Karin Dyrstad

Perceived Barriers for Accessing Health Services among Individuals with Disability in Four African Countries

There is an increasing awareness among researchers and others that marginalized and vulnerable groups face problems in accessing health care. Access problems in particular in low-income countries may jeopardize the targets set by the United Nations through the Millennium Development Goals. Thus, identifying barriers for individuals with disability in accessing health services is a research priority. The current study aimed at identifying the magnitude of specific barriers, and to estimate the impact of disability on barriers for accessing health care in general. A population based household survey was carried out in Sudan, Namibia, Malawi, and South Africa, including a total of 9307 individuals. The sampling strategy was a two-stage cluster sampling within selected geographical areas in each country. A listing procedure to identify households with disabled members using the Washington Group six screening question was followed by administering household questionnaires in households with and without disabled members, and questionnaires for individuals with and without disability. The study shows that lack of transport, availability of services, inadequate drugs or equipment, and costs, are the four major barriers for access. The study also showed substantial variation in perceived barriers, reflecting largely socio-economic differences between the participating countries. Urbanity, socio-economic status, and severity of activity limitations are important predictors for barriers, while there is no gender difference. It is suggested that education reduces barriers to health services only to the extent that it reduces poverty. Persons with disability face additional and particular barriers to health services. Addressing these barriers requires an approach to health that stresses equity over equality.

After ethnic civil war

While the study of the causes of civil war is a well-established subdiscipline in international relations, the effects of civil war on society remain less understood. Yet, such effects could have crucial implications for long-term stability and democracy in a country after the reaching of a peace agreement. This article contributes to the understanding of the effects of warfare on interethnic relations, notably attitudes of ethno-nationalism. Two hypotheses are tested: first, that the prevalence of ethno-nationalism is higher after than before the war, and second, that individuals who have been directly affected by the war are more nationalist than others. The variation in ethno-nationalism is examined over time, between countries, and between ethnic groups. Three countries that did not experience conflict on their own territory serve as a control group. The effect of individual war exposure is also tested in the analysis. Sources include survey data from the former Yugoslavia in 1989, shortly before the outbreak of war in Croatia and Bosnia and Herzegovina, and in 2003, some years after the violence in the region ended. Contrary to common beliefs, the study shows that ethno-nationalism does not necessarily increase with ethnic civil war. The individual war experiences are less important than expected.

Does civil war breed authoritarian values? An empirical study of Bosnia-Herzegovina, Kosovo and Croatia

This article analyses how armed conflict affects individual support for liberal values. It is commonly assumed that the consolidation of democracy depends on individual values such as tolerance as well as aspirations of civil and political liberty. For post-conflict societies, consolidating democracy is also a means of reducing the risk of recurring violent conflict. However, democracy has proven to be especially hard to achieve and consolidate in ethnically divided societies. While previous research has centred mainly on institutions and political elites, I expand the focus to also include ordinary citizens. Using survey data from post-war Bosnia-Herzegovina, Kosovo and Croatia, I examine the effect of exposure to violence on a scale of authoritarian values. While the effects are small, the results show that war-related violence in some cases leads people to embrace authoritarian values.

Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011–2012 by means of a two-stage cluster sampling and comprised 400–500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

Ethnonationalism in post-war Bosnia-Herzegovina and Kosovo The effects of local violence and ethnic composition

In this article we examine attitudes of ethnonationalism in two countries that have experienced ethnic civil war: Bosnia-Herzegovina and Kosovo. We analyse the strength of attitudes of ethnonationalism on the individual level, and how ethnonationalism is related to local ethnic settlement patterns and previous experiences of local inter-ethnic violence. We combine data at the municipality level with data from the South-East European Social Survey Program from 2003 and conduct a multilevel analysis for each case. In both cases, ethnonationalism dominates, but it is stronger in Kosovo than in Bosnia-Herzegovina. We find a clear difference between members of local majorities and minorities, but the effect in Bosnia-Herzegovina is the opposite of the effect in Kosovo. In Bosnia-Herzegovina, members of both minority and majority groups tend to be more ethnonationalist the larger their group. Contrary to our initial expectations, people express less ethnonationalism in municipalities that were more severely hit by violence, whereas in Kosovo no effect of local violence can be found. The more recent conflict and less consolidated institutions in Kosovo may help explain these divergent results. Still, the lack of consistent findings makes it hard to infer beyond the two cases examined.

Combining survey data, GIS and qualitative interviews in the analysis of health service access for persons with disabilities

BackgroundEquitable access to health services is a key ingredient in reaching health for persons with disabilities and other vulnerable groups. So far, research on access to health services in low- and middle-income countries has largely relied on self-reported survey data. Realizing that there may be substantial discrepancies between perceived and actual access, other methods are needed for more precise knowledge to guide health policy and planning. The objective of this article is to describe and discuss an innovative methodological triangulation where statistical and spatial analysis of perceived distance and objective measures of access is combined with qualitative evidence.MethodsThe data for the study was drawn from a large household and individual questionnaire based survey carried out in Namibia and Malawi. The survey data was combined with spatial data of respondents and health facilities, key informant interviews and focus group discussions. To analyse access and barriers to access, a model is developed that takes into account both measured and perceived access. The geo-referenced survey data is used to establish four outcome categories of perceived and measured access as either good or poor. Combined with analyses of the terrain and the actual distance from where the respondents live to the health facility they go to, the data allows for categorising areas and respondents according to the four outcome categories. The four groups are subsequently analysed with respect to variation in individual characteristics and vulnerability factors. The qualitative component includes participatory map drawing and is used to gain further insight into the mechanisms behind the different combinations of perceived and actual access.ResultsPreliminary results show that there are substantial discrepancies between perceived and actual access to health services and the qualitative study provides insight into mechanisms behind such divergences.ConclusionThe novel combination of survey data, geographical data and qualitative data will generate a model on access to health services in poor contexts that will feed into efforts to improve access for the most vulnerable people in underserved areas.

Explaining variations in general practitioners’ experiences of doing medically based assessments of work ability in disability benefit claims. A survey-based analysis

Abstract Purpose: Assessing patients’ work ability is a task that many general practitioners consider challenging. Increase of mental and musculoskeletal disorders further complicate the assessments. The purpose of this paper is to explain variation between general practitioners related to how they experience the assessment of work ability in disability cases. Methods: Combining data from an original postal survey among all general practitioners in Norway (N = 1,466; response rate = 32.5%) with characteristics of the municipality where they work, we use multilevel logistic regression to estimate the relationship between a set of dependent variables measuring how confident general practitioners feel when assessing patients’ work ability in disability cases, physician-related characteristics and structural factors. Results: A main finding is that length of service explains most of the variation between general practitioners (B = 0.492 [0.015, 0.970]–2.127 [1.457, 2.798]); in most of the regressions, this variable turns out as positive and significant (p < 0.01). The general practitioners’ knowledge of possibilities of workplace adaptations in different occupations (B = 0.309 [0.026, 0.592]–0.461 [0.154, 0.768]), as well as the importance they assign to tasks related to sick-listing (B = 0.239 [0.003, 0.475]–0.639 [0.336, 0.941]), were also significantly associated with the general practitioners’ experience of assessing work capacity. The structural variables in the model provided few significant results. Conclusions: Better education and training in doing work ability assessments could be a proper measure to increase general practitioners’ confidence in doing these assessments in connection with disability benefit applications.

Sick of waiting: Does waiting for elective treatment cause sickness absence?

Sickness absence represents a substantial cost in most of Western Europe, whether the insurance scheme is public or private. The objective of this study was to analyse whether waiting time for elective treatment in specialist health care is associated with the length of individual sickness absence in Norway. To estimate the association between waiting time and the duration of sick leave, we used data from the working population aged 18-67 years in 2010-2012. The files combined register data from The Norwegian Patient Registry with individual characteristics and sickness absence data from Statistics Norway, and was analysed using zero-truncated negative binomial regression. We found that about one in four employees who had one or more spells of sick leave in the period, was also waiting for consultation or treatment in specialist health care. Yet, the length of the waiting period had no substantial effect on the length of sickness absence (i.e., less than 0.1% reduction). Therefore, while measures to reduce waiting times for hospital treatment in many instances could be beneficial for the individual patient, such policies would probably not have any substantial impact on the national sickness absence rate.

Citizens’ Confidence in European Parliaments: Institutions and Issues

Parliament is a key institution in democracy and the main arena for inter-party politics. Citizens’ confidence in parliament is an important indicator for how democracy works in society. In this chapter, we present an overview of recent research on comparative trends in voters’ confidence in European parliaments in the last quarter century. We also compare trends for confidence in parliament and other political institutions with private institutions like major companies and the press. The literature has pursued explanations for variations in political trust in several directions. Building on the early studies by Miller, several scholars have explained the decline of trust from the evolvement of policy distance between government elites and citizens. In discussion and analysis, this chapter includes factors at the individual level as well as the national, aggregated level. Our main interest lies in the effect of political institutions and policy issues on political trust. While mature democracies see only smaller variations in confidence over time, there are larger fluctuations and decline in post-Communist Europe. Contrary to our expectations, institutional factors do not explain much of the differences in confidence in parliament in Europe, while policy issues play an important role.