Katarina Hjelm

Health-care seeking behaviour among persons with diabetes in Uganda: an interview study

BackgroundHealthcare-seeking behaviour in patients with diabetes mellitus (DM) has been investigated to a limited extent, and not in developing countries. Switches between different health sectors may interrupt glycaemic control, affecting health. The aim of the study was to explore healthcare-seeking behaviour, including use of complementary alternative medicine (CAM) and traditional healers, in Ugandans diagnosed with DM. Further, to study whether gender influenced healthcare-seeking behaviour.MethodsThis is a descriptive study with a snowball sample from a community in Uganda. Semi-structured interviews were held with 16 women and 8 men, aged 25-70. Data were analysed by qualitative content analysis.ResultsHealthcare was mainly sought among doctors and nurses in the professional sector because of severe symptoms related to DM and/or glycaemic control. Females more often focused on follow-up of DM and chronic pain in joints, while males described fewer problems. Among those who felt that healthcare had failed, most had turned to traditional healers in the folk sector for prescription of herbs or food supplements, more so in women than men. Males more often turned to private for-profit clinics while females more often used free governmental institutions.ConclusionsHealthcare was mainly sought from nurses and physicians in the professional sector and females used more free-of-charge governmental institutions. Perceived failure in health care to manage DM or related complications led many, particularly women, to seek alternative treatment from CAM practitioners in the folk sector. Living conditions, including healthcare organisation and gender, seemed to influence healthcare seeking, but further studies are needed.

Uptake of dioxin-like compounds from sewage sludge into various plant species - assessment of levels using a sensitive bioassay.

A bioassay for the detection of dioxin-like compounds was used to estimate uptake of dioxin-like compounds in carrots, oil seed rape seeds, zucchinis and cucumbers grown in soil amended with sewage sludge from Swedish sewage treatment plants (STP). This sensitive bioassay is based on 7-ethoxyresorufin O-deethylase (EROD)-induction in cultured chicken embryo livers and reflects the combined biological effect of all dioxin-like compounds in a sample, including ones that seldom are analyzed. The bioassay detected low concentrations of dioxin-like compounds in all carrot, zucchini and cucumber samples, but did not detect any dioxin-like compounds in the rape seeds. In carrots the concentrations were increased up to seven times when grown in soil amended with high applications of some of the sludge samples, while others did not increase the concentrations compared to control. More realistic sludge applications only increased the concentrations slightly. The sludge-fertilized carrots contained the highest concentrations of the investigated plants (up to 14 pg bioassay-derived TCDD equivalents (bio-TEQs)/g d.w.). In the carrots, differences in uptake of dioxin-like compounds depended on the sludge origin, which may be due to more easily bioaccumulated dioxin-like compounds in some sludge samples, or other components that facilitated uptake into the carrots. In the cucumbers, a more than two-fold increase (from 0.2 to 0.5 pg bio-TEQs/g d.w.) was observed in specimens grown in sludge-amended soil when compared to controls, suggesting a small uptake from the roots to the shoots. No sludge-dependent increase in uptake was seen in the zucchini fruits. The bio-TEQ levels were generally low in the consumable above ground plant parts of the investigated species. However, the question if repeated sludge application results in a soil accumulation of dioxin-like compounds, thereby increasing the risk of plant uptake, remains to be investigated.

Levels of dioxin-like compounds in sewage sludge determined with a bioassay based on EROD induction in chicken embryo liver cultures.

A bioassay for the detection of dioxin-like compounds was used to estimate levels in sewage sludge from Swedish sewage treatment plants (STPs). The sludge extracts were HPLC-separated into three fractions containing a) monoaromatic/aliphatic, b) diaromatic (e.g. polychlorinated biphenyls [PCBs], polychlorinated dibenzodioxins and polychlorinated dibenzofurans [PCDDs/Fs]), and c) polyaromatic compounds (e.g. polycyclic aromatic hydrocarbons [PAHs]). The bioassay, which is based on EROD (7-ethoxyresorufin O-deethylase) induction in cultured chicken embryo livers detected dioxin-like activity in all unfractionated extracts and in the di- and polyaromatic fractions of all sludge extracts, but not in the monoaromatic/aliphatic fractions. The levels ranged between 6 and 109 pg bio-TEQ/g sludge (d.w.). In sediment samples from rural lakes in Sweden, levels of about 5 pg bio-TEQ/g (d.w.) have been found. The polyaromatic fractions of the sludge samples were potent in the bioassay, probably due to various PAHs and other polyaromatics in the sludge. The levels of six PAHs that are screened for in the sludge at Swedish STPs accounted for only 3-10% of the observed EROD-induction by the polyaromatic fractions. Consequently, many other polyaromatic EROD-inducing compounds were present in the sludge. Inclusion of a biological test like the chicken embryo liver bioassay in the screening of sludge would improve the ability to detect the presence of bioactive dioxin-like compounds. A theoretical estimation of bio-TEQ concentrations in farm-soil following long-term application of sludge with bio-TEQ concentrations similar to those observed in this investigation indicated that the bio-TEQ levels in soil would increase very slowly over time. The chicken embryo liver bioassay proved useful in assessing levels of dioxin-like compounds in sewage sludge and it gives valuable complementary information to chemical analysis data.

Beliefs about health and illness : a comparison between Ugandan men and women living with diabetes mellitus

BACKGROUND The diabetes mellitus (DM) pandemic greatly affects developing countries. Self-care is an important part of management, guided by beliefs about health and illness. Dissimilarities in health-related behaviour in men and women have been described but not comparisons of their beliefs about health and illness. AIM To explore beliefs about health and illness that might affect self-care practice and healthcare-seeking behaviour in men and women with DM in Uganda. METHODS This was an exploratory study with a consecutive sample from an outpatient diabetes clinic at a university hospital. Semi-structured interviews were conducted with 15 women and 10 men aged 21-70 years. Data analysis was conducted by qualitative content analysis. FINDINGS Mens and womens beliefs about health and illness indicated limited knowledge about the body and DM. Dissimilar were mens focus on socio-economic factors, particularly affordability of drugs, sexual function and lifestyle, while women valued well-being, support in daily life and household activities and had a higher risk-awareness of DM. Irrespective of gender, limited self-care measures were used, and health professionals were consulted about health problems. CONCLUSION Similarities and dissimilarities were found between men and women in beliefs about health and illness that affect self-care practice and healthcare seeking. Underlying living conditions, with different gender roles, appear to determine the beliefs about health and illness, which are based on individual knowledge. Measures to increase knowledge about DM are urgently needed in Uganda. In diabetes care, it is important to search for individual beliefs and consider gender and living conditions.Background:  The diabetes mellitus (DM) pandemic greatly affects developing countries. Self-care is an important part of management, guided by beliefs about health and illness. Dissimilarities in health-related behaviour in men and women have been described but not comparisons of their beliefs about health and illness. Aim:  To explore beliefs about health and illness that might affect self-care practice and healthcare-seeking behaviour in men and women with DM in Uganda. Methods:  This was an exploratory study with a consecutive sample from an outpatient diabetes clinic at a university hospital. Semi-structured interviews were conducted with 15 women and 10 men aged 21–70 years. Data analysis was conducted by qualitative content analysis. Findings:  Mens and womens beliefs about health and illness indicated limited knowledge about the body and DM. Dissimilar were mens focus on socio-economic factors, particularly affordability of drugs, sexual function and lifestyle, while women valued well-being, support in daily life and household activities and had a higher risk-awareness of DM. Irrespective of gender, limited self-care measures were used, and health professionals were consulted about health problems. Conclusion:  Similarities and dissimilarities were found between men and women in beliefs about health and illness that affect self-care practice and healthcare seeking. Underlying living conditions, with different gender roles, appear to determine the beliefs about health and illness, which are based on individual knowledge. Measures to increase knowledge about DM are urgently needed in Uganda. In diabetes care, it is important to search for individual beliefs and consider gender and living conditions.

Problems and consequences in the use of professional interpreters : qualitative analysis of incidents from primary healthcare.

The aim of this study was to explore what problems are reported by healthcare professionals in primary healthcare concerning the use of interpreters and what the problems lead to. The study involved a single case in a real-life situation with qualitative content analysis of 60 incident reports written by different healthcare professionals. The main problems documented were related to language, such as lack of the interpreters with proficiency in a particular language, and to organisational routines, with difficulties in the availability of interpreters and access to the interpreter agency. The problems reported led to incorrect use of time and resources, which increased the workload and thus delayed treatment. Other consequences were limited possibilities to communicate and thus consultation was carried out without a professional interpreter, using family members instead. The results highlight the importance of developing good co-operation between the interpreter agency and the primary healthcare centre in order to fulfil the existing policy of using professional interpreters to provide the right interpreter at the right time and guarantee high-quality care.

Foreign- and Swedish-born diabetic patients : a population-based study of prevalence, glycaemic control and social position

In this study foreign- and Swedish-born individuals with diabetes mellitus were compared regarding prevalence and characteristics. In a Swedish county 1,568 patients aged 20-64 years were identified, of whom 97.4% were included (143 foreign- and 1,384 Swedish-born) in the study of medical records. There was no difference in prevalence of diabetes (1.4% (95% CI 1.2-1.7%) vs 1.5% (95% CI 1.4-1.6%)) but diagnosis at or after the age of 30 years was more common in foreign-born patients (p<0.001). They were also less often treated with insulin (p<0.001), had shorter duration of diabetes (p<0.001), were more often classified as having a low social position in Sweden (p<0.001) and less often controlled in specialized diabetes care departments (p<0.001, 18% vs 43%). There was a higher occurrence of albuminuria among foreign-born women (p<0.05). No differences were found in glycaemic control, but low social position was related to poor glycaemic control independent of being foreign- or Swedish-born, and it seems to be more important than place of birth.

Health, health care utilization and living conditions in foreign-born diabetic patients in southern Sweden

Hjelm K, Apelqvist J, Nyberg P, Sundquist J, Isacsson Å (Department of Community Health Sciences Dalby/Lund, University of Lund, Sweden, and Department of Internal Medicine, Lund University Hospital, Sweden). Health, health care utilization and living conditions in foreign‐born diabetic patients in southern Sweden. J Intern Med 1997; 242: 131–41.

Beliefs about health and illness in Swedish and African-born women with gestational diabetes living in Sweden.

AIMS This paper is a report on a study exploring beliefs about health and illness in women with gestational diabetes born in Sweden and Africa living in Sweden. A further aim is to study the influence of beliefs on self-care and care seeking. BACKGROUND Extensive global migration leading to multicultural societies implies challenges to health care. Health/illness beliefs are culturally related and determine health-related behaviour, including self-care, which is crucial in management of gestational diabetes. The risk of developing gestational diabetes is increased in migrants, particularly of African origin, when residing in Western countries. No previous studies, except one, have been found comparing health/illness beliefs in women with gestational diabetes of different origin. DESIGN Exploratory descriptive study. METHODS Semi-structured interviews. Consecutive sample of women diagnosed with gestational diabetes, 13 born in Sweden and 10 born in Africa, from a diabetes clinic in Sweden. Qualitative content analysis of data was applied. RESULTS Beliefs were mainly related to individual and social factors. Health was described as freedom from disease and being healthy. Swedish women perceived heredity and hormonal changes as causing gestational diabetes, avoided work-related stress, had a healthy lifestyle, worried about the babys health and development of type 2 diabetes, sought information, used more medications and health care and were on sick-leave more often because of pregnancy-related problems than African women, who did not know the cause of gestational diabetes, had a passive self-care attitude and followed prescriptions, often reported being told by staff that gestational diabetes would disappear after delivery and stated more pregnancy-related problems which they treated with rest or watchful waiting. CONCLUSIONS Health/illness beliefs differed and affected self-care and care seeking. Lower risk awareness in African-born women was related to limited knowledge about the body and gestational diabetes, which was further amplified by healthcare professionals informing them about gestational diabetes being transient. RELEVANCE TO CLINICAL PRACTICE Individual beliefs and risk awareness must be elicited, and adequate information must be given to prevent negative health effects of gestational diabetes.

Healthcare staffs perceptions of using interpreters: a qualitative study

Aim: To describe how healthcare professionals experience and perceive the use of interpreters in their contacts with patients with whom they do not share a common language. Methods: An explorative ...

Higher Mortality and Different Pattern of Causes of Death Among Foreign-Born Compared to Native Swedes 1970–1999

In a previous Swedish longitudinal study of mortality among 723,948 foreign born and native-born Swedes, 1970–1999, increased mortality was found among foreign-born persons. This study describes and analyses the differences in mortality between 361,974 foreign-born persons and 361,974 native Swedes during the period 1970–1999, based on data from Statistics Sweden and the National Board of Health and Welfare. The mortality pattern showed dissimilarities; with a significantly higher number of deaths among foreign-born persons in six diagnose groups and a significantly lower mean age at time of death. A high number of deaths were found for migrants from Denmark in Neoplasm, for migrants from Finland and Poland in Diseases of the circulatory system and for migrants from Yugoslavia in Symptoms, signs and ill-defined conditions. There is a tendency to a more similar pattern between foreign- and Swedish-born persons over time. Migration may be a risk factor for health, and therefore seems to be an important factor to consider when studying morbidity and health and when planning preventive work.