Exploring sex variations in the incidence of cardiovascular events: a counterfactual decomposition analysis.

BACKGROUND: Some cardiovascular risk factors (CVRFs) that occur differently in men and women can be addressed to reduce the risk of suffering a major adverse cardiovascular event (MACE). Furthermore, the development of MACE is highly influenced by social determinants of health. Counterfactual decomposition analysis is a new methodology that has the potential to be used to disentangle the role of different factors in health inequalities. This study aimed to assess sex differences in the incidence of MACE and to estimate how much of the difference could be attributed to the prevalence of diabetes, hypertension, hypercholesterolaemia and socioeconomic status (SES). METHODS: Descriptive and counterfactual analyses were conducted in a population of 278 515 people with CVRFs. The contribution of the causal factors was estimated by comparing the observed risk ratio with the causal factor distribution that would have been observed if men had been set to have the same factor distribution as women. The study period was between 2018 and 2021. RESULTS: The most prevalent CVRF was hypercholesterolaemia, which was similar in both sexes, while diabetes was more prevalent in men. The incidence of MACE was higher in men than in women. The main causal mediating factors that contributed to the sex differences were diabetes and SES, the latter with an offsetting effect. CONCLUSIONS: This result suggests that to reduce the MACE gap between sexes, diabetes prevention programmes targeting men and more gender-equal salary policies should be implemented.

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data.

BACKGROUND: The Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform's impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities. METHODS: This register-based study used a multiple-group interrupted time-series design for the study period 2001-2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18-85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII). RESULTS: All three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)). CONCLUSIONS: The study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Prevalence and change in social inequalities in physical activity before and during the COVID-19 pandemic in Sweden.

BACKGROUND: Physical activity is crucial for our wellbeing. Since the COVID-19 pandemic emerged, physical activity behaviour has changed globally, and social inequalities that already exist in physical activity have increased. However, there is limited knowledge of how these inequalities have evolved in Sweden. Thus, the aim of this study was to assess the prevalence of physical activity, and the socioeconomic inequalities in physical activity before and during the COVID-19 pandemic. METHODS: This study analysed data from the national 'Health on Equal Terms' survey which was conducted on participants between 16 and 84, through a repeated cross-sectional design in 2018 (pre-pandemic) and 2021 (during the pandemic). The socioeconomic variables included gender, age, education, occupation, income, and place of birth. For both years, the prevalence of low physical activity, the absolute risk differences, the slope index of inequality, and the slope index difference for each of the variables were calculated. RESULTS: The level of physical activity increased for the total population studied. However, the social inequalities that existed in 2018 increased over time and across age, education, occupation, income, and place of birth, but not with regard to gender. CONCLUSIONS: Even though the Swedish population increased their levels of physical activity during the COVID-19 pandemic, the social inequalities that already existed in physical activity increased. Interventions to increase the level of physical activity among the young, people with low socioeconomic status, and those born outside Sweden are needed to reduce these social inequalities, and to improve the Swedish population's wellbeing.

Explaining gender inequalities in overweight people: a Blinder-Oaxaca decomposition analysis in northern Sweden.

BACKGROUND: Being overweight and obesity are considered serious public health concerns worldwide. At the population level, factors contributing to overweight as well as the differences in overweight between men and women in terms of prevalence or associated factors are relatively well-known. What is less known is what explains the inequalities in overweight between men and women. In this study, we examined the contribution of material, behavioural, and psychosocial factors in explaining the gender differences in overweight among adults in northern Sweden. METHODS: This study was based on the 2018 Swedish Health on Equal Terms survey, which was carried out in Sweden's four northernmost regions. The analytical sample consisted of 20,855 participants (47% men) aged 20-84 years. Overweight (including obesity) was the outcome, and the selected explanatory variables were grouped according to three theoretical perspectives: material, behavioural and psychosocial. Descriptive statistics and Blinder-Oaxaca decomposition were applied for analysing the data. RESULTS: Our study showed that the prevalence of overweight was 64% and 52% among men and women, respectively. It, therefore, revealed a gender gap in overweight people of 11.7% points with explanatory factors accounting for 39% of that gap. This gender gap in overweight people was mostly explained by behavioural variables (19.3%), followed by the materialistic variables and age accounting for 16.2% and 3.1%, respectively. Specifically, having low education, being in the lowest income quintile, alcohol drinking and snus usage contributed to explain 8.4%, 8.9%, 2.8% and 6.3% of the gender difference, respectively. CONCLUSIONS: We found a considerable gender inequality in overweight between men and women. The findings highlight that future overweight prevention initiatives would benefit from targeting the uncovered contributing factors to reduce gender inequalities in overweight people.

Prevalence and risk factors for self-reported asthma among sámi in Sweden: a cross-sectional study.

OBJECTIVE: Literature about asthma among Indigenous communities worldwide is scarce. This study aimed to estimate the prevalence of self-reported asthma and to identify the risk factors associated with it among the Sámi population in Sweden. METHODS: A population-based health study (SámiHET) was conducted among the Sámi population aged 18-84 years in 2021. The asthma outcome was self-reported. Potential risk factors included sociodemographic, socioeconomic, cultural, behavioral and psychosomatic factors. Frequencies and percentages of the independent variables and the outcome were calculated. Then, the magnitude of the association between the independent variables and asthma was summarized with the prevalence ratio (PR) using the 95% confidence interval (95% CI) for inferential purposes. RESULTS: Overall, 20.6% of participants reported having asthma and 13.9% suffering from asthma with symptoms. Women (PR: 1.19; 95% CI: 1.01-1.42), those living in the Västerbotten region (PR: 1.35; 95% CI: 1.11-1.63) and those suffering financial strain (PR: 1.34; 95% CI: 1.07-1.69) had a higher risk of self-reported asthma. Among the psychosomatic factors, self-reported allergy (PR: 6.45; 95% CI: 5.11-8.17), overweight (PR: 1.46; 95% CI: 1.19-1.78) and obesity (PR: 1.75; 95% CI: 1.41-2.17) were statistically significant associated to asthma symptoms. CONCLUSION: A higher prevalence of asthma was found among the Sámi in Sweden compared to the average Swedish population. The associated risk factors were similar to those described in the literature. To understand the reason behind the higher prevalence of asthma among Sámi, more asthma-specific research, including register data, is needed.

Ethnic discrimination and mental health in the Sámi population in Sweden: The SámiHET study.

AIMS: To assess the association between experiences of discrimination and mental health among the Sámi population in Sweden. METHODS: Cross-sectional study among the self-identified Sámi population living in Sweden in 2021, registered in the electoral roll of the Sámi Parliament, the reindeer mark register and the 'Labour statistics based on administrative sources'. The analysis was based on a final sample of 3658 respondents aged between 18 and 84 years. Adjusted prevalence ratios aPRs for psychological distress (Kessler scale), self-reported anxiety and depression were estimated for four different forms of discrimination (direct experience of discrimination, offended because of ethnicity, historical trauma, and combined discrimination). RESULTS: Higher aPRs of psychological distress, anxiety and depression were observed in women experiencing direct discrimination because of their ethnicity, having been offended because of their ethnicity, and those with a family history of discrimination. Among men, higher aPRs for psychological distress were observed in those experiencing the four different forms of discrimination, but not for anxiety. Depression was only detected in the case of having been offended. Adding experiences of discrimination was associated with a higher prevalence of negative outcomes for all the indicators in women and for psychological distress in men. CONCLUSIONS: The observed association between experiences of discrimination and mental health problems would support a gender approach when considering ethnic discrimination in public health policies concerning the Sámi in Sweden.

The self-reported health of the Sámi in Sweden: the SámiHET study.

BACKGROUND: The Sámi are an ethnic minority and the only Indigenous people in the European Union. Population-based health studies among Sámi in Sweden are scarce and outdated. The aim of this study was to analyse the ethnic, Sámi vs. non-Sámi, health differences among men and women living in Sweden. METHODS: This study combined two data sources: the national Health on Equal Terms (HET) survey and a similar study conducted among the Sámi population, the SámiHET study, both carried out during spring 2021. Twelve outcomes were used to capture different aspects of the population's health organized along four dimensions: general health, physical health, mental health and lifestyle behaviours. Prevalence ratios, adjusted for age, civil status, education and income, were used as the measure of effect with 95% confidence intervals to provide inference. Analyses were disaggregated by sex. RESULTS: The prevalence of poor self-rated dental health (and chronically ill health among men), asthma and overweight were higher among the Sámi; however, the mental health outcomes were similar or lower among the Sámi participants. The Sámi ate less vegetables and fruits, but they were smoking and drinking alcohol less than the national Swedish population. These patterns were similar among both men and women. CONCLUSION: Poor self-rated dental health, asthma, overweight and a low consumption of vegetables and fruits were a concern among the Sámi population in both men and women. These areas therefore require specific targeted interventions to decrease the observed ethnic health inequalities in Sweden. The design of this study opens the possibility for continuous monitoring of the health of the Sámi but also offers the best possible comparison with Swedish population health data.

Rural-urban disparities in postpartum contraceptive use among women in Nigeria: a Blinder-Oaxaca decomposition analysis.

BACKGROUND: Unintended pregnancies are a global public health concern that could be prevented with appropriate access to contraceptive methods. Evidence from research has indicated that avoidance of closely space birth/pregnancy within the first year of postpartum, mitigates the risk of adverse health outcomes such as preterm birth, low birth-weight, etc. Postpartum family planning helps women to minimize closely spaced and unplanned pregnancies within the first 12 months after delivery. Less contraceptive use is often present in more socially disadvantaged groups. Studies from Nigeria have shown a persistent disparity on contraceptive use between rural and urban residents. To identify the factors explaining these inequalities is important to implement targeted interventions. This study aimed to identify the factors contributing to the rural-urban disparity in postpartum contraceptive use among women in Nigeria. METHODS: This is a cross-sectional study using the Nigerian Demographic Health Survey. In total, 28,041 postpartum Nigerian women were included. Self-reported contraceptive use was the outcome, while the selected explanatory variables were grouped according to three theoretical perspectives: materialistic, behavioural/cultural, and psychosocial variables. Descriptive statistics and Blinder-Oaxaca decomposition were used to summarize and identify the factors contributing to the rural-urban disparity in postpartum contraceptive use. RESULTS: In this study, 27% of women reported to have used contraceptives during the postpartum period. The rural-urban disparity in postpartum contraceptive use accounted for 18.2 percentage points. The findings further showed that the disparities in postpartum contraceptive use between rural-urban residence were mostly explained by materialistic variables (82%), followed by the behavioural/cultural variables and age (included as covariate) accounting for 15.6 and 3.0%, respectively. Household wealth (37%) and educational attainment (38%) had the most significant contribution to the differences in postpartum contraceptive use. Only 15% of the difference in postpartum contraceptive use remained unexplained. CONCLUSION: This study has shown important inequalities in postpartum contraceptive use between rural and urban residents in Nigeria. These differences were mainly explained by materialistic factors. These findings highlight crucial areas for the government to target in order to close the existing gap between rural and urban settings in contraceptive use in the country.

Social inequalities in women exposed to obstetric and gyneco-obstetric violence in Ecuador: a cross-sectional study.

BACKGROUND: Obstetric and gyneco-obstetric violence (OV, GOV) is a concerning public health problem, particularly in Latin America. This study aimed to determine the prevalence of OV and GOV and to assess its socio-geographical distribution in Ecuador. METHODS: This cross-sectional study used data from a national survey conducted in 2019 (n = 17,211) among women aged 15 years and over. Independent variables included age, marital status, education, ethnicity, place of residence and region. The chosen outcomes were lifetime experience of OV and GOV. Frequency tables were calculated and crude and adjusted regression models estimating prevalence ratios and their 95% confidence intervals were computed. RESULTS: Nearly one-third (32.8%) of the participants had experienced OV and two-fifths (41.86%) GOV at least once in their lifetime. Prevalence of OV were particularly common in women 26-35 and 46-55 years old, with primary or middle education and in urban regions. In comparison, GOV had a higher prevalence in women aged > 65 years and with no formal education. Both subtypes of violence were more common among women with current or earlier partners compared with the single ones. Also the two outcomes were more prevalent in the non-white population, OV among the populations of colour (POC), while GOV both, in the POC and Indigenous group. Additionally, women from the Highlands and Amazon reported higher OV and GOV than the Coastal group. CONCLUSION: Our study showed that OV and GOV are common in Ecuador and identified an unequal distribution of their prevalence across different socio-geographical groups. Further studies including more social factors and a continuous monitoring of OV and GOV are recommended. Current policies, laws to protect women and guidelines regarding the treatment of women, particularly in health care settings, need to be constantly advocated for and effectively implemented in the country.

Social factors associated with trust in the health system in northern Sweden: a cross-sectional study.

BACKGROUND: Despite the importance of having trust in the health system, there is a paucity of research in this field in Sweden. The aim of this study was to estimate the level of trust in the health system and to assess the factors associated with it in northern Sweden. METHODS: A cross-sectional survey was conducted in 2014 in the four northern regions of Sweden. A total of 24 795 participants (48% response rate) aged 18 to 84 years were involved in the study. A log-binomial regression was used to measure the association between sociodemographic factors and trust in the health system. RESULTS: Two thirds of the participants (68.5%) reported high trust in the health system i.e. had very much or quite a lot confidence in the health system. Women had lower prevalence of trust compared to men (PR = 0.96; 95% CI = 0.94-0.98) while older participants had a higher trust compared to youth (PR = 1.11; 95% CI = 1.06-1.16). Participants with lower level of education, those who experienced economic stress, those who were born outside Sweden and those living in small municipalities also had lower prevalence of trust in the health system. Conversely, lower income was associated with higher trust (PR = 1.08; 95% CI = 1.04-1.12). Finally, a strong relationship between higher social capital (having emotional and instrumental support, horizontal trust, and higher social participation) and trust in the health system was also found. CONCLUSIONS: Trust in the health system was moderately high in northern Sweden and strongly associated with sociodemographic and social capital factors. Trust is a complex phenomenon and a deeper exploration of the relation between trust in the health system and sociodemographic factors is needed.

Social inequalities in healthcare utilization during Ecuadorian healthcare reform (2007-2017): a before-and-after cross-sectional study.

BACKGROUND: Limited research is available about the impact of healthcare reforms on healthcare utilization according to socioeconomic group. Although most health reforms in Latin America have focused on reducing the gap between the most advantaged and disadvantaged groups and improving the quality of health services, the available information has shown limited progress. Therefore, this study assessed whether the recent Ecuadorian healthcare reform (2007-2017) contributed to decreasing the socioeconomic inequalities in healthcare utilization. METHODS: We used data from the National Living Standards Measurement surveys conducted in 2006 and 2014. Unmet healthcare needs (UHCN) were used as the dependent variable and proxy for difficulties in accessing health services. Place of residence, ethnicity, education and wealth were selected as indicators of socioeconomic status. The slope and relative inequality indexes were calculated for adult men and women for each period and socioeconomic variable. A multiplicative interaction term between midpoint scores and time was applied to estimate changes in inequalities over time. Sample weights were applied to all analyses, and 95% confidence intervals were calculated to assess statistical significance in the regression analysis. RESULTS: In 2006, the poor, Indigenous, those living in rural areas and with low education had lower access to health services. In 2014, the overall prevalence of UHCN decreased from 27 to 18% and was higher in women than men. Statistically significant reductions of refraining were observed in absolute and relative terms in all social groups, both in men and women. CONCLUSIONS: Our results showed remarkable and significant decreases in inequalities in all examined socioeconomic groups in absolute and relative terms in this period. Although a new model of healthcare was established to achieve universal health coverage, its performance must be continuously evaluated and monitored with specific indicators. Further studies are also needed to identify the main barriers that contribute to UHCN among socially disadvantaged groups.

Prevalence and sociogeographical inequalities of violence against women in Ecuador: a cross-sectional study.

BACKGROUND: Violence against women (VAW) is a vast public health problem in Latin America. The aim of this study was to determine the prevalence of violence against women and to assess its sociogeographical inequalities in Ecuador during 2019. METHODS: This cross-sectional study used data from a national survey conducted in 2019 (n = 17,211) among women aged 15 years and over. Independent variables included age, marital status, education, ethnicity, place of residence and region. The chosen outcomes were lifetime experience of total violence, sexual violence, physical violence, psychological violence and economic violence. Frequency tables were first calculated, and then crude and adjusted regression models estimating risk differences and their 95% confidence intervals were computed. RESULTS: Nearly two-thirds (64.86%) of the participating women had experienced some form of violence during their lifetime, mainly psychological violence (56.92%). The second most prevalent type of violence was physical (35.44%) closely followed by sexual (32.67%). Almost one-fifth (16.38%) stated to have experienced some form of economic violence. Physical and psychological violence were more common among women aged 26-35 and less among older women. All forms of violence were more often reported among women with no education except for sexual violence, which was more frequent among those with higher education. Physical, psychological and economic violence were more often reported by those living with a partner, being married or divorced/separated. Sexual violence was associated with those belonging to a non-indigenous ethnic group, while all types of violence were more common among those living in an urban setting (except physical violence), in the Highlands or in the Amazon region. CONCLUSIONS: Our study showed that VAW is a common event in Ecuador and identified several sociogeographical inequalities that varied depending on the type of violence. VAW was more common among the younger age groups, those with low education, those living with a partner or being divorced/separated, or residing in an urban setting, in the Highlands or in the Amazon. Further studies including more social factors and a continuous monitoring of VAW are recommended. Current policies and laws to protect women need to be expanded and effectively implemented to reduce VAW in the Ecuador.

Assessing the impact of the 2008 health reform in Ecuador on the performance of primary health care services: an interrupted time series analysis.

BACKGROUND: In 2008, Ecuador started a national health reform based on the principles of Alma Ata to achieve Universal Health Coverage. While coverage indicators have increased, a systematic assessment of the impact of the reform on the delivery of health services at primary level is lacking. The aim of this study was to assess the impact of the 2008 health reform on the performance of primary health care services in Ecuador. METHODS: Ambulatory Care Sensitive Conditions (ACSC) are a subset of diseases where hospital admission is potentially avoidable by high quality well-functioning primary care. Thus, observing the behaviour of ACSC hospitalizations can serve as an indicator of how the primary health care level is performing. Crude and adjusted rates, stratified by sex, were calculated from ten selected ACSC hospitalization discharges during 22 years of data representing 11 years before and after the health reform. An interrupted time series analysis was then conducted by applying a negative binomial regression and adjusting for overdispersion and autocorrelation. RESULTS: Overall higher crude and adjusted rates for ACSC hospitalizations were observed in women compared to men; both increased gradually since the start of the observation, reaching a peak around 2010, and then started a downwards trend. In men, the incidence rate ratio increased significantly by 3 % per year during the period before the intervention. During the first year after intervention, an increase (13 %) was detected, and then a statistically significant 1 % decrease (IRR = 0.99; 95 % CI: 0.98, 0.99) was observed in the ACSC rate ratio per year in the period after the intervention. Similar trends and effect sizes were found for women. CONCLUSIONS: The study revealed significant decreasing trends of the ACSC hospitalization rates in both sexes, indicating an improvement of the performance of the primary health care services following the 2008 national health reform. A continuous strengthening of the primary care model as well as a regular monitoring of ACSC hospitalization rates in the country is recommended. A health economic evaluation considering hospitalizations avoided and associated costs is also advisable.

"The devil is in the detail": geographical inequalities of femicides in Ecuador.

BACKGROUND: Femicide is a very important public health problem in Ecuador. Since regional and country-level femicide rates can obscure significant variations at the sub-national level, it is important to provide information at the lowest relevant level of disaggregation to be able to develop targeted preventive policies. The aim of this study was to assess the spatial distribution of the femicide rate and to examine its spatial clustering at the canton level in Ecuador in the period 2018-2019. METHODS: Data on cases were collected by a national network of non-governmental organizations. Two age-disaggregated analyses were done, one for the 15 to 24 years-olds and the other for the female population of 15 and older. Age-specific population data were obtained from the National Institute of Statistics for the study period. Standardized mortality ratios for mapping the mortality were calculated using hierarchical Bayesian models and spatial scan statistics were applied to identify local clusters. Thematic maps of age-specific femicide rates were also constructed. RESULTS: During the two-year period, 61 and 183 women were killed in the age ranges 15-24 and 15 years and older, respectively. The annual rate of femicides in Ecuador was 1.0 and 0.8 per 100,000 in the female population aged 15-24 and 15+, respectively, with substantial variations among cantons. The spatial analysis contributed to visualize high risk cantons, which were mainly located in a small area in the central part of the country (for those 15+) but especially in the Amazon region, for both of the studied age groups. CONCLUSIONS: This study has shown the usefulness of applying spatial analysis to the problem of femicides in Ecuador. The study has revealed important variations among cantons but also a spatial clustering, mainly in the Amazon region of the country. The results should help policymakers to focus on current prevention programmes for violence against women into these high-risk areas. Continuous monitoring of femicides at low-level geographical areas is highly recommended.

Young migrants' sexual rights in Sweden: a cross-sectional study.

BACKGROUND: In national public health surveys including those assessing sexual and reproductive health, migrants generally tend to be underrepresented due to cultural, linguistic, structural and legal barriers, minimising the possibility to measure sexual rights' fulfilment in this group. This study aims to describe to what extent sexual rights of young migrants in Sweden are being fulfilled. METHODS: A self-administered questionnaire was used to collect data from 1773 young (16-29 years) migrants by post, online, and at language schools and other venues. Sexual rights were operationalised and categorised into five domains adapted from the Guttmacher-Lancet Commission's definition. These domains included the right to: 1) access sexual and reproductive healthcare, 2) access information and education about sexuality and sexual and reproductive health and rights, 3) have bodily integrity, 4) make free informed decisions about sexuality and sexual relations and 5) have a satisfying and safe sexual life. Descriptive analysis was used to assess the extent of fulfilment for each right. RESULTS: There were wide variations in the fulfilment of sexual rights between subgroups and among the five domains. Most respondents rated their sexual health as good/fair, however, 6.3% rated their sexual health as bad/very bad. While most of those who visited related services were satisfied, 17.4% of respondents refrained from visiting the services despite their needs. Around four in ten respondents did not know where to get information about sexuality and sexual health. One-fourth of respondents reported sexual violence. Another 12.7% were limited by family members or fellow countrymen regarding with whom they can have an intimate relationship. Most respondents were satisfied with their sexual life, except for 11.9%. Men, non-binary respondents, lesbians, gays, bisexuals, asexuals, those who were awaiting a decision regarding residence permit and those born in South Asia reported poor sexual health to a greater extent and fulfilment of their sexual rights to a lesser extent than other groups. CONCLUSIONS: Timely and culturally adapted information about sexual rights, gender equalities, laws and available services in Sweden should be provided in appropriate languages and formats in order to raise awareness about sexual rights and improve access to available services. Tailored attention should be paid to specific vulnerable subgroups.

Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania.

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.

Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden.

BACKGROUND: Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach. METHODS: Data on participants (N = 22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization. RESULTS: Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56-6.19), but with no significant horizontal inequity - by gender, education, or their combination - remaining after needs adjustment. CONCLUSION: This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study.

BACKGROUND: Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population. METHODS: A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors. RESULTS: A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (- 1; 95% CI: - 1.45, - 0.45) and inpatient (- 2; 95% CI: - 2.69, - 1.30) care. CONCLUSION: The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

Income inequalities in leisure time physical inactivity in northern Sweden: A decomposition analysis.

Aims: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden. Methods: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis. Results: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance. Conclusions: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

Rural-urban differences in suicide attempts and mortality among young people in northern Sweden, 1998-2017: A register-based study.

Aim: The aim of this study was to assess trends in suicide attempts and mortality between 1998 and 2017 by residential area and gender among northern Swedish youths. Methods: Events of suicide attempts and deaths for each municipality in the four counties of the northern Swedish region, stratified by gender, were retrieved for each year from 1998 to 2017. All cases identified within the registers with the diagnostic codes X60-X84 or Y10-Y34 (International Classification of Diseases, 10th revision) for individuals aged 15-24 years were included. Place of residence at municipal level was categorized into three groups: rural - municipalities with a population of <10,000 inhabitants; semi-rural - those between 10,000 and 50,000; and urban - those with >50,000 inhabitants. Results: The rates of attempted suicides in the northern region were higher in both men and women than in Sweden, while the rates of suicide deaths were slightly higher in young men but similar in young women compared to the national averages. Overall, the risk of suicide attempts was higher in semi-rural municipalities compared to urban ones, particularly among women. A significantly higher risk of mortality was also observed for men and women in semi-rural municipalities, but only in the period 2010-2013. Conclusions: The high rates of attempted and completed suicides among youth in northern Sweden and the higher risks in rural and semi-rural municipalities need close attention. The implementation of suicide prevention programs, especially in rural and semi-rural municipalities, should be intensified.