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1.
Purpose
Despite significant contribution by India’s informal sector, tattered conditions have inflated the burden of health shocks in many ways. This study tries to examine the economic burden of health shocks and its associated consequences on households whose members are involved in informal sector. We primarily focus on three objectives for our analysis: (1) compute distribution and magnitude of health shocks and health expenditure between formal and informal workers; (2) evaluate the incidence and intensity of catastrophic health expenditure (CHE), and measure its impoverishment effect; (3) estimate the major determinants of CHE for informal sector households.Methods
Underlying objectives have been estimated using standard catastrophic and impoverishment measures (poverty headcount and poverty gap) and Poisson, logit and Tobit multivariate regression models. For empirical analysis, data is exploited from the recent round of Indian Human Development Survey (IHDS-II), 2012.Results
We find that around 27% of households engaged in the informal sector spends more than 5% threshold on their health payment. We also find that OOP health expenditure pushes 7.12% informal sector households in poverty. Moreover, we also find that the impoverishment effect mainly rests on outpatient health expenditure and poverty deepening for informal sector households.Conclusion
Our findings indicate that informal sector workers are highly vulnerable to health shocks and economic burden in terms of high treatment costs and low insurance coverage. Further, we also show that workers engaged in the informal sector witness greater probability of incurring CHE and impoverishment. Results from the Tobit model suggests that various factors such as insurance coverage, severity of illness and others are crucial predictor of catastrophic spending.2.
James Akazili John Ele-Ojo Ataguba Edmund Wedam Kanmiki John Gyapong Osman Sankoh Abraham Oduro Di McIntyre 《BMC international health and human rights》2017,17(1):13
Background
There is a global concern regarding how households could be protected from relatively large healthcare payments which are a major limitation to accessing healthcare. Such payments also endanger the welfare of households with the potential of moving households into extreme impoverishment. This paper examines the impoverishing effects of out-of-pocket (OOP) healthcare payments in Ghana prior to the introduction of Ghana’s national health insurance scheme.Methods
Data come from the Ghana Living Standard Survey 5 (2005/2006). Two poverty lines ($1.25 and $2.50 per capita per day at the 2005 purchasing power parity) are used in assessing the impoverishing effects of OOP healthcare payments. We computed the poverty headcount, poverty gap, normalized poverty gap and normalized mean poverty gap indices using both poverty lines. We examine these indicators at a national level and disaggregated by urban/rural locations, across the three geographical zones, and across the ten administrative regions in Ghana. Also the Pen’s parade of “dwarfs and a few giants” is used to illustrate the decreasing welfare effects of OOP healthcare payments in Ghana.Results
There was a high incidence and intensity of impoverishment due to OOP healthcare payments in Ghana. These payments contributed to a relative increase in poverty headcount by 9.4 and 3.8% using the $1.25/day and $2.5/day poverty lines, respectively. The relative poverty gap index was estimated at 42.7 and 10.5% respectively for the lower and upper poverty lines. Relative normalized mean poverty gap was estimated at 30.5 and 6.4%, respectively, for the lower and upper poverty lines. The percentage increase in poverty associated with OOP healthcare payments in Ghana is highest among households in the middle zone with an absolute increase estimated at 2.3% compared to the coastal and northern zones.Conclusion
It is clear from the findings that without financial risk protection, households can be pushed into poverty due to OOP healthcare payments. Even relatively richer households are impoverished by OOP healthcare payments. This paper presents baseline indicators for evaluating the impact of Ghana’s national health insurance scheme on impoverishment due to OOP healthcare payments.3.
Background
As compared to other countries in South East Asia, India’s health care system is characterized by very high out of pocket payments, and consequently low financial protection and access to care. This paper describes the relative importance of ill-health compared to other adverse events, the conduits through which ill-health affects household welfare and the coping strategies used to finance these expenses.Methods
Cross-sectional data are used from a survey conducted with 5241 households in Uttar Pradesh and Bihar in 2010 that included a household shocks module and detailed information about health care use and spending.Results
Health-related adverse events were the second most common adverse events (34%), after natural disasters (51%). Crop and livestock disease and weddings each affected about 8% of households. Only a fourth of households reported to have recovered from illness and/or death in the family (by the time of the survey). Most of the households’ economic burden related to ill-health was depending on direct medical costs, but indirect costs (such as lost earnings and transportation or food costs) were also not negligible. Close to half of the health expenditures were made for chronic conditions. Households tried to cope with health-related expenditures mostly by dissaving, borrowing and selling assets. Few households reported having to reduce (food) consumption in response to ill-health.Conclusions
In the absence of pre-financing schemes, ill-health events pose a substantial threat to household welfare in rural India. While most households seem to be able to smooth consumption in the short term, coping strategies like selling assets and borrowing from moneylenders are likely to have severe long term consequences. As most of the households’ economic risk related to ill-health appears to depend on out of pocket spending, introducing health insurance may contribute significantly to alleviate economic hardship for families in rural India. The importance of care for chronic diseases, however, represents a big challenge for the sustainability of community based health insurance schemes, since it is necessary to ensure a sufficient degree of risk pooling.4.
Background
China is reforming the way it finances health care as it moves towards Universal Health Coverage (UHC) after the failure of market-oriented mechanisms for health care. Improving financing equity is a major policy goal of health care system during the progression towards universal coverage.Methods
We used progressivity analysis and dominance test to evaluate the financing channels of general taxation, pubic health insurance, and out-of-pocket (OOP) payments. In 2012 a survey of 8854 individuals in 3008 households recorded the socioeconomic and demographic status, and health care payments of those households.Results
The overall Kakwani index (KI) of China’s health care financing system is 0.0444. For general tax KI was ?0.0241 (95% confidence interval (CI): ?0.0315 to ?0.0166). The indices for public health schemes (Urban Employee Basic Medical Insurance, Urban Resident’s Basic Medical Insurance, New Rural Cooperative Medical Scheme) were respectively 0.1301 (95% CI: 0.1008 to 0.1594), ?0.1737 (95% CI: –0.2166 to ?0.1308), and ?0.5598 (95% CI: –0.5830 to ?0.5365); and for OOP payments KI was 0.0896 (95%CI: 0.0345 to 0.1447). OOP payments are still the dominant part of China’s health care finance system.Conclusion
China’s health care financing system is not really equitable. Reducing the proportion of indirect taxes would considerably improve health care financing equity. The flat-rate contribution mechanism is not recommended for use in public health insurance schemes, and more attention should be given to optimizing benefit packages during China’s progression towards UHC.5.
Background
User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e. subsidised price set at 900 Communauté Financière Africaine francs (CFA) for all, but free for the poorest). Taking into account the challengeslinked to implementing exemption policies, we aimed to test the hypothesis that the user fee reductionpolicy had favoured the least poor more than the poor.Methods
We used data from six consecutive rounds (2006–2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20 % according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy.Findings
A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA.Conclusions
The Burkinabè policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.6.
Background
Schizophrenia remains a priority condition in mental health policy and service development because of its early onset, severity and consequences for affected individuals and households.Aims and methods
This paper reports on an ‘extended’ cost-effectiveness analysis (ECEA) for schizophrenia treatment in India, which seeks to evaluate through a modeling approach not only the costs and health effects of intervention but also the consequences of a policy of universal public finance (UPF) on health and financial outcomes across income quintiles.Results
Using plausible values for input parameters, we conclude that health gains from UPF are concentrated among the poorest, whereas the non-health gains in the form of out-of-pocket private expenditures averted due to UPF are concentrated among the richest income quintiles. Value of insurance is the highest for the poorest quintile and declines with income.Conclusions
Universal public finance can play a crucial role in ameliorating the adverse economic and social consequences of schizophrenia and its treatment in resource-constrained settings where health insurance coverage is generally poor. This paper shows the potential distributional and financial risk protection effects of treating schizophrenia.7.
Background
In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.Aim
The study proposed a framework to assess the public health care facilities for vulnerability.Methods
A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.Results
Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.Conclusion
Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.8.
Maria Liljeroos Susanna Ågren Tiny Jaarsma Kristofer Årestedt Anna Strömberg 《Quality of life research》2017,26(2):367-379
Background
Partners of patients with heart failure provide both practical and emotional support. Many partners assume caregiving responsibilities without being aware of the burden related with this role.Objective
Our work has established that a psycho-educational intervention has benefits at 3, but not at 12 months for patients with heart failure. Further we had not described the long-term effects in caregivers. This study aimed to determine the 24-months effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure and study factors associated with a change in caregiver burden.Design
A randomized controlled study design, with a follow-up assessment after 24 months.Setting and participants
Partners to patients with heart failure were recruited from two hospitals in the southeast of Sweden.Intervention
A three session nurse-led psycho-educational program was tested and included psychosocial support to maintain the partners’ physical and mental functions, and perceived control. Several instrument were used to measure caregiver burden, perceived control, physical and mental health, depression and morbidity.Results
One hundred fifty-five partners were included. There were no significant differences in any index of caregiver burden or morbidity among the partners in the intervention and control groups after 24 months. Overall, the mean total caregiver burden was found to be significantly increased compared to baseline (36 ± 12 vs 38 ± 14, p < 0.05). A younger partner, less comorbidity, higher levels of perceived control, better physical health and less symptoms of depression in patients, and better mental health in the partners were factors associated with absence of increased caregiver burden over time.Discussion and conclusion
Our intervention did not significantly decrease caregiver burden or morbidity. Over time, several aspects of burden increased in both groups. To improve outcomes, individualized and targeted interventions might be beneficial.Registered on ClinicalTrials.gov Identifier
NCT02398799.9.
Background
Equitable financing is a key objective of health care systems. Its importance is evidenced in policy documents, policy statements, the work of health economists and policy analysts. The conventional categorisations of finance sources for health care are taxation, social health insurance, private health insurance and out-of-pocket payments. There are nonetheless increasing variations in the finance sources used to fund health care. An understanding of the equity implications would help policy makers in achieving equitable financing.Objective
The primary purpose of this paper was to comprehensively assess the equity of health care financing in Malaysia, which represents a new country context for the quantitative techniques used. The paper evaluated each of the five financing sources (direct taxes, indirect taxes, contributions to Employee Provident Fund and Social Security Organization, private insurance and out-of-pocket payments) independently, and subsequently by combined the financing sources to evaluate the whole financing system.Methods
Cross-sectional analyses were performed on the Household Expenditure Survey Malaysia 1998/99, using Stata statistical software package. In order to assess inequality, progressivity of each finance sources and the whole financing system was measured by Kakwani's progressivity index.Results
Results showed that Malaysia's predominantly tax-financed system was slightly progressive with a Kakwani's progressivity index of 0.186. The net progressive effect was produced by four progressive finance sources (in the decreasing order of direct taxes, private insurance premiums, out-of-pocket payments, contributions to EPF and SOCSO) and a regressive finance source (indirect taxes).Conclusion
Malaysia's two tier health system, of a heavily subsidised public sector and a user charged private sector, has produced a progressive health financing system. The case of Malaysia exemplifies that policy makers can gain an in depth understanding of the equity impact, in order to help shape health financing strategies for the nation.10.
Hao Huang Siqi Liu Xiaoxing Cui Junfeng Zhang Hui Wu 《Quality of life research》2018,27(12):3255-3263
Purpose
Specific medical and living conditions in rural China may predispose people there to a poor quality of life. This study aimed to evaluate factors affecting the quality of life among married women in rural China.Methods
This cross-sectional study was conducted in rural areas of Liaoning Province in China. Out of the 3900 married women, 3163 (81%) completed the questionnaire survey. Quality of life was assessed using the WHOQOL-BREF scale. Sociodemographic factors, such as monthly income, and living and health conditions, such as left-behind status, stress (quantified by the Perceived Stress Scale), and coping styles (assessed by the Simplified Coping Style Questionnaire) were collected through self-reported questionnaires. Hierarchical multiple regression was used to explore the factors related to quality of life.Results
The mean scores of quality of life were 14.08?±?2.27 for the domain of physical health, 11.78?±?2.28 for psychological health, 13.07?±?2.69 for social relationships, and 12.26?±?2.67 for environmental conditions. Older age, having chronic diseases, being left-behind, sense of marriage insecurity, and stress were all negatively associated with quality of life scores, whereas a higher monthly income was associated with higher scores. Coping styles could be moderating factors in the relationship between stress and quality of life.Conclusions
Overall, married women living in rural China had relatively low scores for quality of life. Improving family income, providing access to affordable and high-quality medical care, facilitating couple communication, and promoting active coping styles could be intervention strategies to improve the quality of life of these rural residents.11.
Aim
The main aim of this study was to assess the psychological consequences that displacement brings into the lives of India’s tribal populations, specifically, in the form of mental illness.Subject and methods
Literature review.Results
The impact of forced displacement on the mental state of tribal populations is significant and multi-faceted. In spite of sufficient evidence indicating the extent of mental health challenges, the Governmental response in India has been completely missing. Some of the challenges in the path of Indian health providers are poor diagnostic facilities, lack of psychiatric epidemiological data for tribal populations, and culturally inappropriate instruments. Scientists and practitioners can play an important role in bridging the knowledge gap in the field.Conclusion
It is necessary to perceive the mental health status of displaced tribal populations within the larger framework of social justice. A strictly biomedical approach is insufficient when the individuals seeking help are under constant stress. Thus, a mental health program is needed for tribal people that offers a perspective broad enough to address the needs of individuals and the local worlds in which they live.12.
Background
Changes in third party financing, whether public or private, are linked to a household's ability to access dental care. By removing costs at point of purchase, changes in financing influence the need to reach into one's pocket, thus facilitating or limiting access. This study asks: How have historical changes in dental care financing influenced household out-of-pocket expenditures for dental care in Canada?Methods
This is a mixed methods study, comprised of an historical review of Canada's dental care market and an econometric analysis of household out-of-pocket expenditures for dental care.Results
We demonstrate that changes in financing have important implications for out-of-pocket expenditures: with more financing come drops in the amount a household has to spend, and with less financing come increases. Low- and middle-income households appear to be most sensitive to changes in financing.Conclusions
Alleviating the price barrier to care is a fundamental part of improving equity in dental care in Canada. How people have historically spent money on dental care highlights important gaps in Canadian dental care policy.13.
Background
A hantavirus risk perception and communication study was performed in the years 2011–2012 as part of the EU-funded EDENext project in endemic areas of Germany.Methods
Three focus groups were conducted: one in urban and two in rural regions. Participants of one rural group were exposed to the hantavirus due to their occupation. All groups were analysed regarding their risk perception, their risk knowledge about the hantavirus and its transmission, their coping strategies and their information behaviour and expectations in case of an outbreak.Results
The analysed groups living in endemic areas are well aware of the hantavirus risk. They have basic knowledge about protection measures. However, not all of them who know the latter would also apply protection measurements for practical reasons. Information provided by mass media or others are more trustworthy if the source mentioned is a public (health) authority. Static warning signs, such as tables, are less appreciated than risk maps for reasons of timeliness.Conclusions
The development of health communication strategies, including health campaigns, should be based on risk perception studies, in order to reach the target groups. This is particularly relevant in case of rare or locally limited diseases.14.
Adverse Childhood Experiences,Coping Resources,and Mental Health Problems among Court-Involved Youth
Patricia Logan-Greene Robert L. Tennyson Paula S. Nurius Sharon Borja 《Child & youth care forum》2017,46(6):923-946
Background
Mental health problems are gaining attention among court-involved youth with emphasis on the role of childhood adversity, but assessment lags.Objective
The present study uses a commonly delivered assessment tool to examine mental health problems (current mental health problem, mental health interfered with probation goals, and suicide ideation) as a function of an expanded set of adverse childhood experiences (ACEs; childhood maltreatment, family dysfunction, and social disadvantage). Adaptive coping resources–impulse control, aspirations, and social support–were tested as both direct contributors and moderators of the influence of ACEs on mental health.Methods
Using a diverse sample of youth on probation (N = 5378), this study utilized logistic regression models to test contributions of the three domains of childhood adversity–childhood maltreatment, family dysfunction, and social disadvantage. These models also examined the moderating roles of coping resources.Results
Childhood maltreatment emerged as the strongest contributor to mental health problems, with significant moderation from social support. Youth aspirations were inversely related to mental health problems and moderated the relation with ACEs and mental health problems that interfered with probation.Conclusions
Assessment and mitigation of the detrimental effects of childhood maltreatment are important considerations in the intervention programs that target mental health outcomes of court-involved youth. Intervention programs to prevent recidivism and improve mental health should improve impulse control and aspirations.15.
Anita L. Hansen G. Ambroziak D. Thornton L. Dahl B. Grung 《The journal of nutrition, health & aging》2018,22(4):513-518
Objectives
To investigate the effect of a long-term fatty fish intervention on a pure cognitive mechanism important for self-regulation and mental health, i.e. working memory (WM), controlling for age and IQ.Design
A randomized controlled trial.Setting
A forensic facility.Participants
Eighty-four young to middle aged male forensic inpatients with psychiatric disorders.Intervention
Consumption of farmed salmon or control meal (meat) three times a week during 23 weeks.Measurement
Performance on WM tasks, both accuracy and mean reaction time, were recorded pre and post intervention.Results
Performance on a cognitive functioning tasks taxing WM seemed to be explained by age and IQ.Conclusion
Fatty fish consumption did not improve WM performance in a group of young to middle aged adults with mental health problems, as less impressionable factors such as aging and intelligence seemed to be the key components. The present study improves the knowledge concerning the interaction among nutrition, health and the aging process.16.
Ama de-Graft Aikins Mawuli Kushitor Kwadwo Koram Stella Gyamfi Gbenga Ogedegbe 《BMC public health》2014,14(Z2):S3
Background
The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.Methods
We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.Results
The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.Conclusions
We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.17.
Catherine E. Mosher Ekin Secinti Shelley A. Johns Bert H. O’Neil Paul R. Helft Safi Shahda Shadia I. Jalal Victoria L. Champion 《Quality of life research》2018,27(2):515-528
Purpose
At the end of life, spiritual well-being is a central aspect of quality of life for many patients and their family caregivers. A prevalent spiritual value in advanced cancer patients is the need to actively give. To address this need, the current randomized trial examined whether adding a peer helping component to a coping skills intervention leads to improved meaning in life and peace for advanced gastrointestinal cancer patients and their caregivers. Feasibility and acceptability outcomes were also assessed.Methods
Advanced gastrointestinal cancer patients and caregivers (n = 50 dyads) were randomly assigned to a 5-session, telephone-based coping skills intervention or a peer helping + coping skills intervention. One or both dyad members had moderate–severe distress. Peer helping involved contributing to handouts on coping skills for other families coping with cancer. Patients and caregivers completed measures of meaning in life/peace, fatigue, psychological symptoms, coping self-efficacy, and emotional support. Patient pain and caregiver burden were also assessed.Results
Small effects in favor of the coping skills group were found regarding meaning in life/peace at 1 and 5 weeks post-intervention. Other outcomes did not vary as a function of group assignment, with both groups showing small decreases in patient and caregiver fatigue and caregiver distress and burden. High recruitment and retention rates supported feasibility, and high participant satisfaction ratings supported acceptability.Conclusions
Although a telephone-based intervention is feasible and acceptable for this population, peer helping in the context of a coping skills intervention does not enhance spiritual well-being relative to coping skills alone.18.
Health status in a transitional society: urban-rural disparities from a dynamic perspective in China
Background
The phenomenon of urban-rural segmentation has emerged and is remarkable, and the health disparities between rural and urban China should be stressed.Methods
Based on data from the Chinese General Social Survey from 2005 to 2013, this study not only explored the net age, period, and cohort effects of self-rated health, but compared these effects between rural and urban China from a dynamic perspective through hierarchical age-period-cohort-cross-classified random effects model.Results
Urban-rural disparities, as well as work status and gender disparities in health increased with age, in line with the cumulative advantage/disadvantage effects theory, while marital status disparities in health declining with age was in line with the age-as-leveler effects theory. The war cohort, famine cohort, later cultural revolution cohort, and early reform cohort had poorer health than did those in the early China cohort, economic recovery cohort, and later reform cohort. The economic crisis period, war cohort, baby boomer, and early cultural revolution cohort encountered larger urban-rural health disparities, while the early China cohort and early reform cohort experienced smaller urban-rural disparities in health.Conclusions
Population health is closely related to social context and health care development. It is necessary to keep economic development stable and boost medical technology improvements and the construction of the health care system.19.
20.
D. M. Mijnarends Y. C. Luiking R. J. G. Halfens S. M. A. A. Evers E. L. A. Lenaerts S. Verlaan M. Wallace Jos M. G. A. Schols J. M. M. Meijers 《The journal of nutrition, health & aging》2018,22(7):766-773