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Abstract
General practitioners (GPs) often meet patients with medically unexplained symptoms (MUS). From a patient perspective, MUS is a well-acknowledged problem within the primary health care services today, but less is known about the GPs’ perceptions. This study aims to elucidate GPs’ perceptions of patients with MUS, focusing on stressing situations, emotional reactions and coping strategies. Twenty-seven physicians participated in focus-group discussions. In the analysis, where a phenomenographic approach was used, six situations were identified as being especially stressful in the encounter with these patients. The GPs described how they used both problem-focused and emotion-focused strategies, but with emotion-focused strategies slightly dominating, indicating that the GPs had difficulties in managing their own stress when working with patients with MUS.
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Umubyeyi A, Persson M, Mogren I, Krantz G. Gender Inequality Prevents Abused Women from Seeking Care Despite Protection Given in Gender-Based Violence Legislation: A Qualitative Study from Rwanda. PLoS One 2016; 11:e0154540. [PMID: 27152680 PMCID: PMC4859471 DOI: 10.1371/journal.pone.0154540] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/25/2016] [Indexed: 11/19/2022] Open
Abstract
Objective Despite its burden on a person’s life, Intimate Partner Violence (IPV) is known to be poorly recognised and managed in most countries and communities. This study aimed to explore health care professionals’ experiences of the health care seeking processes of women exposed to intimate partner violence in Rwanda. Methods Six focus group discussions were conducted in three district hospitals and three mental health units in Rwanda. A sample of 43 health care professionals with various professions and length of work experience, who regularly took care of patients subjected to IPV, was selected for focus group discussions. The analysis was performed using qualitative content analysis. Results The theme “Gendered norms and values defeat the violence legislation in women’s health care seeking when women are abused” expressed the health care professionals’ experiences of the double-faced situation which women exposed to IPV met in their help seeking process. Positive initiatives to protect women were identified, but the potential for abused women to seek help and support was reduced because of poverty, gender inequality with prevailing strong norms of male superiority, and the tendency to keep abuse as a private family matter. Conclusion Legislative measures have been instituted to protect women from abuse. Still many Rwandan women do not benefit from these efforts. The role of the health care services needs to be reinforced as an important and available resource for help and support for abused women but further legislative changes are also needed. Initiatives to further improve gender equality, and institutionalised collaboration between different sectors in society would contribute to protecting women from IPV.
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Umubyeyi A, Mogren I, Ntaganira J, Krantz G. Help-seeking behaviours, barriers to care and self-efficacy for seeking mental health care: a population-based study in Rwanda. Soc Psychiatry Psychiatr Epidemiol 2016; 51:81-92. [PMID: 26433379 PMCID: PMC4720720 DOI: 10.1007/s00127-015-1130-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/22/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Mental disorders commonly affect young people but usually go unrecognized and untreated. This study aimed to investigate help-seeking behaviours, barriers to care and self-efficacy for seeking mental health care among young adults with current depression and/or suicidality in a low-income setting. METHODS This cross-sectional study used two sub-populations: a sub-sample of those suffering from current depression and/or suicidality (n = 247) and another of those not suffering from these conditions and not suffering from any other mental condition investigated (n = 502). Help-seeking behaviours, barriers to care and self-efficacy for mental health care seeking were measured among those suffering from current depression and/or suicidality (n, %). Logistic regression was used to identify risk factors for experiencing barriers to care. Self-efficacy for seeking mental health care was compared between men and women in the two sub-populations. RESULTS Of the 247 men and women with current depression and/or suicidality, 36.0 % sought help at a health care unit and 64.0 % from trusted people in the community. Only six people received help from a mental health professional. The identified barriers were mainly related to accessibility and acceptability of health services. For the population suffering from current depression and/or suicidality, the self-efficacy scale for seeking mental health care suggested a low confidence in accessing mental health care but a high confidence in respondents' ability to successfully communicate with health care staff and to cope with consequences of seeking care. CONCLUSION The current study clearly highlights young adults' poor access to mental health care services. To reach universal health coverage, substantial resources need to be allocated to mental health, coupled with initiatives to improve mental health literacy in the general population.
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Rugema L, Krantz G, Mogren I, Ntaganira J, Persson M. "A constant struggle to receive mental health care": health care professionals' acquired experience of barriers to mental health care services in Rwanda. BMC Psychiatry 2015; 15:314. [PMID: 26672596 PMCID: PMC4682265 DOI: 10.1186/s12888-015-0699-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 12/14/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In Rwanda, many people are still mentally affected by the consequences of the genocide and yet mental health care facilities are scarce. While available literature explains the prevalence and consequences of mental disorders, there is lack of knowledge from low-income countries on health care seeking behavior due to common mental disorders. Therefore, this study sought to explore health care professionals' acquired experiences of barriers and facilitators that people with common mental disorders face when seeking mental health care services in Rwanda. METHODS A qualitative approach was applied and data was collected from six focus group discussions (FGDs) conducted in October 2012, including a total of 43 health care professionals, men and women in different health professions. The FGDs were performed at health facilities at different care levels. Data was analyzed using manifest and latent content analysis. RESULTS The emerging theme "A constant struggle to receive mental health care for mental disorders" embraced a number of barriers and few facilitators at individual, family, community and structural levels that people faced when seeking mental health care services. Identified barriers people needed to overcome were: Poverty and lack of family support, Fear of stigmatization, Poor community awareness of mental disorders, Societal beliefs in traditional healers and prayers, Scarce resources in mental health care and Gender imbalance in care seeking behavior. The few facilitators to receive mental health care were: Collaboration between authorities and organizations in mental health and having a Family with awareness of mental disorders and health insurance. CONCLUSION From a public health perspective, this study revealed important findings of the numerous barriers and the few facilitating factors available to people seeking health for mental disorders. Having a supportive family with awareness of mental disorders who also were equipped with a health insurance was perceived as vital for successful treatment. This study highlights the need of improving availability, accessibility, acceptability and quality of mental health care at all levels in order to improve mental health care among Rwandans affected by mental disorders.
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Osika Friberg I, Krantz G, Määttä S, Järbrink K. Sex differences in health care consumption in Sweden: A register-based cross-sectional study. Scand J Public Health 2015; 44:264-73. [DOI: 10.1177/1403494815618843] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2015] [Indexed: 11/15/2022]
Abstract
Background: Generally, health care consumption, especially primary care, is greater among women than men. The extent to which this sex difference is explained by reproduction and sex-specific morbidity is unclear. Methods: We examined age- and sex-specific health care service utilization and costs in the western region of Sweden. Data were retrieved from a regional health care database of information on total health care consumption in the population. Use of health care resources was divided into the following diagnosis categories: health care associated with reproduction; health care received for sex-specific morbidity; and health care provided for all other conditions. Results: Total per capita cost for health care was 20% higher for women than for men. When adjusted for reproduction and sex-specific morbidity, the cost-difference decreased to 8%. The remaining cost-difference could be explained by women’s substantially higher costs for mental and behavioral disorders and diseases of the musculoskeletal system. Women were more likely to receive more accessible, less expensive primary care, while men were more likely to receive specialist inpatient care. Conclusions: The substantially greater use of reproduction-associated care among women, which largely occurs within primary care, might make it easier to also seek health care for other reasons. Efforts to eliminate barriers that prevent men from investing in their health and seeking primary care could reduce future morbidity and costs for specialist care. More studies and appropriate actions are needed to determine why women are overrepresented in mental, behavioral and musculoskeletal disorders.
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Ehn S, Agardh A, Holmer H, Krantz G, Hagander L. Global health education in Swedish medical schools. Scand J Public Health 2015; 43:687-93. [PMID: 26142351 DOI: 10.1177/1403494815591720] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2015] [Indexed: 11/16/2022]
Abstract
AIMS Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students' perceived needs for such education. METHODS Data on global health education were collected from all medical faculties in Sweden for the years 2000-2013. In addition, 76% (439/577) of all Swedish medical students in their final semester answered a structured questionnaire. RESULTS Global health education is offered at four of Sweden's seven medical schools, and most medical students have had no global health education. Medical students in their final semester consider themselves to lack knowledge and skills in areas such as the global burden of disease (51%), social determinants of health (52%), culture and health (60%), climate and health (62%), health promotion and disease prevention (66%), strategies for equal access to health care (69%) and global health care systems (72%). A significant association was found between self-assessed competence and the amount of global health education received (p<0.001). A majority of Swedish medical students (83%) wished to have more global health education added to the curriculum. CONCLUSIONS Most Swedish medical students have had no global health education as part of their medical school curriculum. Expanded education in global health is sought after by medical students and could strengthen the professional development of future medical doctors in a wide range of topics important for practitioners in the global world of the twenty-first century.
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Rugema L, Mogren I, Ntaganira J, Krantz G. Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide. BMJ Open 2015; 5:e006778. [PMID: 26109109 PMCID: PMC4480039 DOI: 10.1136/bmjopen-2014-006778] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To investigate mental health effects associated with exposure to trauma in Rwanda during the 1994 genocide period, and over the lifetime, in Rwandan men and women aged 20-35 years. SETTING This was a cross-sectional population-based study conducted in the southern province of Rwanda. Data was collected during December 2011 to January 2012. PARTICIPANTS A total population of 917 individuals were included, 440 (48%) men and 477 (52%) women aged 20-35 years. Number of households for inclusion in each village was selected proportional to the total number of households in each selected village. The response rate was 99.8%. Face-to-face interviewing was done by experienced and trained clinical psychologists, following a structured questionnaire. RESULTS Women were slightly less exposed during the genocide period (women 35.4% and men 37.5%; p=0.537), but more women than men were exposed to traumatic episodes over their lifetime (women 83.6%, n=399; men 73.4%, n=323; p<0.001). Current major depressive episodes (MDE) were twice as prevalent in women as in men. Traumatic episodes experienced in the genocide period severely affected men's current mental health status with relative risk (RR) 3.02 (95% CI 1.59 to 5.37) for MDE past and with RR 2.15 (95% CI 1.21 to 3.64) for suicidality. Women's mental health was also affected by trauma experienced in the genocide period but to an even higher extent, by similar trauma experienced in the lifetime with RR 1.91 (95% CI 1.03 to 3.22) for suicidality and RR 1.90 (95% CI 1.34 to 2.42) for generalised anxiety disorder, taking spousal physical/sexual violence into consideration. CONCLUSIONS Depression, post-traumatic stress disorder, anxiety and suicidal attempts are prevalent in Rwanda, with rates twice as high in women compared with men. For women, exposure to physical and sexual abuse was independently associated with all these disorders. Early detection of gender-based violence through homes and community interventions is important.
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Umubyeyi A, Mogren I, Ntaganira J, Krantz G. Intimate partner violence and its contribution to mental disorders in men and women in the post genocide Rwanda: findings from a population based study. BMC Psychiatry 2014; 14:315. [PMID: 25406929 PMCID: PMC4245842 DOI: 10.1186/s12888-014-0315-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 10/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low income countries, mental disorders are a neglected health problem. Mental disorders are influenced by a number of factors in people's everyday life of which intimate partner violence (IPV) commonly form an important part. The aim of this study was to investigate the prevalence of mental disorders in young men and women in Rwanda and their risk factors with main emphasis on IPV and its contribution to mental disorders, taking into account the genocide context. METHODS This population-based study included a representative sample of 917 men and women aged 20-35 years. The prevalence of mental disorders was investigated using of a diagnostic tool, the "MINI: Mini International Neuropsychiatric Interview". Risk factor patterns were analysed with bi- and multivariate logistic regression. To find the proportion of mental disorders attributed to IPV, the population attributable fraction was computed. RESULTS The prevalence rates of current depression, suicide risk and PTSD were more than two times higher in women than in men while for generalized anxiety disorder, the prevalence was about the same. Physical, sexual and psychological intimate partner violence exposure was highly associated with all forms of mental disorders for women. For physical violence, after adjusting for socio-demographic factors and exposure to traumatic episodes during the Rwandan genocide, the risk of current depression for women was elevated four times. Even though few men reported partner violence exposure, physical violence in the past year was found to be a statistically significant risk factor for current depression and for generalized anxiety disorder. However, having an experience of traumatic episodes during the genocide contributed to the risk of most of mental disorders investigated for men. CONCLUSION In Rwanda, IPV contributed considerably to mental disorders investigated. Thus, prevention of IPV should be considered as a public health priority, as its prevention would considerably reduce the prevalence of mental disorders.
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Umubyeyi A, Mogren I, Ntaganira J, Krantz G. The contribution of intimate partner violence to mental disorders in young men and women in Rwanda, a population based study from December 2011 to January 2012. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku165.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Rugema L, Mogren I, Ntaganira J, Krantz G. Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide. - In the southern province of Rwanda December 2011 to January 2012. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku161.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Umubyeyi A, Mogren I, Ntaganira J, Krantz G. Women are considerably more exposed to intimate partner violence than men in Rwanda: results from a population-based, cross-sectional study. BMC WOMENS HEALTH 2014; 14:99. [PMID: 25155576 PMCID: PMC4148406 DOI: 10.1186/1472-6874-14-99] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 08/15/2014] [Indexed: 11/22/2022]
Abstract
Background Intimate partner violence (IPV) against women is an important, yet often neglected public health issue. The existence of gender norms imbalance expressed by men’s and women’s attitudes in relation to power and decision-making in intimate relationships may influence the magnitude of IPV. The aim of this study was to investigate the prevalence and potential risk factors of physical, sexual and psychological IPV in young men and women in Rwanda. Methods This population-based, cross-sectional study included a representative sample of men and women from the Southern Province of Rwanda. Face-to-face interviews were performed using the World Health Organization (WHO) questionnaire for violence exposure to estimate past year and earlier in life IPV occurrence. Risk factor patterns were analyzed by use of bi- and multivariate logistic regression. Results Women were, to a considerably higher extent, exposed to physical, sexual and psychological IPV than men. Of the women, 18.8% (n = 78) reported physical abuse in the past year, compared to 4.3% (n = 18) of men. The corresponding figures for women and men for sexual abuse were 17.4% (n = 71) and 1.5% (n = 6), respectively, and for psychological abuse, the corresponding figures were 21.4% (n = 92) and 7.3% (n = 32). Findings illustrate that violence against women was recurrent, as the highest frequency (>3 times) dominated in women for the various acts of all forms of violence. Identified risk factors for women’s exposure to physical violence were being low educated, having poor social support, being poor and having many children. For men exposed to physical violence, no statistically significant risk factor was identified. Conclusions In this setting, IPV exposure was more common in women than men in the Southern Province of Rwanda. Promotion of gender equality at the individual level is needed to make a positive difference in a relatively short term perspective. Men’s lower reporting of IPV confirms women’s subordinate position, but men’s denial of incidents could also explain the gender role pattern.
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Nybergh L, Taft C, Enander V, Krantz G. Self-reported exposure to intimate partner violence among women and men in Sweden: results from a population-based survey. BMC Public Health 2013; 13:845. [PMID: 24034631 PMCID: PMC3848440 DOI: 10.1186/1471-2458-13-845] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 09/05/2013] [Indexed: 11/10/2022] Open
Abstract
Background Few population-based studies assessing IPV among randomly selected women and men have been conducted in Sweden. Hence, the aim of the current study was to explore self-reported exposure, associated factors, social and behavioural consequences of and reasons given for using psychological, physical and sexual intimate partner violence (IPV) among women and men residing in Sweden. Methods Cross-sectional postal survey of women and men aged 18–65 years. Bivariate and multivariate logistic regression analyses were used to identify factors associated with exposure to IPV. Results Past-year IPV exposure rates were similar in women and men; however, earlier-in-life estimates were higher in women. Poor to moderate social support, growing up with domestic violence and being single, widowed or divorced were associated with exposure to all forms of IPV in men and women. Women and men tended to report different social consequences of IPV. Conclusions Our finding that women reported greater exposure to IPV earlier-in-life but not during the past year suggests the importance of taking this time frame into account when assessing gender differences in IPV. In-depth, qualitative studies that consider masculinities, femininities power and gender orders would be beneficial for extending and deepening our understanding of the gendered matter of IPV.
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Jakobsson A, von Borgstede C, Krantz G, Spak F, Hensing G. Possibilities and hindrances for prevention of intimate partner violence: perceptions among professionals and decision makers in a Swedish medium-sized town. Int J Behav Med 2013; 20:337-43. [PMID: 22622818 PMCID: PMC3767886 DOI: 10.1007/s12529-012-9238-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Intimate partner violence (IPV) is a major public health problem, but few evidence-based prevention programs have yet been implemented. PURPOSE This study explored the perceptions and beliefs of local-level decision makers, social and health-care professionals, and representatives from the police force regarding the possibilities and hindrances for prevention of IPV. METHOD An explorative qualitative approach was used, and participants were strategically selected for focus group discussions. The participants, 19 men and 23 women, were professionals or decision makers within health-care services, social welfare, municipal administration, the police force, local industry, and local politicians in a Swedish town of 54,000 inhabitants. The focus group discussions were audio recorded, transcribed verbatim, and thematically analyzed. A manifest content analysis was performed on the text. RESULTS Preschools, schools, sports associations, workplaces, and the mass media were suggested as possible arenas for prevention measures. The proposed activities included norm building and improved social support structures. Hindrances were conceptualized as societal beliefs and attitudes, shame, silence, gender inequality, the counteracting influence of the media, and lack of resources. The participants demonstrated closeness and distance to IPV, expressed as acceptance or referral of responsibility to others regarding where and by whom prevention measures should be executed. CONCLUSION This study gave new insights in the prevailing perceptions of professionals and decision makers of a medium-sized Swedish town, which can be a useful knowledge in future preventive work and contribute to bridge the gap between research and practice.
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Graner S, Klingberg-Allvin M, Duong LQ, Krantz G, Mogren I. Pregnant women's perception on signs and symptoms during pregnancy and maternal health care in a rural low-resource setting. Acta Obstet Gynecol Scand 2013; 92:1094-100. [DOI: 10.1111/aogs.12170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 05/05/2013] [Indexed: 11/28/2022]
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Nybergh L, Taft C, Krantz G. Psychometric properties of the WHO Violence Against Women instrument in a female population-based sample in Sweden: a cross-sectional survey. BMJ Open 2013; 3:bmjopen-2012-002053. [PMID: 23793692 PMCID: PMC3664346 DOI: 10.1136/bmjopen-2012-002053] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore psychometric properties of the Violence Against Women instrument in a randomly selected national sample of women (N=573) aged 18-65 years and residing in Sweden. DESIGN Cross-sectional survey study. SETTING Sweden. PARTICIPANTS A postal survey was sent to 1006 women between January and March 2009, during which 624 women (62%) returned the questionnaire. 51 women who did not answer any of the violence items were excluded from the analyses, resulting in a final sample of 573 women. PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported exposure to psychological, physical and sexual intimate partner violence. RESULTS Cronbach's α coefficients were 0.79 (psychological scale), 0.80 (physical scale), 0.72 (sexual scale) and 0.88 (total scale). A predetermined three-component solution largely replicated the explored three component conceptual model of the Violence Against Women instrument. The instrument was able to discriminate between groups known from previous studies to differ in exposure to physical and/or sexual violence, that is, respondents with poor versus good self-rated health and witnessed versus not witnessed physical violence at home when growing up. Past-year prevalence of physical (8.1%; 95% CI 5.9 to 10.3) and sexual (3%; 1.6 to 4.4) violence was similar to that reported in other Nordic studies; however, earlier-in-life prevalence was lower in the current study (14.3%; 95% CI 11.4 to 17.2 and 9.2%; 95% CI 6.8 to 11.6, respectively). Reported exposure rates were higher than those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire). CONCLUSIONS The Violence Against Women instrument demonstrated good construct validity and internal reliability in an adult female population in Sweden. However, further studies examining these and other psychometric properties need to be conducted in other countries.
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Farid-ul-Hasnain S, Johansson E, Gulzar S, Krantz G. Need for multilevel strategies and enhanced acceptance of contraceptive use in order to combat the spread of HIV/AIDS in a Muslim society: a qualitative study of young adults in urban Karachi, Pakistan. Glob J Health Sci 2013; 5:57-66. [PMID: 23985107 PMCID: PMC4776849 DOI: 10.5539/gjhs.v5n5p57] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 05/12/2013] [Indexed: 11/22/2022] Open
Abstract
This qualitative study explored knowledge, attitudes, beliefs and perceptions of sexual and reproductive health, focusing specifically on contraceptive use and HIV prevention among young unmarried men and women, 17-21 years, in urban Karachi, Pakistan. The main theme, identified as underlying meaning in the focus group discussions was “Societal norms and perceptions create barriers to knowledge and awareness about sexual and reproductive health matters among young adults”. A knowledge gap was revealed concerning HIV/AIDS and contraceptive use among young males and females, who have to rely on media and peers for information seeking. Study participants perceived that HIV/AIDS is incurable and carries a social stigma. It was further revealed, that there is an opposition towards contraceptive use from religious leaders. Young adults in Pakistan are in need of improved knowledge about HIV/AIDS and contraceptive use. Youth clinics and schools/colleges may play a significant role in this regard. The religious leaders need to be informed about the beneficial effects of contraceptives and they should be part of any family planning/contraceptive use program to ensure better community acceptance. At the structural level there is an urgent need for policies targeting the issue of sexual and reproductive health, particularly HIV/AIDS information and contraceptive use to target the young population. The health care services should be able to respond by offering relevant services.
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Leander K, Berlin M, Eriksson A, Gadin KG, Hensing G, Krantz G, Swahnberg K, Danielsson M. Violence: Health in Sweden: The National Public Health Report 2012. Chapter 12. Scand J Public Health 2012; 40:229-54. [DOI: 10.1177/1403494812459609] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lövestad S, Krantz G. Men's and women's exposure and perpetration of partner violence: an epidemiological study from Sweden. BMC Public Health 2012; 12:945. [PMID: 23116238 PMCID: PMC3534228 DOI: 10.1186/1471-2458-12-945] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 10/24/2012] [Indexed: 11/29/2022] Open
Abstract
Background Over the past 30 years, intimate partner violence (IPV) against women and its health consequences has become a well established research area and is recognized worldwide as a significant public health issue. Studies on IPV directed at men are less explored, however recently women’s use of IPV and men’s victimization is gaining growing attention. Earlier population-based studies performed in Sweden have primarily investigated men’s violence against women, while women’s use of violence and men’s exposure as well as the existence of controlling behaviours have been neglected research areas This explorative study investigated the exposure to and perpetration of intimate partner violence, the use of control behaviours and the associated risk factors among a sample of Swedish men and women. Methods This cross-sectional population-based study included 173 men and 251 women of age 18–65 randomly selected among the Swedish population. A questionnaire based on the revised Conflicts Tactics Scale (CTS2) and the subscale ‘isolating control’ from the Controlling Behaviour Scale (CBS) was used to collect data on violence exposure and perpetration. Regression analyses were used for risk factor assessment. Results More men (11%) than women (8%) reported exposure to physical assault in the past year, while more women reported exposure to sexual coercion. Duration of present relationship ≤ 3 years was identified as a significant risk factor for men’s exposure. Young age, lack of social support and being single, constituted risk factors for women’s exposure. Surprisingly many men (37%) and women (41%) also reported exposure to controlling behaviours. Conclusions In partner violence research, both men’s and women’s exposure should be explored however findings need to be interpreted with caution. This first study in a Swedish sample establishes the basis for future investigations on partner violence and coercive control tactics.
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Ali TS, Krantz G, Mogren I. Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan. Int J Womens Health 2012; 4:577-85. [PMID: 23152709 PMCID: PMC3496530 DOI: 10.2147/ijwh.s33325] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Indexed: 11/23/2022] Open
Abstract
Background: This study explored how married women perceive situations which create family conflicts and lead to different forms of violence in urban Pakistan. In addition, it examines perceptions of consequences of violence, their adverse health effects, and how women resist violence within marital life. Methods: Five focus group discussions were conducted with 28 women in Karachi. Purposive sampling, aiming for variety in age, employment status, education, and socioeconomic status, was employed. The focus group discussions were conducted in Urdu and translated into English. Manifest and latent content analysis were applied. Results: One major theme emerged during the analysis, ie, family violence through the eyes of females. This theme was subdivided into three main categories. The first category, ie, situations provoking violence and their manifestations, elaborates on circumstances that provoke violence and situations that sustain violence. The second category, ie, actions and reactions to exposure to violence, describes consequences of ongoing violence within the family, including those that result in suicidal thoughts and actions. The final category, ie, resisting violence, describes how violence is avoided through women’s awareness and actions. Conclusion: The current study highlights how female victims of abuse are trapped in a society where violence from a partner and family members is viewed as acceptable, where divorce is unavailable to the majority, and where societal support of women is limited. There is an urgent need to raise the subject of violence against women and tackle this human rights problem at all levels of society by targeting the individual, family, community, and societal levels concurrently.
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Hasnain SFU, Johansson E, Mogren I, Krantz G. Young adults' perceptions on life prospects and gender roles as important factors to influence health behaviour: a qualitative study from Karachi, Pakistan. Glob J Health Sci 2012; 4:87-97. [PMID: 22980235 PMCID: PMC4776929 DOI: 10.5539/gjhs.v4n3p87] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/12/2011] [Indexed: 11/12/2022] Open
Abstract
The purpose of this qualitative study was to explore perceptions and expectations of young males and females, in Karachi, Pakistan, regarding their life prospects and gender roles, with resulting implications for health behaviour. The main theme emerging was “Young adults’ prospects in life are hampered by psychosocial and gender equality constraints”. Gender inequality and the low status of women in society were described as major obstacles to the prosperity and development. Persistent withholding of information to the younger generation on sexual and reproductive health issues was perceived to increase exposure to health risks, particularly sexually transmitted infections (STIs). The present study reveals new discourses on equality among young adults, pointing towards an increasing, sound interaction between the sexes and aspirations for more gender equal relationships. The study further reveals serious misconceptions about HIV/AIDS. Such views and awareness among the younger generation constitutes a strong force towards change of traditional norms, including reproductive health behaviour, and calls for policy change.
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Nybergh L, Taft C, Krantz G. Psychometric properties of the WHO Violence Against Women instrument in a male population-based sample in Sweden. BMJ Open 2012. [PMID: 23187972 PMCID: PMC3533088 DOI: 10.1136/bmjopen-2012-002055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the psychometric properties of the WHO's Violence Against Women instrument (VAWI) in a randomly selected national sample of Swedish men. DESIGN Cross-sectional survey study. SETTING Sweden. PARTICIPANTS A postal survey was sent to 1009 men between January and March 2009, during which 458 men (45.4%) returned the questionnaire. 49 men who did not answer any of the violence items were excluded from the analyses, resulting in a final sample of 399 men. PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported exposure to psychological, physical and sexual intimate partner violence. RESULTS Cronbach's α were 0.74 (psychological scale), 0.86 (physical scale), 0.82 (sexual scale) and 0.88 (total scale). Principal components analysis did not corroborate the conceptual three-dimensional model of the VAWI and other constructs were found. Past-year prevalence of physical (7.6%; 95% CI 5.0% to 10.2%) and sexual (2.3%; 95% CI 0.8% to 3.8%) violence was higher than in other Nordic studies; earlier-in-life prevalence of physical violence (6.8%; CI 95% 4.3% to 9.3%) was lower and sexual violence (2.5%; 95% CI 1.0% to 4.0%) was higher. Reported exposure rates were generally higher than those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire). CONCLUSIONS The VAWI conceptual model was only partially replicated and boundaries between psychological, physical and sexual acts of violence were indistinct among men exposed to intimate partner violence (IPV). This finding suggests that there is need for research instruments assessing intimate partner violence to be validated separately in male and female samples in order to ensure their suitability for the respective groups. Furthermore, theoretical frameworks for understanding men's exposure to intimate partner violence need to be advanced and should serve to guide in the development and evaluation of gender-specific IPV assessment instruments.
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Ali TS, Krantz G, Gul R, Asad N, Johansson E, Mogren I. Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study. Glob Health Action 2011; 4:7448. [PMID: 22065609 PMCID: PMC3208374 DOI: 10.3402/gha.v4i0.7448] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women's and men's life prospects. OBJECTIVE The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men's and women's life circumstances. DESIGN Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied. FINDINGS TWO MAJOR THEMES EMERGED DURING ANALYSIS: 'Reiteration of gender roles' and 'Agents of change'. The first theme included perceptions of traditional gender roles and how these preserve women's subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation. CONCLUSIONS This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment.
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Ali TS, Asad N, Mogren I, Krantz G. Intimate partner violence in urban Pakistan: prevalence, frequency, and risk factors. Int J Womens Health 2011; 3:105-15. [PMID: 21573146 PMCID: PMC3089428 DOI: 10.2147/ijwh.s17016] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Indexed: 11/24/2022] Open
Abstract
Background: Intimate partner violence (IPV) is an important public health issue with severe adverse consequences. Population-based data on IPV from Muslim societies are scarce, and Pakistan is no exception. This study was conducted among women residing in urban Karachi, to estimate the prevalence and frequency of different forms of IPV and their associations with sociodemographic factors. Methods: This cross-sectional community-based study was conducted using a structured questionnaire developed by the World Health Organisation for research on violence. Community midwives conducted face-to-face interviews with 759 married women aged 25–60 years. Results: Self-reported past-year and lifetime prevalence of physical violence was 56.3 and 57.6%, respectively; the corresponding figures for sexual violence were 53.4% and 54.5%, and for psychological abuse were 81.8% and 83.6%. Violent incidents were mostly reported to have occurred on more than three occasions during the lifetime. Risk factors for physical violence related mainly to the husband, his low educational attainment, unskilled worker status, and five or more family members living in one household. For sexual violence, the risk factors were the respondent’s low educational attainment, low socioeconomic status of the family, and five or more family members in one household. For psychological violence, the risk factors were the husband being an unskilled worker and low socioeconomic status of the family. Conclusion: Repeated violence perpetrated by a husband towards his wife is an extremely common phenomenon in Karachi, Pakistan. Indifference to this type of violence against women stems from the attitude that IPV is a private matter, usually considered a justifiable response to misbehavior on the part of the wife. These findings point to serious violations of women’s rights and require the immediate attention of health professionals and policymakers.
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Graner S, Klingberg-Allvin M, Phuc HD, Huong DL, Krantz G, Mogren I. Adverse perinatal and neonatal outcomes and their determinants in rural Vietnam 1999-2005. Paediatr Perinat Epidemiol 2010; 24:535-45. [PMID: 20955231 DOI: 10.1111/j.1365-3016.2010.01135.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Population-based estimations of perinatal and neonatal outcomes are sparse in Vietnam. There are no previously published data on small for gestational age (SGA) infants. A rural population in northern Vietnam was investigated from 1999 to 2005 (n=5521). Based on the birthweight distributions within the population under study, reference curves for intrauterine growth for Vietnamese infants were constructed and the prevalence and distribution of SGA was calculated for each sex. Neonatal mortality was estimated as 11.6 per 1000 live births and the perinatal mortality as 25.0 per 1000 births during the study period. The mean birthweight was 3112 g and the prevalence of low birthweight was 5.0%. The overall prevalence of SGA was 6.4%. SGA increased with gestational age and was 2.2%, 4.5% and 27.1% for preterm, term and post-term infants, respectively. Risk factors for SGA were post-term birth: adjusted odds ratio (AOR) 7.75 [95% CI 6.02, 9.98], mothers in farming occupations AOR 1.72 [95% CI 1.21, 2.45] and female infant AOR 1.61 [95% CI 1.27, 2.03]. There was a pronounced decrease in neonatal mortality after 33 weeks of gestation. Suggested interventions are improved prenatal identification of SGA infants by ultrasound investigation for fetal growth among infants who do not follow their expected clinical growth curve at the antenatal clinic. Other suggestions include allocating a higher proportion of preterm deliveries to health facilities with surgical capacity and neonatal care.
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Graner S, Mogren I, Duong LQ, Krantz G, Klingberg-Allvin M. Maternal health care professionals' perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam. BMC Public Health 2010; 10:608. [PMID: 20946681 PMCID: PMC3091560 DOI: 10.1186/1471-2458-10-608] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 10/14/2010] [Indexed: 11/16/2022] Open
Abstract
Background High quality maternal health care is an important tool to reduce maternal and neonatal mortality. Services offered should be evidence based and adapted to the local setting. This qualitative descriptive study explored the perspectives and experiences of midwives, assistant physicians and medical doctors on the content and quality of maternal health care in rural Vietnam. Method The study was performed in a rural district in northern Vietnam. Four focus group discussions with health care professionals at primary health care level were conducted. The data was analysed using qualitative manifest and latent content analysis. Result Two main themes emerged: "Contextual conditions for maternal health care" and "Balancing between possibilities and constraints". Contextual conditions influenced both pregnant women's use of maternal health care and health care professionals' performance. The study participants stated that women's uses of maternal health care were influenced by economical constraints and cultural norms that impeded their autonomy in relation to childbearing. Structural constraints within the health care system included inadequate financing of the primary health care, resulting in lack of human resources, professional re-training and adequate equipment. Conclusion Contextual conditions strongly influenced the performance and interaction between pregnant women and health care professionals within antenatal care and delivery care in a rural district of Vietnam. Although Vietnam is performing comparatively well in terms of low maternal and child mortality figures, this study revealed midwives' and other health care professionals' perceived difficulties in their daily work. It seemed maternal health care was under-resourced in terms of staff, equipment and continuing education activities. The cultural setting in Vietnam constituting a strong patriarchal society and prevailing Confucian norms limits women's autonomy and reduce their possibility to make independent decisions about their own reproductive health. This issue should be further addressed by policy-makers. Strategies to reduce inequities in maternal health care for pregnant women are needed. The quality of client-provider interaction and management of pregnancy may be strengthened by education, human resources, re-training and provision of essential equipment.
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