesquisando-se as dez principais causas de mortalidade para homens e mulheres e tambÃm no banco de dados de 2010 do Instituto Brasileiro de Geografia e EstatÃstica (IBGE). O programa STATA 10.0 foi utilizado para a organizaÃÃo do banco de dados estruturado a partir dos seguintes indicadores socioeconÃmicos: densidade demogrÃfica, Ãndice de condiÃÃo de vida, GINI, razÃo da renda mÃdia entre os 10% mais ricos e os 40% mais pobres, taxa de analfabetismo, Ãndice de pobreza e renda mÃdia. Mapas temÃticos foram elaborados para todos os indicadores socioeconÃmicos e de mortalidade por bairro de Fortaleza para o ano de 2010, utilizando o aplicativo ArcGis 10.1. Os resultados apontam que o espaÃo urbano de Fortaleza constituiu-se de maneira diferenciada, o que à refletido na espacializaÃÃo das condiÃÃes de vida da populaÃÃo da cidade. Para algumas causas, a relaÃÃo foi diretamente proporcional Ãs condiÃÃes de vida, ou seja, quanto piores eram estas condiÃÃes, maiores eram as taxas de mortalidade por causa especifica. Chama atenÃÃo a AgressÃo por meio de disparo de outra arma de fogo ou de arma nÃo especificada (AGRES), que percentualmente representa a maior causa bÃsica de morte para homens em Fortaleza, com 35,6% do nÃmero total de mortes em 2010 e apresentando uma relaÃÃo direta com todos os indicadores socioeconÃmicos; quanto piores foram as condiÃÃes de vida encontradas, maiores as taxas de morte por AGRES. AVC nÃo especificado e SÃndrome de DependÃncia tambÃm foram causas bÃsicas de morte, nas quais a relaÃÃo estabelecida foi de quanto piores os indicadores, 10 maiores eram as taxas de mortalidade. Para outras doenÃas como, DoenÃa de Alzheimer de Inicio Precoce, Neoplasia Maligna da Mama e Neoplasia Maligna dos BrÃnquios ou PulmÃes, a relaÃÃo foi quanto melhores os indicadores socioeconÃmicos, maiores eram as taxas de mortalidade. Diante dos resultados encontrados no trabalho, conclui-se que a populaÃÃo mais carente e historicamente segregada à aquela que està sujeita Ãs piores condiÃÃes de vida e consequentemente, mais vulnerÃvel. / This work aimed at analyzing the process of construction of the territory of Fortaleza, Cearà State, Brazil and its relationship with the health of the city population. Therefore, it was necessary to describe the evolution of its occupation based on the variation of population density and socio-occupational characteristics of the neighborhoods in the period 1970-2010 and the movements (waves) of territorial occupation and its relation to the socioeconomic profile in 2010, characterizing socioeconomic profile and mortality by sex of the population of Fortaleza in 2010 and identifying the relationships between socioeconomic profiles and mortality with social determinants of the population of Fortaleza by sex in 2010. This was an ecological study, using secondary data collection, from the Mortality Information System (SIM) of Fortaleza, in 2010, investigating the ten leading causes of mortality for men and women and also from the 2010 database of the Brazilian Institute of Geography and Statistics (IBGE). The program STATA 10.0 was used for organizing the database structured by the following socioeconomic indicators: population density, index of living conditions, GINI, ratio of average income of the 10% richer and 40% poorer, illiteracy rate, poverty rate and average income. Thematic maps were produced for all socioeconomic indicators and of mortality by Fortaleza neighborhood for the year 2010, using the 10.1 ArcGIS applicative. The results show that urban space in Fortaleza was constituted in a differentiated manner, which is reflected in the spatial distribution of living conditions of the city population. For some causes, the relationship was directly proportional to life conditions, that is, the worst were these conditions, higher were the rates of mortality by specific cause. Noteworthy is Aggression by means of another firearm shooting or by unspecified weapon (AGRES), which percentage represents the highest basic cause of death for men in Fortaleza, with 35.6% of the total number of deaths in 2010 and presenting a direct relationship with all socioeconomic indicators; the worst were living conditions found, higher the death rates by AGRES. Unspecified stroke and Dependence Syndrome were also basic death causes in which the relationship established was of the worst the indicators, higher were 12 the mortality rates. For other diseases such as Early-onset Alzheimer Disease, Breast malignant neoplasm and Bronchi or lungs malignant neoplasm, the relationship was much better were socioeconomic indicators, higher were mortality rates. Considering the results found in the study, we conclude that the most needy and historically segregated population is that which is subject to the worst living conditions and consequently, the most vulnerable.

Introdução - A maioria dos estudos sobre a teoria da renda relativa tem encontrado associação estatísticamente significativa entre alta desigualdade de renda e piores condições de saúde em grandes regiões como estados norte-americanos ou países. Por outro lado, análises realizadas em municípios e áreas fora dos EUA tem apresentado resultados no mínimo conflitantes. Os maiores obstáculos para que se atinja consenso na área são a inexistência de elevada desigualdade em regiões menores e a dificuldade de controlar pelo conjunto de variáveis de confusão que podem ter efeito na saúde além da desigualdade de renda. O presente estudo objetiva auxiliar na solução desse problema ao analisar o Município de São Paulo por meio de uma metodologia estatística chamada propensity score matching. Metodologia - A análise abordou os 96 distritos da cidade. Foram incluídas 16 variáveis no modelo para identificar distritos comparáveis. Do total de 96 distritos, 27 foram pareados com algum outro (alguns mais de uma vez), formando 17 pares, dos quais apenas um foi composto por distritos que fazem fronteira entre si. Resultados - Após a aplicação do propensity score matching, distritos mais desiguais apresentaram maior mortalidade geral ajustada por idade (41,58 por 10.000 hab; IC 95por cento : 8,85 73,3 por 10.000 hab). Foram também estatísticamente significativas as diferenças de mortalidade para homicídios (8,57 por 10.000; IC 95por cento : 2,60 14,53), doença isquêmica do coração (5,47 por 10.000; IC 95por cento : 0,76 10,17), aids (3,58 por 10.000; IC 95por cento : 0,58 6,57), doença respiratória (3,56 por 10.000; IC 95por cento : 0,18 6,94) e mortalidade infantil (2,8 por 10.000; IC 95por cento : 0,86 4,74). As dez causas 9 básicas mais frequentes foram responsáveis por 72,3por cento do total da diferença de mortalidade entre os distritos mais e menos desiguais. Conclusões - A metodologia estatística foi eficaz para diminuir as diferenças sociais e demográficas, possibilitando a comparação entre distritos semelhantes. A presença de alta desigualdade de renda no Município de São Paulo permitiu a análise do seu efeito na mortalidade / Introduction - The majority of studies on the relative income theory has detected statistically significant associations between high income inequality and worse health conditions for larger areas such as countries or USA states. Nevertheless, for smaller areas such as municipalities or regions outside the USA, the results have been, at best, mixed. The biggest hindrances to a consensus are the lack of high inequalities within smaller areas and the difficulty to control for the many variables that may also affect health beyond the effect of income inequality. This analysis aims to help to solve these problems by applying a statistical analysis known as propensity score matching and by focusing on a very diverse and unequal city such as São Paulo. Methodology - The analysis was done for the 96 distritos of the Municipality of São Paulo, Brazil. The statistical model included 16 variables to account for local heterogeneity. Of the 96 distritos, 27 were matched with a similar one (sometimes, more than once), making a total of 17 pairs (of those, only one pair was made out of two bordering distritos). Results - After the propensity score matching approach, higher inequality distritos had higher age-adjusted overall mortality rate (41.58 per 10,000, 95per cent CI: 8.85 73.3). The difference between high and low inequality was also statistically significant for homicide (8.57 per 10,000; 95per cent CI: 2.60 14.53), ischemic heart disease (5.47 per 10,000; 95per cent CI: 0.76 10.17), HIV/AIDS (3.58 per 10,000; 95per cent CI: 0.58 6.57), respiratory diseases (3.56 per 10,000; 95per cent CI: 0.18 6.94) and infant mortality (2.8 per 10,000; 95per cent CI: 0.86 4.74). The ten most common causes of death accounted for 72.3per cent of total difference in mortality. 11 Conclusion - The statistical methodology was effective to control for local social and demographic heterogeneity, allowing the comparison of only similar distritos. The use of a large and diverse city such as São Paulo made it possible to analyze the effects of income inequality on health

South Asia has the highest absolute number of women with an unmet need for contraception in the world. The total number of women with unmet need is 142 million. Of this, Asia accounts for 84 million followed by Sub-Saharan Africa at 32 million. Within South Asia, some countries have seen unmet need decrease and the contraception rate increase; however, Pakistan remains the exception to the rule. Pakistan has a low rate of contraception use, high rate of contraception discontinuation, high unmet need and high rate of unwanted fertility. A number of theories have hypothesized that community-level factors influence a couple’s fertility decisions. Yet until recently, studies of contraceptive use dynamics have focused on individual and household-level determinants. Within Pakistan, this focus on individual and household level has not been able to explain the changes in use, which goes beyond socio-economic and cultural boundaries. As a result, there is impetus on researchers to shift focus and look at the interaction between and within the individual and the community. This study aims to address this gap in the literature by examining the association between community contextual factors and modern contraception use in a developing country using multilevel modeling. The Commission on Social Determinants of Health and the Determinants of Fertility framework were used to test five research questions, on the association between modern contraception use and socioeconomic and political context, social position, social class, health system and overall community contextual factors. Community contextual factors tested were found to be associated with modern contraception use and explained 32% of the variance in the outcome. Specifically, the variables that played a significant role and showed a strong association with modern contraception use were related to public policy; community knowledge of the presence of a lady health worker, community access to a family planning service outlet, and community region of residence, and women’s autonomy; community women’s education, community women’s ability to choose a spouse and own land or home. This study moves the discussion from a focus on individual level factors that impact contraceptive us to community-level factors. Numerous studies and anecdotal evidence have pointed to the importance of community context in contraceptive use; however, there has been a paucity of research investigating this realm. This study bridges this gap by providing evidence for existing programs and policies, strengthening the call for more community-based initiatives and helping to understand individual behavior as it relates to the community in which the person resides.

This is an inter-disciplinary argument for a moral entitlement to a capability to be healthy. Motivated by the goal to make a human right to health intelligible and justifiable, the thesis extends the capability approach, advocated by Amartya Sen and Martha Nussbaum, to the theory and practice of the human health sciences. Moral claims related to human health are considered at the level of ethical theory, or a level of abstraction where principles of social justice that determine the purpose, form, and scope of basic social institutions are proposed, evaluated, and justified. The argument includes 1) a conception of health as capability, 2) a theory of causation and distribution of health capability as well as 3) an argument for the moral entitlement to a sufficient and equitable capability to be healthy grounded in the respect for human dignity. Moreover, the entitlement to the capability to be healthy is defended against alternative ethical approaches that focus on welfare or resources in evaluating and satisfying health claims. In specific, it is argued that human health is best understood as a capability to be healthy - a meta-capability to achieve a cluster of basic and inter-related capabilities and functionings. Such a cluster of capabilities and functionings is in line with Martha Nussbaum's central human capabilities. A theory of causation and distribution of health capability is put forward that integrates the 'classic' biomedical factors of disease (genetic endowment, exposure to hazardous materials, behaviour), social determinants of disease, and Drèze and Sen's econometric analysis of the causation and distribution of acute and endemic malnutrition. Furthermore, the argument critiques Norman Daniels's revised Rawlsian theory of health justice, and advocates for the capability approach to recognize group capabilities in light of 'population health' phenomena. Lastly, the thesis also argues that a coherent, capability conception of health as a species-wide conception will tend to make any theory of justice recognizing health claims a cosmopolitan theory of justice.

Introdução - A maioria dos estudos sobre a teoria da renda relativa tem encontrado associação estatísticamente significativa entre alta desigualdade de renda e piores condições de saúde em grandes regiões como estados norte-americanos ou países. Por outro lado, análises realizadas em municípios e áreas fora dos EUA tem apresentado resultados no mínimo conflitantes. Os maiores obstáculos para que se atinja consenso na área são a inexistência de elevada desigualdade em regiões menores e a dificuldade de controlar pelo conjunto de variáveis de confusão que podem ter efeito na saúde além da desigualdade de renda. O presente estudo objetiva auxiliar na solução desse problema ao analisar o Município de São Paulo por meio de uma metodologia estatística chamada propensity score matching. Metodologia - A análise abordou os 96 distritos da cidade. Foram incluídas 16 variáveis no modelo para identificar distritos comparáveis. Do total de 96 distritos, 27 foram pareados com algum outro (alguns mais de uma vez), formando 17 pares, dos quais apenas um foi composto por distritos que fazem fronteira entre si. Resultados - Após a aplicação do propensity score matching, distritos mais desiguais apresentaram maior mortalidade geral ajustada por idade (41,58 por 10.000 hab; IC 95por cento : 8,85 73,3 por 10.000 hab). Foram também estatísticamente significativas as diferenças de mortalidade para homicídios (8,57 por 10.000; IC 95por cento : 2,60 14,53), doença isquêmica do coração (5,47 por 10.000; IC 95por cento : 0,76 10,17), aids (3,58 por 10.000; IC 95por cento : 0,58 6,57), doença respiratória (3,56 por 10.000; IC 95por cento : 0,18 6,94) e mortalidade infantil (2,8 por 10.000; IC 95por cento : 0,86 4,74). As dez causas 9 básicas mais frequentes foram responsáveis por 72,3por cento do total da diferença de mortalidade entre os distritos mais e menos desiguais. Conclusões - A metodologia estatística foi eficaz para diminuir as diferenças sociais e demográficas, possibilitando a comparação entre distritos semelhantes. A presença de alta desigualdade de renda no Município de São Paulo permitiu a análise do seu efeito na mortalidade / Introduction - The majority of studies on the relative income theory has detected statistically significant associations between high income inequality and worse health conditions for larger areas such as countries or USA states. Nevertheless, for smaller areas such as municipalities or regions outside the USA, the results have been, at best, mixed. The biggest hindrances to a consensus are the lack of high inequalities within smaller areas and the difficulty to control for the many variables that may also affect health beyond the effect of income inequality. This analysis aims to help to solve these problems by applying a statistical analysis known as propensity score matching and by focusing on a very diverse and unequal city such as São Paulo. Methodology - The analysis was done for the 96 distritos of the Municipality of São Paulo, Brazil. The statistical model included 16 variables to account for local heterogeneity. Of the 96 distritos, 27 were matched with a similar one (sometimes, more than once), making a total of 17 pairs (of those, only one pair was made out of two bordering distritos). Results - After the propensity score matching approach, higher inequality distritos had higher age-adjusted overall mortality rate (41.58 per 10,000, 95per cent CI: 8.85 73.3). The difference between high and low inequality was also statistically significant for homicide (8.57 per 10,000; 95per cent CI: 2.60 14.53), ischemic heart disease (5.47 per 10,000; 95per cent CI: 0.76 10.17), HIV/AIDS (3.58 per 10,000; 95per cent CI: 0.58 6.57), respiratory diseases (3.56 per 10,000; 95per cent CI: 0.18 6.94) and infant mortality (2.8 per 10,000; 95per cent CI: 0.86 4.74). The ten most common causes of death accounted for 72.3per cent of total difference in mortality. 11 Conclusion - The statistical methodology was effective to control for local social and demographic heterogeneity, allowing the comparison of only similar distritos. The use of a large and diverse city such as São Paulo made it possible to analyze the effects of income inequality on health