Community perceptions and factors influencing utilization of health services in Uganda

<p>Abstract</p> <p>Background</p> <p>Healthcare utilization has particular relevance as a public health and development issue. Unlike material and human capital, there is little empirical evidence on the utility of social resources in overcoming barriers to healthcare utilization in a developing country context. We sought to assess the relevance of social resources in overcoming barriers to healthcare utilization.</p> <p>Study Objective</p> <p>To explore community perceptions among three different wealth categories on factors influencing healthcare utilization in Eastern Uganda.</p> <p>Methods</p> <p>We used a qualitative study design using Focus Group Discussions (FGD) to conduct the study. Community meetings were initially held to identify FGD participants in the different wealth categories, ('least poor', 'medium' and 'poorest') using poverty ranking based on ownership of assets and income sources. Nine FGDs from three homogenous wealth categories were conducted. Data from the FGDs was analyzed using content analysis revealing common barriers as well as facilitating factors for healthcare service utilization by wealth categories. The Health Access Livelihood Framework was used to examine and interpret the findings.</p> <p>Results</p> <p>Barriers to healthcare utilization exist for all the wealth categories along three different axes including: the health seeking process; health services delivery; and the ownership of livelihood assets. Income source, transport ownership, and health literacy were reported as centrally useful in overcoming some barriers to healthcare utilization for the 'least poor' and 'poor' wealth categories. The 'poorest' wealth category was keen to utilize free public health services. Conversely, there are perceptions that public health facilities were perceived to offer low quality care with chronic gaps such as shortages of essential supplies. In addition to individual material resources and the availability of free public healthcare services, social resources are perceived as important in overcoming utilization barriers. However, there are indications that having access to social resources may compensate for the lack of material resources in relation to use of health care services mainly for the least poor wealth category.</p> <p>Conclusion</p> <p>The differential patterning of social resources may explain or contribute to the persisting inequities in health care utilization. Additional research using quantitative analytical methods is needed to test the robustness of the contribution of social resources to the utilization of and access to healthcare services.</p

Institutional trust and alcohol consumption in Sweden: The Swedish National Public Health Survey 2006

<p>Abstract</p> <p>Background</p> <p>Trust as a measure of social capital has been documented to be associated with health. Mediating factors for this association are not well investigated. Harmful alcohol consumption is believed to be one of the mediating factors. We hypothesized that low social capital defined as low institutional trust is associated with harmful alcohol consumption.</p> <p>Methods</p> <p>Data from the 2006 Swedish National Survey of Public Health were used for analyses. The total study population comprised a randomly selected representative sample of 26.305 men and 30.584 women aged 16–84 years. Harmful alcohol consumption was measured using a short version the Alcohol Use Disorders Identification Test (AUDIT), developed and recommended by the World Health Organisation. Low institutional trust was defined based on trust in ten main welfare institutions in Sweden.</p> <p>Results</p> <p>Independent of age, country of birth and socioeconomic circumstances, low institutional trust was associated with increased likelihood of harmful alcohol consumption (OR (men) = 1.52, 95% CI 1.34–1.70) and (OR (women) = 1.50, 95% CI 1.35–1.66). This association was marginally altered after adjustment for interpersonal trust.</p> <p>Conclusion</p> <p>Findings of the present study show that lack of trust in institutions is associated with increased likelihood of harmful alcohol consumption. We hope that findings in the present study will inspire similar studies in other contexts and contribute to more knowledge on the association between institutional trust and lifestyle patterns. This evidence may contribute to policies and strategies related to alcohol consumption.</p

Trends in absolute socioeconomic inequalities in mortality in Sweden and New Zealand. A 20-year gender perspective

BACKGROUND: Both trends in socioeconomic inequalities in mortality, and cross-country comparisons, may give more information about the causes of health inequalities. We analysed trends in socioeconomic differentials by mortality from early 1980s to late 1990s, comparing Sweden with New Zealand. METHODS: The New Zealand Census Mortality Study (NZCMS) consisting of over 2 million individuals and the Swedish Survey of Living Conditions (ULF) comprising over 100, 000 individuals were used for analyses. Education and household income were used as measures of socioeconomic position (SEP). The slope index of inequality (SII) was calculated to estimate absolute inequalities in mortality. Analyses were based on 3–5 year follow-up and limited to individuals aged 25–77 years. Age standardised mortality rates were calculated using the European population standard. RESULTS: Absolute inequalities in mortality on average over the 1980s and 1990s for both men and women by education were similar in Sweden and New Zealand, but by income were greater in Sweden. Comparing trends in absolute inequalities over the 1980s and 1990s, men's absolute inequalities by education decreased by 66% in Sweden and by 17% in New Zealand (p for trend <0.01 in both countries). Women's absolute inequalities by education decreased by 19% in Sweden (p = 0.03) and by 8% in New Zealand (p = 0.53). Men's absolute inequalities by income decreased by 51% in Sweden (p for trend = 0.06), but increased by 16% in New Zealand (p = 0.13). Women's absolute inequalities by income increased in both countries: 12% in Sweden (p = 0.03) and 21% in New Zealand (p = 0.04). CONCLUSION: Trends in socioeconomic inequalities in mortality were clearly most favourable for men in Sweden. Trends also seemed to be more favourable for men than women in New Zealand. Assuming the trends in male inequalities in Sweden were not a statistical chance finding, it is not clear what the substantive reason(s) was for the pronounced decrease. Further gender comparisons are required

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance.

Investment in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing in Africa over the past year has led to a major increase in the number of sequences that have been generated and used to track the pandemic on the continent, a number that now exceeds 100,000 genomes. Our results show an increase in the number of African countries that are able to sequence domestically and highlight that local sequencing enables faster turnaround times and more-regular routine surveillance. Despite limitations of low testing proportions, findings from this genomic surveillance study underscore the heterogeneous nature of the pandemic and illuminate the distinct dispersal dynamics of variants of concern-particularly Alpha, Beta, Delta, and Omicron-on the continent. Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve while the continent faces many emerging and reemerging infectious disease threats. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Socioeconomic status and cardiovascular vulnerability in women : psychosocial, behavioral and biological mediators

Background: Cardiovascular disease (CVD) is the leading cause of death in both men and women in the industrialized world, and represents a major health and economic burden. Coronary heart disease (CHD), one of the most common of the cardiovascular diseases, is invariably more frequent in men and women of lower than higher socioeconomic status (SES). In spite of the overall decline in CHD rates, socioeconomic differences persist, and may even be widening, particularly in women. Most studies of SES and CHD have been done in men, and relatively little is known about the socioeconomic determinants of CHD risk in women. Studying SES and CHD in women is even more important than in men, because the attributable fraction of low SES for CVD, may be higher in women due to their more disadvantaged socioeconomic position. Aims of the study: 1) To study the association between SES and CHD development in women, 2) To estimate the relative contribution of social and behavioral factors to the socioeconomic disparities in women's CHD, 3) To study the effects of SES and childhood circumstances on CHD prognosis in women, and 4) To study the associations between SES and physiological risk factors for CHD (obesity, atherogenic lipid profile and hemostatic dysfunction) in women. Material and Methods: This is the first doctoral thesis which is based on data from the Stockholm Female Coronary Risk (FemCorRisk) Study. The FemCorRisk study is a population-based case-control study which comprises all women aged 65 years or younger who were admitted for an acute event of CHD between 1991 and 1994 in any of the coronary care units of all hospitals in the greater Stockholm area. Healthy controls from the census register were matched with CHD patients with regard to age and catchment area. To study the association between SES and CHD development, case-control analyses were done. To study the effects of SES and childhood circumstances on CHD prognosis, CHD patients were followed for 5-years after an acute event of CHD. Deaths from CHD, recurrent acute myocardial infarctions, and revascularizations were monitored. To study the associations between SES and physiological risk factors, cross-sectional analyses of the population-based healthy women (control-group) of the FemCorRisk Study were done. Results: Low SES increases vulnerability to CHD in women. Low SES (as measured by low educational attainment and low occupational status) had a substantial impact on both cardiovascular risk, and physiological risk factors for CHD (obesity, atherogenic lipid profile and hemostatic dysfunction). After adjustment for age, women with only mandatory school education (<9 years) had a two-fold increased risk for CHD as compared to women who had attained college/university. Psychosocial stress, unhealthy behaviors and poorer physiological risk factor profiles explained the association between low education and increased CHD risk. Of these factors, psychosocial stress and unhealthy behaviors were the most important. Un/semiskilled workers had a four-fold increased risk for CHD as compared to executives/professionals, after adjustment for age. Traditional cardiovascular risk factors and work-related factors however, explained "only in part" why women with lower status jobs had an increased risk of CHD. The impact of low SES on a poorer prognosis of CHD, was unclear, but adverse childhood circumstances (as measured by short stature), showed a strong negative effect on CHD prognosis. In healthy women, low SES was associated with obesity, atherogenic lipid profile (mainly low HDL) and hemostatic dysfunction. Conclusions: Findings in this thesis underline the importance of low SES in the etiology of CHD in women. The factors explaining the CHD-SES association in women range from adverse childhood circumstances, individual personality, social relations, health behaviors, biological risk factor profiles, to stressors that operate both at work and at home. Because of the structural positions that women occupy in society, one of the challenges for future preventive efforts is to create favorable conditions for socioeconomically deprived women. Such efforts should combine both work and non-work related factors

What has trust in the health-care system got to do with psychological distress? Analyses from the national Swedish survey of public health

Mental health disorders are a rapidly growing public health problem. Despite the fact that lack of trust in the health-care system is considered to be an important determinant of health, there is scarcity of empirical evidence demonstrating its associations with health outcomes. This is the first study which aims to evaluate the association between trust in the health-care system and psychological distress. Cross-sectional study. The association between trust in the health-care system and psychological distress was analysed with multiple logistic regression analysis adjusting for other factors. A randomly selected representative sample of women and men aged 16-84 years from the Swedish population who responded to the 2006 Swedish National Survey of Public Health. A total of 26 305 men and 30 584 women participated in the study. None. The main outcome measure was psychological distress measured by the General Health Questionnaire. Very low trust in health-care services was associated with an increased risk for psychological distress among men (odds ratio = 1.59, 95% confidence intervals 1.25-2.02) and among women (odds ratio = 1.83, 95% confidence intervals 1.47-2.27) after controlling for age, country of birth, socioeconomic circumstances, long-term illness and interpersonal trust. Our results suggest that health-care system mistrust is associated with an increased likelihood of psychological distress. Although causal relationships cannot be established, patient mistrust of health-care providers may have detrimental implications on health. Public health policies should include strategies aimed at increasing access to health-care services, where trust plays a substantial role

Is cumulative exposure to economic hardships more hazardous to women's health than men's? A 16‐year follow‐up study of the Swedish Survey of Living Conditions

Background: There is currently a growing interest in the role of social structures, social conditions and social relationships in explaining patterns of population health, as well as the need to connect individual health outcomes to their socio-economic context. This thesis contributes to this young, but fast growing field by analyzing the role of social and economic conditions in determining health. Aim: To study the socioeconomic determinants of health by focusing on the relevance of economic and social capital. Methods: The thesis comprises four studies, three of which are based on cross-sectional data from the National Public Health Survey 2006 (N= 56,889) and 2009 (N= 51,414) (Study II, III and IV) and one based on longitudinal data from the Swedish Survey of Living Conditions (ULF) panel study from the years 1981–1997 (N= 3,780) (Study I). While Study I and II analyzed associations between measures of economic capital and health outcomes, Study III focused on associations between measures of social capital and health outcomes. Finally, in Study IV independent associations, and interactions, of a lack of economic capital and social capital on health outcomes were analyzed. Low economic capital (i.e. economic hardships) was measured by low household income and self-reported financial stress (inability to meet expenses and a lack of cash reserves). Social capital was measured on the individual level by social participation, interpersonal (horizontal) and institutional (vertical) trust. Health outcomes included self-rated health, psychological health (severe anxiety, GHQ-12, anti-depressant medication), physical health (musculoskeletal disorders) and health behaviors (harmful alcohol consumption). Results: In Study I, based on longitudinal data, a dose-response effect on women‟s health was observed with an increasing score of cumulative exposure to financial stress, but not for low income. The results for men were more inconclusive. Cumulative exposure to financial stress seemed to affect men‟s self-rated health, while exposure to low income seemed to affect men‟s psychological distress, and neither exposure to low income nor financial stress seemed to affect men‟s musculoskeletal disorders. In Study II, financial stress (but not low income) was significantly associated with both women‟s and men‟s mental health problems (all indicators). Additionally, a graded association was found between mental health problems and levels of economic hardships (as measured by a combined economic hardships measure capturing both self-reported financial stress and low income). In Study III, low social capital (as measured by institutional trust in ten main welfare institutions in Sweden) was associated with increased likelihood of harmful alcohol consumption. Furthermore, a graded association was found between harmful alcohol consumption and levels of institutional trust. In Study IV, a measure of economic hardships (including both self-reported financial stress and low income) and low social capital (i.e., low interpersonal and institutional/political trust and low social participation) were significantly associated with men‟s and women‟s poor health status, with only a few exceptions. Furthermore, statistically significant interaction effects measured as a synergy index were observed between economic hardships and all different types of social capital. Gender differences in health outcomes related to low economic and social capital were analyzed in all studies. However, only very small gender differences were revealed throughout the studies with the exception of Study I where financial stress was consistently associated with poor health outcomes for women, but not for men. Conclusions: This thesis adds to the scientific evidence that economic and social capital at the individual level are multifaceted concepts independently connected to poor health outcomes, both physical and mental. However, when combined they seem to be associated with a further increased magnitude of poorer health. Hence, the social and the economic determinants should not be considered as exclusive and separate in relation to health. Policy initiatives minimizing the extent to which individuals perceive themselves as excluded in several dimensions in society, e.g., by channeling resources at improving the economic conditions under which people live and encouraging social connectedness and social cohesion, are desirable