The transmission of social inequalities through economic difficulties and lifestyle factors on body mass index: An intersectional mediation analysis in the Swedish population.

Body mass index (BMI) has increased in Sweden, disproportionally for socially disadvantaged groups, including women, low-educated, and immigrants, who may also face economic constraints, physical inactivity, and poor-quality diets. Intersectional public health research aims to unravel such complex social inequalities, but the intersectional transmission of inequalities to BMI remains unexplored. We aimed to examine intersectional inequalities in BMI mediated by economic strain and health-related lifestyle in the Swedish population. By using the Health on Equal Terms cross-sectional surveys in 2016, 2018, 2020, and 2021 (n = 44,177 inhabitants aged 25 and over), we performed an intersectional mediation analysis to analyze how inequalities across social intersectional strata (by gender, education, and migration status) may be transmitted through economic strain and unhealthy lifestyle (physical inactivity or inadequate fruit/vegetables consumption) to BMI. Our findings showed a sequential transmission that indicates the fact that socially disadvantaged strata (compared with high-educated native men) experienced more economic strain, which in turn led to poorer health-related lifestyles and ultimately to a higher BMI. We also found that certain intersectional strata, such as high-educated women, were more vulnerable to economic strain, despite having lower BMI than high-educated native men. Additionally, the highest BMI and unhealthy lifestyle risk was observed among low- and middle-educated men. In conclusion, not only inequalities in BMI, but also the economic and behavioral pathways underpinning the inequalities, act by intersectional patterns. Public health interventions should provide economic security, particularly for women and migrant population as well as promoting a healthy lifestyle in lower-educated strata, especially among men, to achieve healthy BMI levels.

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.

Did the COVID-19 quarantine policies applied in Cochabamba, Bolivia mitigated cases successfully? an interrupted time series analysis.

BACKGROUND: The COVID-19 pandemic prompted varied policy responses globally, with Latin America facing unique challenges. A detailed examination of these policies' impacts on health systems is crucial, particularly in Bolivia, where information about policy implementation and outcomes is limited. OBJECTIVE: To describe the COVID-19 testing trends and evaluate the effects of quarantine measures on these trends in Cochabamba, Bolivia. METHODS: Utilizing COVID-19 testing data from the Cochabamba Department Health Service for the 2020-2022 period. Stratified testing rates in the health system sectors were first estimated followed by an interrupted time series analysis using a quasi-Poisson regression model for assessing the quarantine effects on the mitigation of cases during surge periods. RESULTS: The public sector reported the larger percentage of tests (65%), followed by the private sector (23%) with almost double as many tests as the public-social security sector (11%). In the time series analysis, a correlation between the implementation of quarantine policies and a decrease in the slope of positive rates of COVID-19 cases was observed compared to periods without or with reduced quarantine policies. CONCLUSION: This research underscores the local health system disparities and the effectiveness of stringent quarantine measures in curbing COVID-19 transmission in the Cochabamba region. The findings stress the importance of the measures' intensity and duration, providing valuable lessons for Bolivia and beyond. As the global community learns from the pandemic, these insights are critical for shaping resilient and effective health policy responses.

Main findings: The findings highlight the importance of stringent quarantine measures in managing infectious disease outbreaks, offering valuable insights for policymakers worldwide in strategizing effective public health interventions.Added knowledge: By providing a detailed analysis of testing disparities and quarantine policies' effectiveness within a specific Latin American context, our research fills a critical gap in understanding their impacts on health system responses and disease control.Global health impact for policy and action: The findings highlight the importance of stringent quarantine measures in managing infectious disease outbreaks, offering valuable insights for policymakers worldwide in strategizing effective public health interventions.

Sámi community perspectives on the COVID-19 pandemic: a mixed methods case study in Arctic Sweden.

The COVID-19 pandemic posed a grave threat not only to Indigenous people's health and well-being, but also to Indigenous communities and societies. This applies also to the Indigenous peoples of the Arctic, where unintentional effects of public health actions to mitigate the spread of virus may have long-lasting effects on vulnerable communities. This study aim was to identify and describe Sámi perspectives on how the Sámi society in Sweden was specifically affected by the pandemic and associated public health actions during 2020-2021. A mixed-method qualitative case study approach was employed, including a media scoping review and stakeholder interviews. The media scoping review included 93 articles, published online or in print, from January 2020 to 1 September 2021, in Swedish or Norwegian, regarding the pandemic-related impacts on Sámi society in Sweden. The review informed a purposeful selection of 15 stakeholder qualitative interviews. Thematic analysis of the articles and interview transcripts generated five subthemes and two main themes: "weathering the storm" and "stressing Sámi culture and society". These reflect social dynamics which highlight stressors towards, and resilience within, the Sámi society during the pandemic. The results may be useful when evaluating and developing public health crisis response plans concerning or affecting the Sámi society in Sweden.

Prevalence and social determinants of smoking among men in Mauritius: a cross-sectional study.

BACKGROUND: Mauritius has implemented a range of stringent policies to control smoking and promote public health. Regular monitoring focuses on the prevalence of tobacco use, yet there is a gap in understanding its socio-economic patterns. OBJECTIVE: The aim of this study was to estimate the prevalence of tobacco smoking and to identify the social determinants associated with smoking among men in Mauritius in 2021. METHODS: This is a cross-sectional population-based study conducted by the Ministry of Health and Wellness during 2021. In total, 3622 individuals participated (response rate of 84.1%), of which 1663 were men (45.9%). The study mainly focused on men given the low prevalence of smoking among women. Daily smoking was the outcome and a series of sociodemographic and socioeconomic factors were included as independent variables. Prevalence ratios (PR) and their 95% confidence intervals (95% CI) were estimated to fulfill the study objective. RESULTS: The prevalence of smoking among men was 30.4%. People in the 25-34 age group (PR = 1.65; 95% CI: 1.12-2.41), those separated, divorced or widowed (PR = 1.57; 95% CI: 1.16-2.11), the ethnic groups Muslim-Mauritians (PR = 1.70; 95% CI: 1.00-2.89) and Creoles (PR = 1.97; 95% CI: 1.16-3.35), and those with secondary (PR = 1.29; 95% CI: 1.00-1.67) and primary education (PR = 1.47; 95% CI: 1.10-1.98) were statistically significantly associated with daily smoking. CONCLUSIONS: Although a gradual decline in smoking prevalence was observed compared with the previous 2015 survey, the Ministry of Health and Wellness should persist in fortifying its anti-smoking measures and concentrate on crafting tailored interventions aimed at the vulnerable groups identified in this study.

Main findings: This study found a prevalence of smoking of 30.4% among men in Mauritius, identifying the young population, those not married, the Muslim-Mauritians and Creole ethnic groups and those with secondary and primary education as at-risk groups for smoking.Added knowledge: The study provides updated information on the prevalence of smoking and its distribution among different socioeconomic groups in Mauritius.Global health impact for policy and action: The anti-smoking policies implemented by the Ministry of Health and Wellness should continue to be strengthened, and specific interventions for the identified at-risk groups be developed. This can serve as a model for other countries with similar socio-economic profiles, aiming to reduce smoking consumption.

Diverse methodological approaches to a Circumpolar multi-site case study which upholds and responds to local and Indigenous community research processes in the Arctic.

This paper outlines the methodological approaches to a multi-site Circumpolar case study exploring the impacts of COVID-19 on Indigenous and remote communities in 7 of 8 Arctic countries. Researchers involved with the project implemented a three-phase multi-site case study to assess the positive and negative societal outcomes associated with the COVID-19 pandemic in Arctic communities from 2020 to 2023. The goal of the multi-site case study was to identify community-driven models and evidence-based promising practices and recommendations that can help inform cohesive and coordinated public health responses and protocols related to future public health emergencies in the Arctic. Research sites included a minimum of 1 one community each from Canada (Nunavut,) United States of America (Alaska), Greenland, Iceland, Norway, Sweden, Finland. The approaches used for our multi-site case study provide a comprehensive, evidence-based account of the complex health challenges facing Arctic communities, offering insights into the effectiveness of interventions, while also privileging Indigenous local knowledge and voices. The mixed method multi-site case study approach enriched the understanding of unique regional health disparities and strengths during the pandemic. These methodological approaches serve as a valuable resource for policymakers, researchers, and healthcare professionals, informing future strategies and interventions.

Diversity and prevalence of zoonotic infections at the animal-human interface of primate trafficking in Peru.

Wildlife trafficking creates favorable scenarios for intra- and inter-specific interactions that can lead to parasite spread and disease emergence. Among the fauna affected by this activity, primates are relevant due to their potential to acquire and share zoonoses - infections caused by parasites that can spread between humans and other animals. Though it is known that most primate parasites can affect multiple hosts and that many are zoonotic, comparative studies across different contexts for animal-human interactions are scarce. We conducted a multi-parasite screening targeting the detection of zoonotic infections in wild-caught monkeys in nine Peruvian cities across three contexts: captivity (zoos and rescue centers, n = 187); pet (households, n = 69); and trade (trafficked or recently confiscated, n = 132). We detected 32 parasite taxa including mycobacteria, simian foamyvirus, bacteria, helminths, and protozoa. Monkeys in the trade context had the highest prevalence of hemoparasites (including Plasmodium malariae/brasilianum, Trypanosoma cruzi, and microfilaria) and enteric helminths and protozoa were less common in pet monkeys. However, parasite communities showed overall low variation between the three contexts. Parasite richness (PR) was best explained by host genus and the city where the animal was sampled. Squirrel (genus Saimiri) and wooly (genus Lagothrix) monkeys had the highest PR, which was ~2.2 times the PR found in tufted capuchins (genus Sapajus) and tamarins (genus Saguinus/Leontocebus) in a multivariable model adjusted for context, sex, and age. Our findings illustrate that the threats of wildlife trafficking to One Health encompass exposure to multiple zoonotic parasites well-known to cause disease in humans, monkeys, and other species. We demonstrate these threats continue beyond the markets where wildlife is initially sold; monkeys trafficked for the pet market remain a reservoir for and contribute to the translocation of zoonotic parasites to households and other captive facilities where contact with humans is frequent. Our results have practical applications for the healthcare of rescued monkeys and call for urgent action against wildlife trafficking and ownership of monkeys as pets.

Embodiment of discrimination: a cross-sectional study of threats, humiliating treatment and ethnic discrimination in relation to somatic health complaints among Sámi in Sweden.

BACKGROUND: Ethnic discrimination is acknowledged as a social determinant of health for Indigenous populations worldwide. This study aimed to investigate embodiment of perceived ethnic discrimination among the Sámi population in Sweden. METHODS: A population-based health study was conducted among the Sámi population aged 18-84 years in 2021. Perceived discrimination was assessed by three variables: exposure to threat, humiliation treatment and ethnic discrimination. To capture current physical health, complaints of headache, back pain, stomach pain, sleeping problems, dizziness and tiredness were used. An overall somatic complaints score was created by summing up the six individual symptoms. The magnitude of the association between the independent variables and the outcomes was summarised with the ß coefficients and prevalence ratios using 95% credible intervals (95% CrI) for inferential purposes. RESULTS: Overall, 4.3% reported to have been exposed to threat, 26.1% to humiliation and 11.2% and 32.3% to ethnic discrimination in the last 12 months and beyond 12 months, respectively. After mutual adjustment, threat (ß=1.25; 95% CrI=0.88 to 1.60), humiliation (ß=1.29; 95% CrI: 1.14 to 1.44) and the two categories of discrimination (ß=0.92; 95% CI: 0.64 to 1.21 in the last 12 months and ß=0.68; 95% CI: 0.54 to 0.83 beyond) remained significantly associated to the overall somatic complaints score. Similar results were found for individual complaints. CONCLUSIONS: This study has shown a strong relationship between different expressions of perceived ethnic discrimination and a series of somatic complaints among the Sámi in Sweden. Efforts to alleviate interpersonal and institutional discrimination against the Sámi would contribute to improve their health.

A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population.

Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

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.

Public health restrictions, directives, and measures in Arctic countries in the first year of the COVID-19 pandemic.

Beginning January of 2020, COVID-19 cases detected in Arctic countries triggered government policy responses to stop transmission and limit caseloads beneath levels that would overwhelm existing healthcare systems. This review details the various restrictions, health mandates, and transmission mitigation strategies imposed by governments in eight Arctic countries (the United States, Canada, Greenland, Norway, Finland, Sweden, Iceland, and Russia) during the first year of the COVID-19 pandemic, through 31 January 2021s31 January 2021. We highlight formal protocols and informal initiatives adopted by local communities in each country, beyond what was mandated by regional or national governments. This review documents travel restrictions, communications, testing strategies, and use of health technology to track and monitor COVID-19 cases. We provide geographical and sociocultural background and draw on local media and communications to contextualise the impact of COVID-19 emergence and prevention measures in Indigenous communities in the Arctic. Countries saw varied case rates associated with local protocols, governance, and population. Still, almost all regions maintained low COVID-19 case rates until November of 2020. This review was produced as part of an international collaboration to identify community-driven, evidence-based promising practices and recommendations to inform pan-Arctic collaboration and decision making in public health during global emergencies.

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.

Social determinants of self-reported oral health among Sámi in Sweden.

OBJECTIVES: To investigate the prevalence of poor self-reported oral health and to identify socio-demographic, socio-economic and cultural-related risk factors associated with poor oral health among Sámi in Sweden. METHODS: A Sámi sample frame was constructed drawing from three pre-existing registers. All identified persons aged 18-84 were invited to participate in the study during February-May 2021. Among the 9249 invitations, 3779 answered the survey. The frequencies of the independent variables in terms of socio-economic, socio-demographic and cultural-related factors as well as the outcome, self-reported oral health, were calculated first. Prevalence ratios (PRs) and their 95% confidence interval (95% CI) were estimated to assess the relationship between the independent variables and the outcome. RESULTS: Overall, 32.5% of the participants reported a poor oral health with a higher prevalence among men compared to women. Among the socio-demographic factors, being old (PR: 1.99; 95% CI: 1.59-2.51), unmarried (PR: 1.17; 95% CI: 1.03-1.33) and divorced or widow-er (PR: 1.27; 95% CI: 1.09-1.46) were statistically associated to poor self-reported oral health. Among the socio-economic factors, a low education level (PR: 1.56; 95% CI: 1.29-1.89), belonging to the poorest quintile (PR: 1.63; 95% CI: 1.35-1.96), and experiencing difficulties to make ends meet several times during the last 12 months (PR: 1.74; 95% CI: 1.51-1.99) were statistically significant related to poor oral health. CONCLUSIONS: The self-reported oral health among Sámi in Sweden appears to be worse than that of the general Swedish population. Several socio-economic and socio-demographic factors were found to be strongly associated with poor self-reported oral health. Targeted interventions addressing these social determinants are needed to reduce inequalities in oral health among the Sámi population.

Role of health facility governing committees in strengthening social accountability to improve the health system in Tanzania: protocol for a participatory action research study.

INTRODUCTION: Social accountability is important for improving the delivery of health services and empowering citizens. The government of Tanzania has transferred authority to plan, budget and manage financial resources to the lower health facilities since 2017. Health facility governing committees (HFGCs) therefore play a pivotal role in ensuring social accountability. While HFGCs serve as bridges between health facilities and their communities, efforts need to be made to reinforce their capacity. This project therefore aims to understand whether, how and under what conditions informed and competent HFGCs improve social accountability. METHODS AND ANALYSIS: This study adopts a participatory approach to realist evaluation, engaging members of the HFGCs, health managers and providers and community leaders to: (1) map the challenges and opportunities of the current reform, (2) develop an initial programme theory that proposes a plan to strengthen the role of the HFGCs, (3) test the programme theory by developing a plan of action, (4) refine the programme theory through multiple cycles of participatory learning and (5) propose a set of recommendations to guide processes to strengthen social accountability in the Tanzanian health system. This project is part of an ongoing strong collaboration between the University of Dar es Saalam (Tanzania), and Umeå University (Sweden), providing opportunities for action learning and close interactions between researchers, decision-makers and practitioners. ETHICS AND DISSEMINATION: Ethical approval to conduct the study was obtained from the National Ethical Review Committee in Tanzania- National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/3928). Permissions to conduct the study in the health facilities were given by the President's Office Regional Administration and Local Government and relevant regional and district authorities. The results will be published in open-access, peer-reviewed journals and presented at scientific conferences.

"Overcrowded but lonely": exploring mental health and well-being among young prisoners in Cambodia.

PURPOSE: Young prisoners are one of the most vulnerable groups in society for mental health problems and ill-being. Therefore, there is a crucial need to understand their physical, psychological and social situations. This study aims to explore young Cambodian prisoners' experiences and perceptions of mental health and well-being, their determinants and their coping strategies. DESIGN/METHODOLOGY/APPROACH: Six focus group discussions were carried out in three prisons with a total of 48 young prisoners between the ages of 15 and 24 years (50% women, 50% men). Semi-structured questions guided the discussions, and thematic analysis was applied to analyse the data. FINDINGS: Young prisoners reported multifaceted experiences of mental health and well-being. The majority described adverse mental health experiences, while some revealed better well-being, partly influenced by the socio-economic support from outside the prisons and previous involvement or not in drug abuse. The experience of physical overcrowding without emotional attachment among the fellow prisoners was perceived as the overarching determinant of loneliness and mental health problems, while socio-emotional support and rituals were described as the most important coping mechanisms. ORIGINALITY/VALUE: This pioneering study from Cambodia gives young prisoners an opportunity to voice their experiences and perceptions of mental health and well-being in the prison setting. The findings in this study underline the importance of prison authorities tackling overcrowding to promote well-being and reduce mental health problems. Also, the coping mechanisms outlined by the participants should be considered when planning psychosocial interventions.

Prevalence and factors associated with healthcare avoidance during the COVID-19 pandemic among the Sámi in Sweden: the SámiHET study.

The aim of this population-based cross-sectional study was to assess the prevalence of healthcare avoidance during the COVID-19 pandemic and its associated factors among the Sámi population in Sweden. Data from the "Sámi Health on Equal Terms" (SámiHET) survey conducted in 2021 were used. Overall, 3,658 individuals constituted the analytical sample. Analysis was framed using the social determinants of health framework. The association between healthcare avoidance and several sociodemographic, material, and cultural factors was explored through log-binomial regression analyses. Sampling weights were applied in all analyses. Thirty percent of the Sámi in Sweden avoided healthcare during the COVID-19 pandemic. Sámi women (PR: 1.52, 95% CI: 1.36-1.70), young adults (PR: 1.22, 95% CI:1.05-1.47), Sámi living outside Sápmi (PR: 1.17, 95% CI: 1.03-1.34), and those having low income (PR: 1.42, 95% CI:1.19-1.68) and experiencing economic stress (PR: 1.48, 95% CI: 1.31-1.67) had a higher prevalence of healthcare avoidance. The pattern shown in this study can be useful for planning future pandemic responses, which should address healthcare avoidance, particularly among the identified vulnerable groups, including the active participation of the Sámi themselves.

The role of principled engagement in public health policymaking: the case of Zambia's prolonged efforts to develop a comprehensive tobacco control policy.

BACKGROUND: The Framework Convention on Tobacco Control (FCTC) requires countries to develop and implement multi-sectoral tobacco control strategies, including policies and legislation. Zambia, potentially faced by a rising problem of tobacco smoking, signed the FCTC in 2008 but has been unable to enact a tobacco policy for over a decade. OBJECTIVE: This study explores the role of 'principled engagement', a key element of the theoretical framework for collaborative governance, in Zambia's delayed success to develop a comprehensive tobacco control policy. METHODS: This was a qualitative case study of key stakeholders in the collaborative process of trying to develop a tobacco policy in Zambia. Participan-ts were sampled from across various sectors, including government departments and civil society, comprising anti-tobacco activists and researchers. A total of 27 key informant interviews were undertaken. We supplemented the interview data with a document review of relevant policies and legislation. Data were analysed using thematic analysis. RESULTS: Several factors hindered efforts to attain principled engagement, including the adverse legal and socioeconomic environment in which the collaborative regime evolves; poor planning of meetings and frequent changes in tobacco focal point persons; lack of active and meaningful participation; and communication challenges among the key stakeholders. These collaborative dynamics, coupled with the opposition to tobacco control efforts from within some government departments, revealed the inadequacy of the current collaborative governance regime to facilitate enactment of a comprehensive tobacco control policy in Zambia. CONCLUSION: Efforts to develop a comprehensive tobacco control policy in Zambia will require addressing challenges such as disagreements, communication, and leadership at engagement level across interested sectors. We further argue that principled engagement has a greater role to play in unlocking these efforts and should therefore be embraced by those entrusted to lead the process to develop tobacco policy in Zambia.

Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys.

BACKGROUND: Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed. OBJECTIVE: The present study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique. METHODS: The study was based on repeated cross-sectional surveys from nationally representative samples: the Survey of Indicators on Immunisation, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015 and the 2018 Malaria Indicator survey. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage of three indicators: insecticide-treated net use, fever treatment of children, and use of Fansidar malaria prophylaxis for pregnant women. Absolute risk differences and the slope index of inequality (SII) were calculated for the 2015 survey period and the 2018 survey period, respectively. An interaction term between the socioeconomic and geographical variables and the period was included to assess inequality changes between 2015 and 2018. RESULTS: The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. Significant reductions in the inequality related to insecticide-treated net use were observed for all socioeconomic variables. Concerning fever treatment, some reductions in socioeconomic inequalities were observed, though not statistically significant. For malaria prophylaxis, the SII was significant for education, wealth, and residence in both periods, but no significant inequality reductions were observed in any of these variables over time. CONCLUSIONS: We observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. Decision-makers should target underserved populations, specifically the non-educated, poor, and rural women, to address inequalities in health care coverage.

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.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study.

BACKGROUND: Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania. METHODS: An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data. RESULTS: Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement. CONCLUSION: While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.