Understanding household demand for indoor air pollution control in developing countries

More than 2 billion people rely on solid fuels and traditional stoves or open fires for cooking, lighting, and/or heating. Exposure to emissions caused by burning these fuels is believed to be responsible for a significant share of the global burden of disease. To achieve widespread health improvements, interventions that reduce exposures to indoor air pollution will need to be adopted and consistently used by large numbers of households in the developing world. Given that such interventions remain to be adopted by large numbers of these households, much remains to be learned about household demand for interventions designed (in part at least) to reduce indoor air pollution. A general household framework is developed that identifies in detail the determinants of household demand for indoor air pollution interventions, where demand for an intervention is expressed in terms of willingness to pay. Household demand is shown to be a combination of three terms: (1) the direct consumption effect; (2) the child health effect; and (3) the adult health effect. While micro-level data are not available to estimate directly this model, existing data and information are used to estimate just the health effects component of household demand. Based on such existing information, it might be concluded that household demand should seemingly be strong given that willingness to pay, based on existing information, is seemingly large compared to costs for common interventions like improved stoves. Given that household demand is not strong for existing interventions, this analysis shows that more clearly focused research on household demand for interventions is needed if such interventions are going to be demanded (i.e. adopted and used) by large numbers of households throughout the developing world. Four priority areas for future research are: (1) improving information on dose-response relationships between indoor air pollution and various health effects (e.g. increased mortality and morbidity risks); (2) improving information on impacts from interventions in terms of air pollution reductions and also cooking times, fuel use, and heat intensities; (3) improving information on household shadow values for improved health, with separate information for adult and child health; and (4) considering more directly household information, and its adequacy, for their ability to evaluate the relationships between fuel use and health.     

Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling,who is not and why?

To improve equity in the provision of health care and provide risk protection to poor households, low-income countries are increasingly moving to social health insurance. Using data from a household survey of 3301 households conducted in 2009 this study aims to evaluate equity in enrollment in the National Health Insurance Scheme (NHIS) in Ghana and assess determinants of demand across socio-economic groups. Specifically by looking at how different predisposing (age, gender, education, occupation, family size, marital status, peer pressure and health beliefs etc) enabling (income, place of residence) need (health status) and social factors (perceptions) affect household decision to enrol and remain in the NHIS. Equity in enrollment is assessed by comparing enrollment between consumption quintiles. Determinants of enrolling in and dropping out from NHIS are assessed using a multinomial logit model after using PCA to evaluate respondent's perceptions relating to schemes, providers and community health 'beliefs and attitudes'. We find evidence of inequity in enrollment in the NHIS and significant differences in determinants of current and previous enrollment across socio-economic quintiles. Both current and previous enrollment is influenced by predisposing, enabling and social factors. There are, however, clear differences in determinants of enrollment between the rich and the poor. Policy makers need to recognize that extending enrollment will require recognition of all these complex factors in their design of interventions to stimulate enrollment.     

High Prevalence of Food Insecurity and Hunger in Households in the Rural Lower Mississippi Delta

CONTEXT: Residents of the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi are at risk for food insecurity since a high proportion of the population live in households with incomes below the poverty level and have reduced access to food and decreased availability of a variety of foods. However, the magnitude of the problem is unknown because presently only nationwide and state estimates of food insecurity are available. PURPOSE: This study was conducted by the Lower-Mississippi Delta Nutrition Intervention Research Consortium to determine the prevalence of household food insecurity, identify high-risk subgroups in the Lower Delta, and compare to national data. METHODS: A 2-stage stratified cluster sample representative of the population in 36 counties in the Lower Delta was selected using list-assisted random digit dialing telephone methodology. A cross-sectional telephone survey of 1662 households was conducted in 18 of the 36 counties using the US Food Security Survey Module. FINDINGS: Twenty-one percent of Lower Delta households were food insecure, double the 2000 nationwide rate of 10.5%. Within the Lower Delta, groups with the highest rates of food insecurity were households with income below $15,000, black households, and households with children. The prevalence of hunger in Delta households with white children was 3.2% and in households with black children was 11.0%, compared to nationwide estimates of 0.3% and 1.6%. CONCLUSIONS: The Lower Mississippi Delta is characterized by a high prevalence of food insecurity and hunger. Future efforts to identify the household and community determinants of food insecurity to reduce its high prevalence are indicated.     

Exploring intra-household factors for diarrhoeal diseases: a study in slums of Delhi, India

While infrastructure conditions constitute 'primary routes', contamination of water within households and other behavioural determinants are considered as 'secondary routes'. However, recontaminated water has been considered not to constitute a serious risk though it occurs commonly in poorer societies. A study was conducted in Delhi where individual risk factors were located within a larger socio-economic, political and administrative framework, as they were often independent variables. This component of the larger study hypothesised that behavioural factors at individual household levels lose significance as major determinants of diarrhoeal diseases once they are analysed in a holistic epidemiology frame. Determinants at the household level were explored through a dataset based on a primary survey of 300 households in three slum clusters. Amongst households storing municipal water (proven to be safe at source), adhering to the best storage practices did not translate into lower incidence rates as compared to those with relatively unsafe practices. The explanation lay in factors which were external to the home and beyond the control of the affected household. Thus, household level behavioural factors such as storage practises should not be analysed in isolation as determinants of diarrhoeal illness particularly when pitted against stronger neighbourhood and external determinants.     

Exploring intra-household factors for diarrhoeal diseases: a study in slums of Delhi, India

While infrastructure conditions constitute ‘primary routes’, contamination of water within households and other behavioural determinants are considered as ‘secondary routes’. However, recontaminated water has been considered not to constitute a serious risk though it occurs commonly in poorer societies. A study was conducted in Delhi where individual risk factors were located within a larger socio-economic, political and administrative framework, as they were often independent variables. This component of the larger study hypothesised that behavioural factors at individual household levels lose significance as major determinants of diarrhoeal diseases once they are analysed in a holistic epidemiology frame. Determinants at the household level were explored through a dataset based on a primary survey of 300 households in three slum clusters. Amongst households storing municipal water (proven to be safe at source), adhering to the best storage practices did not translate into lower incidence rates as compared to those with relatively unsafe practices. The explanation lay in factors which were external to the home and beyond the control of the affected household. Thus, household level behavioural factors such as storage practises should not be analysed in isolation as determinants of diarrhoeal illness particularly when pitted against stronger neighbourhood and external determinants.     

Impacto sobre el consumo en bares,cafeterías y restaurantes de la modificación de la ley del tabaco española

Objectiveto analyze the impact of Spanish smoke-free legislation (Law 42/2010) on the business activity of bars, cafés, and restaurants.Methodswe used the micro-data from the Household Budget Survey for 2010 and 2011. The linking files allowed close follow-up of the households that remained in the sample for 2 consecutive years. Taking the year 2010 as the base reference for our analyses, we quantified how levels of consumption expenses on hospitality venues have changed over the years, differentiating between smoking households and non-smoking households.Resultsthe marginal effects of the first stage of the two-part model showed that the mean probability of expenditure on hospitality venues was 96% in smoking households and was 86% in non-smoking households. There were no statistically significant variations in the probability of expenditure between 2010 and 2011. The proportion of expenditure on hospitality venues in total household consumption expenditure in smoking households was 7.961% and 7.796% in 2010 and 2011, respectively. These proportions were 7.25% in 2010 and 7.272% in 2011 for non-smoking households. The difference in differences estimator, which takes into account both differences between years and households, showed no statistically significant differences in levels of household consumption.Conclusionsthe introduction of the Law 42/2010 has had noimpact on the levels of household consumption expenses on hospitality venues. Changes in consumption expenses could be explained by sociodemographic characteristics (such as the number of children per household) and the impact of the economic crisis (unemployment and a decrease in household income).     

Do differences in reported expenditures between household scanner data and expenditure surveys matter in health policy research?

Household scanner data are increasingly used to inform health policy such as sugar‐sweetened beverage taxes. This article examines whether differences in the level of reported expenditures between IRI Consumer Network scanner panel and the Consumer Expenditure Survey (CES) lead to important differences in demand elasticities and policy simulation outcomes. Using each dataset, we estimated a structural consumer demand system with seven food groups and a numéraire good. To compare the two datasets on a level playing field, we went to great lengths to ensure that the explanatory variables in the two demand models were comparably constructed. Results indicate that scanner data households are not consistently more price responsive than the general population and underreported Consumer Network expenditures do not seem to result in systematic differences in price elasticities. The income elasticities are uniformly lower in Consumer Network than in CES for higher income households because of the positive association between income and the degree of underreporting. This, however, has limited effects on uncompensated price elasticities and policy simulations because food budget shares are small for higher income households. Overall, these findings support continued use of household scanner data in health policy research related to effects of price (dis)incentives.     

Inequality in household catastrophic health care expenditure in a low-income society of Iran

BACKGROUND We assessed change in household catastrophic health care expenditures (CHE) and inequality in facing such expenditures in south-west Tehran. METHODS A cluster-sampled survey was conducted in 2003 using the World Health Survey questionnaire. We repeated the survey on the same sample in 2008 (635 and 603 households, respectively). We estimated the proportion of households facing CHE using the 'household's capacity to pay'. We identified the determinants of the household CHE using regression analysis and used the concentration index to measure socio-economic inequality and decompose it into its determinants factors. RESULTS Findings showed that the proportion of household facing CHE had no significant change in this period (12.6% in 2003 vs 11.8% in 2008). The key determinants of CHE for both years were health care utilization and health care insurance status. Socio-economic status was the main contributor to inequality in CHE, while unequal utilization of dentistry and outpatient services had reduced the inequality in CHE between socio-economic groups. CONCLUSIONS We observed no significant change in the CHE proportion despite policy interventions aimed at reducing such expenditures. Any solution to the problem of CHE should include interventions aimed at the determinants of CHE. It is essential to increase the depth of social insurance coverage by expanding the basic benefit package and reducing co-payments.     

Household Overcrowding in Iran,a Low-middle-income Country: How Major of a Public Health Concern Is It?

ObjectivesHousehold overcrowding (HC) can contribute to both physical and mental disorders among the members of overcrowded households. This study aimed to measure the status of HC and its main determinants across the provinces of Iran.MethodsData from 39 864 households from the 2016 Iranian Household Income and Expenditures Survey were used in this study. The Equivalized Crowding Index (ECI) and HC index were applied to measure the overcrowding of households. Regression models were estimated to show the relationships between different variables and the ECI.ResultsThe overall, urban, and rural prevalence of HC was 8.2%, 6.3%, and 10.1%, respectively. The highest prevalence of HC was found in Sistan and Baluchestan Province (28.7%), while the lowest was found in Guilan Province (1.8%). The number of men in the household, rural residency, the average age of household members, yearly income, and the household wealth index were identified as the main determinants of the ECI and HC.ConclusionsThe study demonstrated that the ECI and HC were higher in regions near the borders of Iran than in other regions. Therefore, health promotion and empowerment strategies are required to avoid the negative consequences of HC, and screening programs are needed to identify at-risk families.     

Household income and health care expenditures in Mexico

The purpose of this paper is to examine the determinants of household health expenditures in Mexico. Our analysis involves the estimation of household monetary health care expenditures, using the economic and demographic characteristics of the household as covariates. We pay particular attention to the impact of household income on health expenditures, estimating the elasticity of health care expenditures with respect to income for different income groups and according to health insurance status. For the empirical analysis, we use the Mexican National Survey of Income and Expenditures of 1989. Our principle findings show that monetary health expenditures by Mexican households are sensitive to changes in household income levels and that the group which is most responsive to changes in income levels in the lower-income uninsured group. This suggests that in times of economic crisis, these households reduce cash expenditures on health care by proportionately more than higher-income and insured households.     

Demand for voluntary health insurance in developing countries: the case of Vietnam's school-age children and adolescent student health insurance program

Many developing countries are trying to expand health insurance to achieve universal coverage, yet enrolling informal sector workers and the rural population remains a challenge. A good knowledge of factors driving demand for health insurance among these groups is therefore important. The current study contributes to this body of knowledge by analyzing demand for school-age children and adolescent student (aged 6-20) health insurance, a major voluntary health insurance scheme in Vietnam. Data were drawn form the Vietnam National Health Survey (2001-2002). We found that demand increases significantly with the expected benefits of insurance as measured by proximity to and quality of a tertiary hospital. There is a strong socio-economic gradient both at the household and commune levels, with wealthier, more educated households in better-off communes significantly more likely to purchase insurance for their children. No clear evidence of adverse selection is observed whether health status is assessed objectively or subjectively. Finally, while female heads of household are generally more prone to purchase health insurance for their children, households prioritize young children, male children, and those children with more schooling in their purchase decision. Findings emphasize the need to understand the effects of both health system factors and intra-household dynamics in resource allocation to explain the demand for health insurance in developing countries.     

Development and validation of an experience-based measure of household food insecurity within and across seasons in northern Burkina Faso

Organizations measure household food insecurity for program design, planning, targeting, implementation, monitoring, and evaluation, but existing measures often are inadequate. Qualitative and quantitative methods were used to develop and validate an experienced-based measure of the access component of food insecurity in northern Burkina Faso. In-depth interviews on food insecurity were done with 10 household heads and 26 women using interview guides. We identified themes, classified households, created a table of food insecurity categories, identified items to add to or delete from an initial questionnaire, and developed and revised answer choices. A longitudinal study provided quantitative data on changes over time in household food insecurity, economic situation, and related factors. Data were collected on 126 simple and complex households from 9 villages each July and January from 2001 to 2003 (5 waves). These data allowed examination of changes in household food insecurity twice annually across the best and worst seasons for food, and evaluation of the ability of the experience-based measure to differentiate changes in household food insecurity. Validity was assessed by examining reliability and by comparing the experienced-based food insecurity measure with economic status, dietary, and anthropometric measures and with a measure created by an observer who rated the households' food insecurity. The results provide strong evidence that the food insecurity score, calculated from experience-based questionnaire items, was valid for determining seasonal differences in household food insecurity, differences among households in food insecurity at a given time, and changes in household food insecurity over time in northern rural Burkina Faso.     

Multilevel survival analysis of health inequalities in life expectancy

Background

The health status of individuals is determined by multiple factors operating at both micro and macro levels and the interactive effects of them. Measures of health inequalities should reflect such determinants explicitly through sources of levels and combining mean differences at group levels and the variation of individuals, for the benefits of decision making and intervention planning. Measures derived recently from marginal models such as beta-binomial and frailty survival, address this issue to some extent, but are limited in handling data with complex structures. Beta-binomial models were also limited in relation to measuring inequalities of life expectancy (LE) directly.

Methods

We propose a multilevel survival model analysis that estimates life expectancy based on survival time with censored data. The model explicitly disentangles total health inequalities in terms of variance components of life expectancy compared to the source of variation at the level of individuals in households and parishes and so on, and estimates group differences of inequalities at the same time. Adjusted distributions of life expectancy by gender and by household socioeconomic level are calculated. Relative and absolute health inequality indices are derived based on model estimates. The model based analysis is illustrated on a large Swedish cohort of 22,680 men and 26,474 women aged 65-69 in 1970 and followed up for 30 years. Model based inequality measures are compared to the conventional calculations.

Results

Much variation of life expectancy is observed at individual and household levels. Contextual effects at Parish and Municipality level are negligible. Women have longer life expectancy than men and lower inequality. There is marked inequality by the level of household socioeconomic status measured by the median life expectancy in each socio-economic group and the variation in life expectancy within each group.

Conclusion

Multilevel survival models are flexible and efficient tools in studying health inequalities of life expectancy or survival time data with a geographic structure of more than 2 levels. They are complementary to conventional methods and override some limitations of marginal models. Future research on determinants of health inequalities in the LE of the specific cohort on the household and individual factors could reveal some important causes over the marked household level inequalities.     

Ill health and its potential influence on household consumptions in rural China

Ill health is very expensive and could have significant impact on household consumptions. The purpose of this study is to examine the differences in household consumption patterns among households with or without ill health family member(s) in rural China. We also examine the opportunity cost of ill health by estimating the marginal effects of medical spending on consumption patterns. The data used in this study are from the baseline survey of a community-based rural health insurance study in a poor rural area of China conducted in 2002. The unit of analysis in this study is the household; 4553 households are included in this survey. Fractional Logit model is used as our prediction model. Ill health is measured by the presence of hospitalization and presence of diagnosed chronic disease(s) in a household. Findings from this study reveal that ill health and medical expenditure reduces household investment in human capital, physical capital for farm production, and other consumptions that are critical to human well-being. Subgroup analysis displayed that the impacts of medical expenditure on household consumption patterns described above are more significant in low-income households than in high-income households. In addition, the decline of the percentages of other consumptions is much larger for households with hospitalization than for households with chronic diseases.     

Relying on nature's pharmacy in rural Burkina Faso: empirical evidence of the determinants of traditional medicine consumption

Traditional medicine is believed to constitute a crucial healthcare option for poor or remote households in developing countries that have limited access to allopathic medicine and/or a strong cultural attachment to traditional medicine. However, little research has been performed on medicinal plant reliance in developing countries, and the determinants of medicinal plant consumption at the household level in these countries have not been empirically studied. Quantifying the use of traditional medicine at the household level is, therefore, essential to the development of sustainable healthcare policies in the developing world. This paper quantifies household-level use of traditional medicine and identifies determinants of the choice of traditional treatment in the south central region of Burkina Faso. Structured household interviews (n = 205) were conducted in nine villages of rural Burkina Faso from November 2007 to November 2008 and in November 2009 to collect data on household characteristics (e.g., income, education, demographics), illness frequencies, illness types, and treatment strategies employed. Comprehensive analysis of treatment choice was performed through bivariate analyses. Results indicate that traditional medicine was primarily relied on by middle-aged individuals from relatively uneducated households who were living in villages with limited allopathic medicine service provision. Moreover, a differential approach to medicinal plant consumption was used to distinguish between patients using traditional medicine as a self-care treatment and those visiting a traditional healer. Although poorer households were shown to use traditional medicine as a self-treatment, traditional healers’ services were relied on by wealthier households.     

单纯随机抽样设计在社区人群调查中的应用

目的 探讨单纯随机抽样设计在社区人群调查中的可行性及调查样本质量.方法 在杭州市下城区和拱墅区根据社区居民电子底册以单纯随机抽样方法 抽取居民户,对户内18～64岁个体采用KISH方法 随机抽取一名个体,两区各需完成500人的调查.结果 下城区抽取950户,完成调查511户(53.8%);拱墅区抽取1380户,完成调查506户(36.7%).两区因户内不符合年龄要求的个体、原户搬迁、社区集体拆迁、底册错误等导致的无应答分别为38.3%和43.5%;各种原因导致的户(或抽中个体)无应答(或拒答)分别为8.0%和19.9%.调查样本与随机抽样户人群的年龄、性别构成无差异.随机抽样户人群与杭州市市区人群性别构成无差异,但年龄结构偏大.结论 在地域相对局限的社区中,基于社区居民电子底册实施单纯随机抽样具备可行性,对调查员的入户时间提出要求,可保证调查样本对抽样框的代表性.     

Participation in the Women,Infants, and Children (WIC) Program as Reported by Documented and Undocumented Farm Worker Adults in the Households

ABSTRACT

Debate surrounds the provision of Women, Infants, and Children (WIC) benefits to undocumented immigrants. Few studies are available to estimate use of WIC services by documented and undocumented households using nationally representative data. The authors analyzed data from the National Agricultural Workers Survey (NAWS) annual cross-sections from 1993 through 2009 (N = 40,896 person-years). Household documentation status is defined by the status of the adults in the household, not children. Simple mean differences, logistic regressions, and time charts described household participation in WIC over 2-year intervals. Without adjustments for covariates, 10.7% of undocumented farm workers’ households and 12.4% of documented households received WIC benefits, yielding an odds ratio of 0.84 (95% confidence interval [CI]: 0.76–0.94). Logistic regressions revealed that for the same number of children in the household, participation by undocumented persons was higher than participation by documented persons. Time charts and logistic regressions with interaction terms showed a stronger correspondence between participation in WIC and number of children <6 years old in undocumented households than documented households. Undocumented farm workers’ households were only a little less likely to participate in WIC than documented farm workers’ households, and undocumented households’ participation was especially responsive to the presence of children. These results are consistent with the legal requirements for WIC participation, which do not distinguish between documented and undocumented households. These results may be helpful in the debate surrounding the effects of undocumented workers on WIC participation and costs.     

Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh

OBJECTIVE: To study the health-seeking behaviour of elderly members (aged > 60 years) of households in rural Bangladesh, to ascertain how their behaviour differs from that of younger people (aged 20-59 years) living in the same household and to explore the determinants of health-seeking behaviour. METHODS: Structured interviews were conducted to elicit information on the health-seeking behaviour of household members aged > 20 years. Respondents were asked about major illnesses occurring within 15 days prior to the interview. The sample consisted of 966 households that had at least one resident who was aged > 60 (32% of 3031 households). FINDINGS: We found no major differences in health-seeking behaviour between elderly people and younger adults. On average about 35% (405/1169) of those who reported having been ill during the previous 15 days in both age groups chose self-care/self-treatment; for both age groups the most commonly consulted type of provider was a paraprofessional such as a village doctor, a medical assistant or a community health worker. A household''s poverty status emerged as a major determinant of health-seeking behaviour. The odds ratio (OR) that individuals from poor households would seek treatment from unqualified allopathic practitioners was 0.6 (95% confidence interval (CI) = 0.40-0.78); the odds ratio that individuals from poor households would seek treatment from qualified allopathic practitioners was 0.7 (95% CI = 0.60-0.95). For self-care or self-treatment it was 1.8 (95% CI = 1.43-2.36). Patients'' level of education affected whether they avoided self-care/self-treatment and drugstore salespeople (who are usually unlicensed and untrained but who diagnose illnesses and sell medicine) and instead chose a formal allopathic practitioner (OR = 1.5; 95% CI = 1.15-1.96). When a household''s poverty status was controlled for, there were no differences in age or gender in terms of health-care expenditure. CONCLUSION: We found that socioeconomic indicators were the single most pervasive determinant of health-seeking behaviour among the study population, overriding age and sex, and in case of health-care expenditure, types of illness as well.