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Abstract Background Despite an increased use of contraceptive methods by women, unintended pregnancies represent one of the most evident violations of women's sexual and reproductive rights around the world. This study aims to measure the association between individual and community exposure to different forms of violence against women (physical/sexual violence by the partner, sexual abuse by any person, or controlling behavior by the partner) and unintended pregnancies. Methods Data from the 2006/2007 Nicaraguan Demographic and Health Survey were used. For the current study, 5347 women who reported a live birth in the five years prior to the survey and who were married or cohabitating at the time of the data collection were selected. Women's exposure to controlling behaviors by their partners was measured using six questions from the WHO Multi-Country Study on Women's Health and Domestic Violence against Women. Area-level variables were constructed by aggregating the individual level exposures to violence into an exposure measurement of the municipality as a whole (n = 142); which is the basic political division in Nicaragua. Multilevel logistic regression was used to analyze the data. Results In total, 37.1% of the pregnancies were reported as unintended. After adjusting for all variables included in the model, individual exposure to controlling behavior by a partner (AOR = 1.28, 95% CrI = 1.13–1.44), ever exposure to sexual abuse (AOR = 1.31, 95% CrI = 1.03–1.62), and ever exposure to physical/sexual intimate partner violence (AOR = 1.44, 95% CrI = 1.24–1.66) were significantly associated with unintended pregnancies. Women who lived in municipalities in the highest tertile of controlling behavior by a partner had 1.25 times higher odds of reporting an unintended pregnancy than women living in municipalities in the lowest tertile (AOR = 1.25, 95% CrI = 1.03–1.48). Conclusions Nicaraguan women often experience unintended pregnancies, and the occurrence of unintended pregnancies is significantly associated with exposure to different forms of violence against women at both the individual and the municipality level. National policies aiming to facilitate women's ability to exercise their reproductive rights must include actions aimed at reducing women's exposures to violence against women.

Background: Despite an increased use of contraceptive methods by women, unintended pregnancies represent one of the most evident violations of women's sexual and reproductive rights around the world. This study aims to measure the association between individual and community exposure to different forms of violence against women (physical/sexual violence by the partner, sexual abuse by any person, or controlling behavior by the partner) and unintended pregnancies. Methods: Data from the 2006/2007 Nicaraguan Demographic and Health Survey were used. For the current study, 5347 women who reported a live birth in the five years prior to the survey and who were married or cohabitating at the time of the data collection were selected. Women's exposure to controlling behaviors by their partners was measured using six questions from the WHO Multi-Country Study on Women's Health and Domestic Violence against Women. Area-level variables were constructed by aggregating the individual level exposures to violence into an exposure measurement of the municipality as a whole (n = 142); which is the basic political division in Nicaragua. Multilevel logistic regression was used to analyze the data. Results: In total, 37.1% of the pregnancies were reported as unintended. After adjusting for all variables included in the model, individual exposure to controlling behavior by a partner (AOR = 1.28, 95% CrI = 1.13-1.44), ever exposure to sexual abuse (AOR = 1.31, 95% CrI = 1.03-1.62), and ever exposure to physical/sexual intimate partner violence (AOR = 1.44, 95% CrI = 1.24-1.66) were significantly associated with unintended pregnancies. Women who lived in municipalities in the highest tertile of controlling behavior by a partner had 1.25 times higher odds of reporting an unintended pregnancy than women living in municipalities in the lowest tertile (AOR = 1.25, 95% CrI = 1.03-1.48). Conclusions: Nicaraguan women often experience unintended pregnancies, and the occurrence of unintended pregnancies is significantly associated with exposure to different forms of violence against women at both the individual and the municipality level. National policies aiming to facilitate women's ability to exercise their reproductive rights must include actions aimed at reducing women's exposures to violence against women.

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

Background: Even though population health is strongly influenced by employment and working conditions, public health research has to a lesser extent explored the social determinants of health inequalities between people in different positions on the labour market, and whether these social determinants vary across the life course. This study analyses mental health inequalities between unemployed and employed in three age groups (youth, adulthood and mid-life), and identifies the extent to which social determinants explain the mental health gap between employed and unemployed in northern Sweden. Methods: The Health on Equal Terms survey of 2014 was used, with self-reported employment (unemployed or employed) as exposure and the General Health Questionnaire (GHQ-12) as mental health outcome. The social determinants of health inequalities were grouped into four dimensions: socioeconomic status, economic resources, social network and trust in institutional systems. The non-linear Oaxaca decomposition analysis was applied, stratified by gender and age groups. Results: Mental health inequality was found in all age groups among women and men (difference in GHQ varying between 0.12 and 0.20). The decomposition analysis showed that the social determinants included in the model accounted for 43-51% of the inequalities among youths, 42-98% of the inequalities among adults and 60-65% among middle-aged. The main contributing factors were shown to vary between age groups: cash margin (among youths and middle-aged men), financial strain (among adults and middle-aged women), income (among men in adulthood), along with trust in others (all age groups), practical support (young women) and social support (middle-aged men); stressing how the social determinants of health inequalities vary across the life course. Conclusions: The health gap between employed and unemployed was explained by the difference in access to economic and social resources, and to a smaller extent in the trust in the institutional systems. Findings from this study corroborate that much of the mental health inequality in the Swedish labour market is socially and politically produced and potentially avoidable. Greater attention from researchers, policy makers on unemployment and public health should be devoted to the social and economic deprivation of unemployment from a life course perspective to prevent mental health inequality.

Background: Even though population health is strongly influenced by employment and working conditions, public health research has to a lesser extent explored the social determinants of health inequalities between people in different positions on the labour market, and whether these social determinants vary across the life course. This study analyses mental health inequalities between unemployed and employed in three age groups (youth, adulthood and mid-life), and identifies the extent to which social determinants explain the mental health gap between employed and unemployed in northern Sweden. Methods: The Health on Equal Terms survey of 2014 was used, with self-reported employment (unemployed or employed) as exposure and the General Health Questionnaire (GHQ-12) as mental health outcome. The social determinants of health inequalities were grouped into four dimensions: socioeconomic status, economic resources, social network and trust in institutional systems. The non-linear Oaxaca decomposition analysis was applied, stratified by gender and age groups. Results: Mental health inequality was found in all age groups among women and men (difference in GHQ varying between 0.12 and 0.20). The decomposition analysis showed 43–51% of the total inequality among youths, 42–98% among adults and 60–65% among middle-aged. The main contributing factors were shown to vary between age groups: cash margin (among youths and middle-aged men), financial strain (among adults and middle-aged women), income (among men in adulthood), along with trust in others (all age groups), practical support (young women) and social support (middle-aged men); stressing how the social determinants of health inequalities vary across the life course. Conclusions: The health gap between employments was explained by the difference in access to economic and social resources, and to a smaller extent in the trust in the institutional systems. Findings from this study corroborate that much of the mental health inequality in the Swedish labour market is socially and politically produced and potentially avoidable. Greater attention from researchers, policy makers on unemployment and public health should be devoted to the social and economic deprivation of unemployment from a life course perspective to prevent mental health inequality.

Despite advances made by Ecuador in developing policies on reproductive and sexual rights, implementation, and oversight remain a challenge, affecting in particular those living in the Amazon basin. This paper reports on an evaluation of sexual and reproductive health and rights (SRHR) in Orellana, Ecuador, the basis of which was the Health Rights of Women Assessment Instrument, which was altered to focus on government obligations, the reality of access and utilization of services, and the inequities and implementation challenges between the two. A community-based cross-sectional survey conducted in 2006 served to document the current status of SRHR. Local female field workers interviewed 2,025 women on three areas of women's reproductive health: delivery care, family planning, and pregnancy among adolescent girls age 10-19. The results suggest a reality more dismal than that of the official information for the area. Skilled delivery care, modern contraceptive use, and wanted pregnancies were conspicuously lower among indigenous women living in rural areas. Access to reproductive health services varied between rural and urban women. These significant differences in care -- amongst others documented -- raise concerns over the utility of national-level data for addressing inequities. The gaps evident in the validity of available information for monitoring policies and programs, and between national policy and action reveal that much still needs to be done to realize SRHR for women in the Amazon basin, and that current accountability mechanisms are inadequate. Adapted from the source document.

Despite advances made by Ecuador in developing policies on reproductive and sexual rights, implementation, and oversight remain a challenge, affecting in particular those living in the Amazon basin. This paper reports on an evaluation of sexual and reproductive health and rights (SRHR) in Orellana, Ecuador, the basis of which was the Health Rights of Women Assessment Instrument, which was altered to focus on government obligations, the reality of access and utilization of services, and the inequities and implementation challenges between the two. A community-based cross-sectional survey conducted in 2006 served to document the current status of SRHR. Local female field workers interviewed 2,025 women on three areas of women's reproductive health: delivery care, family planning, and pregnancy among adolescent girls age 10-19. The results suggest a reality more dismal than that of the official information for the area. Skilled delivery care, modern contraceptive use, and wanted pregnancies were conspicuously lower among indigenous women living in rural areas. Access to reproductive health services varied between rural and urban women. These significant differences in care -- amongst others documented -- raise concerns over the utility of national-level data for addressing inequities. The gaps evident in the validity of available information for monitoring policies and programs, and between national policy and action reveal that much still needs to be done to realize SRHR for women in the Amazon basin, and that current accountability mechanisms are inadequate. Adapted from the source document.

Background: There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India's National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu. Methods: We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level. Results: We uncover what we have termed "dissonances" and "disconnects" at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for "sense-making" in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project. Conclusions: This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of "problematization" a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system.

BACKGROUND: Reproductive and child health interventions are essential to improving population health in Africa. In Mozambique, although some progress on reproductive and child health has been made, knowledge of social inequalities in health and health care is lacking. OBJECTIVE: To investigate socio-economic and demographic inequalities in reproductive and child preventive health care as a way to monitor progress towards universal health coverage. METHODS: A cross-sectional study was conducted, using data collected from the 2015 Immunization, AIDS and Malaria Indicators Survey (IMASIDA) in Mozambique. The sample included 6946 women aged 15 to 49 years. Outcomes variables were the use of insecticide treated nets (ITN) for children under 5 years, full child immunization and modern contraception use, while independent variables included age, marital status, place of residence, region, education, occupation, and household wealth index. Prevalence ratios (PR) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship between the socio-economic and demographic characteristics and the three outcomes of interest. RESULTS: The percentage of mothers with at least one child under 5 years that did not use ITN was 51.01, 46.25% of women had children aged 1 to 4 years who were not fully immunized, and 74.28% of women were not using modern contraceptives. Non-educated mothers (PR = 1.33; 95% CI: 1.16-1.51) and those living in the Southern region (PR = 1.36; 95% CI: 1.17-1.59) had higher risk of not using ITN, while the poorest quintile (PR = 1.34; 95% CI: 1.04-1.71) was more likely to have children who were not fully immunized. Similarly, non-educated women (PR = 1.17; 95% CI: 1.10-1.25), non-working women (PR = 1.09; 95% CI: 1.04-1.16), and those in the poorest quintile (PR = 1.13; 95% CI: 1.04-1.24) had a higher risk of not using modern contraceptives. CONCLUSION: Our study showed a low rate of ITN utilization, immunization coverage of children, and modern contraceptive use among women of reproductive age. Several socio-economic and demographics factors (region, education, occupation, and wealth) were associated with these preventive measures. We recommend an equity-oriented resource allocation across regions, knowledge dissemination on the importance of ITN and contraceptives use, and an expansion of immunization services to reach socio-economically disadvantaged families in order to achieve universal health coverage in Mozambique.

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

Background: Leishmaniasis is a neglected tropical disease endemic in Bolivia that disproportionately affects people with little social and political capital. Although the treatment is provided free of charge by the Bolivian government, there is an under-utilization of treatments in relation to the estimated affected population. This study explores the experiences of patients with leishmaniasis and the challenges faced when searching for diagnosis and treatment in Bolivia using a human rights approach. Methods: We conducted open-ended interviews with 14 participants diagnosed with leishmaniasis. The qualitative data were analysed using thematic analysis and were interpreted under a human rights approach to health care. Results: Four themes emerged during data analysis: (1) the decision for seeking a cure takes time; (2) the severity of symptoms and disruption of functioning drives the search for Western medicine; (3) the therapeutic journey between Western and traditional medicine; and (4) accessibility barriers to receive adequate medical treatment. This study showed that access to health care limitations were the most important factors that prevented patients from receiving timely diagnosis and treatment. Cultural factors played a secondary role in their decision to seek medical care. Conclusions: Accessibility barriers resulted in a large pilgrimage between public health care and traditional medicinal treatments for patients with leishmaniasis. This pilgrimage and the related costs are important factors that determine the decision to seek health care. This study contributes to the understanding of the under-utilisation problems of medical services in leishmaniasis and other similar diseases in remote and poor populations.

INTRODUCTION: Cutaneous leishmaniasis (CL), endemic in Bolivia, mostly affects poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages and a lack of safe conditions to deliver treatment are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in a Bolivian endemic area. METHODS: The cost-per-patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N = 12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization. Costs were reported in 2017 international dollars (1 INT$ = 3.10 BOB). RESULTS: Treating CL using ILPA was associated with a cost-saving of $248 per-patient-treated from the MoH perspective, and $688 per-patient-treated from the societal perspective. Switching first-line treatment to ILPA while maintaining the current budget would allow two-and-a-half times the current number of patients to be treated. ILPA remained cost-saving compared to SPA in the sensitivity analysis. CONCLUSIONS: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.

BACKGROUND: Prolonged political instability may have exacerbated gender inequitable beliefs in the Democratic Republic of Congo (DRC). The aim of this study was to assess attitudes related to gender-equitable norms and its determinants among young, church-going women and men in Kinshasa, DRC. METHOD: Data were collected through a cross-sectional survey with 291 church-going women and 289 men aged 18-24 years old, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality, and responses to issues related to the gender-equitable men (GEM) scale. The GEM scale is a 24 item-questionnaire developed to measure attitudes towards gender equitable norms. Logistic regression was applied to discover the associations between the independent variables and the GEM outcome. RESULTS: Our study reflected the existence of attitudes hampering gender equality that were endorsed by both women and men. For example, 91.4% of women and 83% of men agreed with the statement "a woman's most important role is to take care of her home and cook for her family". Similarly, 88.3% of women and 82.9% of men concurred with the idea that men need more sex than women. These findings coexisted with a few equitable norms, because 93.7% of women and 92.3% of men agreed that a man and a woman should decide together if they want to have children. A positive association was found in both women and men between being educated, being single and separated and having supportive attitudes towards gender equality and a higher GEM scale score. Residency in Camp Luka and Masina was also a significant social determinant associated with equitable gender norms among men whilst job status was only significant among women. CONCLUSION: While both women and men had high levels of gender inequitable norms, those with more education, single, and with supportive attitudes to gender equality had high GEM scale scores. The results highlight an urgent need for the church to challenge and change gender norms among church youths.

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

BACKGROUND: Over the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women's health care access. METHODS: The present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time. RESULTS: Access to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use. CONCLUSIONS: While most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.