Global health inequality and women - beyond maternal health

"I have to fight for them to investigate things": a qualitative exploration of physical and mental healthcare for women diagnosed with mental illness

Introduction

Women play a significant role in the management of their own healthcare and that of others, however women diagnosed with mental illness and physical health concerns experience significant health inequalities as compared to people living without mental health concerns.

Methods

In this paper, we reflect on the experiences of 20 cis women diagnosed with mental and physical health concerns who agreed to be a part of this research. This qualitative study is part of the larger Healthtalk Australia research project which was not gender specific. Female participants shared many experiences of mental and physical healthcare in interviews with researchers that pointed to the need for a gendered approach to addressing health inequalities. Consequently, we iteratively consolidated transcripts of interviews with participants into thematic categories facilitated by NVIVO 12.

Results

We identified two broad themes and a set of subthemes: in the doctor's office - experience of labelling; negotiating medications; and interactions with physical and mental health, and outside the doctor's office - responses to trauma, financial concerns, and reliance on participant's internal resources to get healthcare needs met.

Discussion

We conclude that participants in this study undertook significant work to manage their own healthcare needs, despite being challenged by clinicians and systems that failed to see them as whole people with expertise regarding their own health.

Sex and gender differences in intensive care medicine

Despite significant advancements in critical care medicine, limited attention has been given to sex and gender disparities in management and outcomes of patients admitted to the intensive care unit (ICU). While "sex" pertains to biological and physiological characteristics, such as reproductive organs, chromosomes and sex hormones, "gender" refers more to sociocultural roles and human behavior. Unfortunately, data on gender-related topics in the ICU are lacking. Consequently, data on sex and gender-related differences in admission to the ICU, clinical course, length of stay, mortality, and post-ICU burdens, are often inconsistent. Moreover, when examining specific diagnoses in the ICU, variations can be observed in epidemiology, pathophysiology, presentation, severity, and treatment response due to the distinct impact of sex hormones on the immune and cardiovascular systems. In this narrative review, we highlight the influence of sex and gender on the clinical course, management, and outcomes of the most encountered intensive care conditions, in addition to the potential co-existence of unconscious biases which may also impact critical illness. Diagnoses with a known sex predilection will be discussed within the context of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where clinical improvement is needed. To optimize patient care and outcomes, it is crucial to comprehend and address sex and gender differences in the ICU setting and personalize management accordingly to ensure equitable, patient-centered care. Future research should focus on elucidating the underlying mechanisms driving sex and gender disparities, as well as exploring targeted interventions to mitigate these disparities and improve outcomes for all critically ill patients.

Geographical and Socioeconomic Inequalities in Maternal Mortality in Ethiopia

In Ethiopia, social inequalities are common among women residing in deprived communities and between the poor and the rich. This study aimed to assess geographical and socioeconomic inequalities in maternal mortality using nationally representative data from Ethiopian Demographic and Health Surveys conducted from 2000 to 2019 (inclusive). Four health-related geographical and socioeconomic factors were assessed. Four relative and absolute health-related inequality measures were also used: rate difference, rate ratio, population attributable risk, and population attributable fraction. A total of 61,610 sister siblings were included. The highest reported inequalities in maternal mortality were residence-related (46% in 2005 among rural women), region-related (66% in 2005 among women in Beshangul-Gumuz regional state), education-related (83% in 2011 among women with primary education), and wealth-related (47% in 2000 among poorer women). So, if education-related inequalities in maternal mortality alone had been averted, the national maternal mortality could have been reduced by 52% in 2000, 51% in 2005, 83% in 2011, and 76% in 2016. In conclusion, inequalities in maternal mortality were high and concentrated among poorer women, women with lower educational status, and rural areas. Therefore, reducing the effects of poverty including social determinants of maternal mortality is recommended.

Interventions for and experiences of shared decision-making underpinning reproductive health, family planning options and pregnancy for women with or at high risk of kidney disease: a systematic review and qualitative framework synthesis

OBJECTIVE

To determine intervention effects and synthesise qualitative research that explored women with or at high risk of kidney disease experiences of shared decision-making in relation to their reproductive health, family planning options and pregnancy.

DESIGN

A systematic review of interventions and a qualitative evidence synthesis.

DATA SOURCES

We searched Cochrane, CINAHL, MEDLINE, Scopus, ProQuest, Elsevier, PubMed, ScienceDirect and Web of Science.

ELIGIBILITY CRITERIA

Shared decision-making interventions and qualitative studies related to reproductive health involving women with or at high risk of kidney disease published from 1980 until January 2021 in English (clinical settings, global perspective).

DATA EXTRACTION AND SYNTHESIS

Titles were screened against the inclusion criteria and full-text articles were reviewed by the whole team. Framework synthesis was undertaken.

RESULTS

We screened 1898 studies. No evidence-based interventions were identified. 18 qualitative studies were included, 11 kidney disease-specific studies and 7 where kidney disease was a common comorbidity. Women frequently felt unprepared and uninformed about their reproductive options. Conversations with healthcare professionals were commonly described as frustrating and unhelpful, often due to a perceived loss of autonomy and a mismatch in preferences and life goals. Examples of shared decision-making were rare. Kidney disease exacerbated societal expectations of traditional gender roles (eg, wife, mother, carer) including capability to have children and associated factors, for example, parenting, (sexual) relationships, body image and independent living (including financial barriers to starting a family). Local interventions were limited to types of counselling. A new health system model was developed to support new interventions.

CONCLUSION

There is a clear need to establish new interventions, test those already in development and develop new clinical guidance for the management of women with or at high risk of kidney disease in relation to their reproductive health, including options to preserve fertility earlier. Other health conditions with established personalised reproductive care packages, for example, cancer, could be used to benchmark kidney practice alongside the new model developed here.

Determinants of accessing healthcare in Sub-Saharan Africa: a mixed-effect analysis of recent Demographic and Health Surveys from 36 countries

OBJECTIVE

This study aimed to assess the determinants of accessing healthcare among reproductive-age women in Sub-Saharan Africa (SSA).

DESIGN, SETTING AND ANALYSIS

Cross-sectional data were sourced from recent Demographic and Health Surveys in 36 SSA countries. We employed mixed-effect analysis to identify the determinants of accessing healthcare in SSA. OR and its 95% CI were reported for determinants associated with accessing healthcare.

OUTCOME

The outcome for this study was whether accessing healthcare was a 'big problem' or 'not a big problem'. Responses to these questions were categorised as a big problem and not a big problem.

PARTICIPANTS

A total weighted sample of 500 439 reproductive-age (15-49 years) women from each country's recent Demographic and Health Surveys from 2006 to 2018 were included in this study.

RESULTS

The pooled prevalence of healthcare access among reproductive-age women in SSA was 42.56% (95% CI 42.43% to 42.69%). The results of the mixed-effect analysis revealed that the determinants of accessing healthcare were urban residence (adjusted OR (AOR)=1.25, 95% CI 1.34 to 1.73), ability to read and write (AOR=1.15, 95% CI 1.22 to 1.28), primary education (AOR=1.08, 95% CI 1.07 to 1.12), secondary education and above (AOR=1.12, 95% CI 1.10 to 1.14), husband with primary education (AOR=1.06, 95% CI 1.07 to 1.1.12), husband with secondary education and above (AOR=1.22, 95% CI 1.18 to 1.27), middle wealth index (AOR=1.43, 95% CI 1.40 to 1.47), rich wealth index (AOR=2.19, 95% CI 2.13 to 2.24) and wanted pregnancy (AOR=1.27, 95% CI 1.19 to 1.29).

CONCLUSION

Healthcare access in SSA was found at 42.56%, which is very low even if Sustainable Development Goal 3.8 targeted universal health coverage for everyone so they can obtain the health services they need. The major determinants of healthcare access among reproductive-age women in SSA were urban residence, higher educational level, higher wealth index and wanted pregnancy. The findings of this study suggest and recommend strengthening and improving healthcare access for women who reside in the countryside, women with low level of education and women of low socioeconomic status.