Inequalities in out-of-pocket payments for health care services among elderly Germans – results of a population-based cross-sectional study

Introduction

In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed.

Methods

This cross-sectional analysis used data of N?=?3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family.

Results

Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one.

Conclusions

This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.     

Risk factors for tuberculosis among health care workers in South India: a nested case–control study

ObjectiveThe epidemiology of tuberculosis (TB) among health care workers (HCWs) in India remains under-researched. This study is a nested case–control design assessing the risk factors for acquiring TB among HCWs in India.Study Design and SettingsIt is a nested case–control study conducted at a tertiary teaching hospital in India. Cases (n = 101) were HCWs with active TB. Controls (n = 101) were HCWs who did not have TB, randomly selected from the 6,003 subjects employed at the facility. Cases and controls were compared with respect to clinical and demographic variables.ResultsThe cases and controls were of similar age. Logistic regression analysis showed that body mass index (BMI) <19 kg/m² (odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.49–5.87), having frequent contact with patients (OR: 2.83, 95% CI: 1.47–5.45) and being employed in medical wards (OR: 12.37, 95% CI: 1.38–110.17) or microbiology laboratories (OR: 5.65, 95% CI: 1.74–18.36) were independently associated with increased risk of acquiring TB.ConclusionHCWs with frequent patient contact and those with BMI <19 kg/m² were at high risk of acquiring active TB. Nosocomial transmission of TB was pronounced in locations, such as medical wards and microbiology laboratories. Surveillance of high-risk HCWs and appropriate infrastructure modifications may be important to prevent interpersonal TB transmission in health care facilities.     

Utilization of delivery care among rural women in china: does the health insurance make a difference? a cross-sectional study

Background  

Since 2003, the New Cooperative Medical Scheme (NCMS) has been implemented throughout rural China, usually covering delivery services in its benefit package. The objective of this study was to compare the difference of utilization of delivery services, expenditures, and local women's perceived affordability between women with and without reimbursement from NCMS.     

The in-home environment and household health: a cross-sectional study of informal urban settlements in northern México

People living in poverty make up nearly half of the global population and a large proportion of these individuals inhabit cities, living in informal settlements. However, only limited research on in-home environmental exposures and the associated health effects in these communities is available. This research investigates the home environment in unplanned settlements of a rapidly growing city on the U.S.-México border and its impact on the health of households with children under 12 years of age. A cross-sectional design was used to assess household exposures and health outcomes at the household level. A total of 202 households were selected from two informal settlements in the peri-urban region of Ciudad Juárez, México. The following variables were significantly associated with the report of at least one household member experiencing a health outcome in a two week period. Allergies were positively associated with insecticide use inside the home (adjusted Relative Odds (RO), 2.71; 95% confidence interval (CI), 1.2-6.3). Respiratory problems were associated with households using a wood burning stove vs. a gas stove (adjusted RO, 5.64; 95% CI, 1.1-27.9). Diarrhea was negatively associated with presence of a flush toilet in the home (adjusted RO, 0.22; 95% CI,0.1-0.6). Finally, eye irritations were positively associated with indoor tobacco smoke (adjusted RO, 2.23; 95% CI, 1.1-4.5). This research highlights exposures associated with poor living conditions in informal settlements and their associations with detrimental effects on health. More efforts should be made to understand the dynamics of poor urban environments including the health effects of exposures linked with poor housing conditions.     

The Bambui health and aging study: is calibration of dietary intake necessary among older adults?

Accurate measurements of food intake in surveys are difficult to be obtained especially in the older adults. Calibration, using two instruments, has been adopted in order to improve the information. This study was carried out in a random sample of older adults (> or =60) living in a Brazilian town. Food intake was obtained by the semi-quantitative food frequency questionnaire associated with photos (SFFQ-P) and the 24 hours recall (R24) with or without food models. Statistical analysis included tests to compare averages, Pearson's correlation coefficient and multiple linear regression. For all nutrients, the average intake obtained through SFFQ-P was significantly higher compared to the obtained by the R24 (p < or =0.05). SFFQ-P correlated better with R24 with food models, which was chosen as the reference method. In the multiple linear regression, vitamin C, fatty acid, protein and zinc intakes were influenced by age, especially when such nutrients were more concentrated in food not frequently reported. For protein and zinc, the significantly interaction between age with the 24 hours recall may have happened because of a differential selection of food sources as a function of age. This fact is probable related to chewing difficulties, reduction in the income and, a diet simplification associated with less complicated preparations, such as meat. This study reinforces the need for calibration of SFFQ in nutritional surveys among older adults, especially in etiological studies where the exposure assessment has to be accurate. In this case, R24 with food models should be used as a reference method to best estimate the true intake.     

Job stress and mental health among nonregular workers in Korea: What dimensions of job stress are associated with mental health?

Although nonregular workers experience higher job stress, poorer mental health, and different job stress dimensions relative to regular workers, little is known about which job stress dimensions are associated with poor mental health among nonregular workers. This study investigated the association between job stress dimensions and mental health among Korean nonregular workers. Data were collected from 333 nonregular workers in Seoul and Gyeonggi Province, and logistic regression analysis was conducted. Results of the study indicated that high job insecurity and lack of rewards had stronger associations with poor mental health than other dimensions of job stress when controlling for sociodemographic and psychosocial variables. It is important for the government and organizations to improve job security and reward systems to reduce job stress among nonregular workers and ultimately alleviate their mental health issues.     

The evaluation of efficacy and efficiency in the health care sector: separate or integrated moments?

Studies on efficacy (clinical trials) and efficiency (Cost Benefit) in health care are frequently disjoint and carried on by researchers with different background in distinct moments. The origin of this division can be found in the profound conviction existing in the healthcare researchers that efficiency and efficacy are distinct and distant concepts, the former pertaining to the economist, the latter to the clinician. Many are the factors at the basis of this separation which consequently lead to the divergence between the two sector of analysis; among those, probably the most relevant factor is the distinction, in the healthcare sector, between the consumer (the patient) and the purchaser (private and/or public insurance). In reality, the organizational evolution of the health care systems, the consciousness of the interdependency between health and economic benefits, and the progressive shortage of economic resources for the growing healthcare needs, require a major integration of analyses concerning efficacy and efficiency. On this line of thought is moving the operational research where models such as the Data Envelope Analysis and the Semi-Markov Decisional Models have been developed.     

Use of prenatal health care and risk of infants born small-for-gestational-age. Preliminary results of a case-control study in the Lódź voivodeship

It is well documented that small-for-gestational age (SGA) infants are at an increased risk of perinatal mortality and morbidity. In order to identify the major modifiable risk factors of SGA birth, a case-control study was launched in the area of Lód? voivodeship, Poland. The project was focused on the evaluation of the role of perinatal health services and avoidance of exposure to tobacco smoke in the prevention of SGA births. The study population consisted of mothers of 153 SGA infants (cases) and 93 mothers of control infants. SGA infants were identified as infants with body weight below 10th percentile for gestational age, using Ballarda scale. The controls were non-SGA infants delivered after 37 week of gestation. The infants from both groups were delivered in 26 maternity wards in the Lód? voivodeship within the period of June 1-November 1, 2003. One month after delivery, each mother of SGA and control infants was visited by an interviewer who collected information about her profile of use of perinatal health care and on active and passive exposure to tobacco smoke in pregnancy. Odds ratios and 95% confidence units (CU) were calculated using EpiInfo software developed by CDC, Atlanta, Georgia, US. Late booking for perinatal care (after 12 week of gestation) and less than 5 visits during pregnancy was found to be related to an increased risk of SGA, however, the OR values included unity. About 1/3 of mothers of SGA infants and "of the controls were served mainly by the private health sector. The use of private care was related to a lower risk of SGA: OR= 0.55 95% CI (0.31-0.96). This protective pattern was observed in the population of women aged 19-25 living in rural areas years and with only primary education. The preconception visits to obstetricians and contacts with health educators during pregnancy were also found to have some protective effect, however, the ORs were not statistically significant. The adverse effect of smoking during pregnancy was clearly confirmed in the study population, OR= 2.69 95%CI (1.37-5.33), while the role of passive smoking was difficult to assess due to the small number of nonsmoking women exposed to ETS. There are some indications that the poor use of perinatal health services may account for the elevated risk of SGA births in the Lód? voivodeship. The use of the private health sector is growing and seems to be related to a lower risk of SGA births. More effective tools to prevent maternal smoking have to be developed and implemented in routine perinatal care.     

The health and social well-being of female sex workers’ children in Bangladesh: A qualitative study from Dhaka,Chittagong, and Sylhet

Numerous studies have documented the health problems of sex workers; however, there has been limited research documenting the well-being of children of sex workers. Threats to the health and welfare of these children span their lives. Problems among infants may be more difficult to observe, but field observations by staff at NGOs, who operate drop-in-centers for sex workers in Bangladesh, suggest that older children of sex workers experience significant risks to their health and safety.

This qualitative study explored the threats to the health and welfare of children of sex workers through focus group discussions with sex workers and brothel madams in Bangladesh, all of whom were mothers. Risks to their children were explored from the time of pregnancy through adolescence.

Findings indicate that stigmatization of and discrimination against these children and their mothers are underlying conditions that compromise their access to safe housing, childcare, health care, education, and the protection of law enforcement. The threats they face may exceed those of other children in Bangladesh and include sexual exploitation, exploitive labor, trafficking for adoption, and forced entry into crime. In addition, many children of sex workers have reportedly been traumatized after witnessing police brutality against their mothers. While both sons and daughters of sex workers face similar barriers in altering their life trajectories, gender-specific challenges were also identified.

Additional research documenting trends among children of sex workers and their mothers is needed; however, much can be done immediately to mitigate potential harm by targeting family-based support to these mothers and children to meet basic needs and ensure their basic rights. Our recommendations are to strengthen health, social welfare, and other services to address protection and prevention needs; ensure access to basic services; and provide interventions that address the marginalization resulting from stigma and discrimination.     

The family health program and the reconstruction of basic health care in the Systema Unico de Saúde: a contribution of Brazilian nursing

The present study is a reflection about the historical, political and administrative dimensions of the reorganization of basic attention health services in Brazil, especially PSF and PACS. It also discusses the insertion of nursing professionals in these organizations, focusing on the management of total care in nursing assistance.     

Influenza vaccination coverages among high risk subjects and health care workers in Spain. Results of two consecutive National Health Surveys (2011–2014)

ObjectivesWe aim to describe influenza vaccination coverage for the Spanish population using data from two consecutive nation-wide representative health surveys. The data was analysed by high risk groups, health care workers (HCWs) and immigrants. Also, coverage trends were analysed.Material and methodsThe 2011/12 Spanish National Health Survey (N = 21,007) and the 2014 European Health Interview Survey for Spain (N = 22,842) were analysed. Influenza vaccination status was self-reported. Time trends for were estimated by a multivariate logistic regression model.ResultsOverall vaccination uptake was similar in 2011/12 and 2014, 19.1% and 18.9%, respectively, (p > 0.05). 47% of the subjects surveyed were in the groups for which vaccination was recommended with coverages of 41.1% in 2011/12 and 40% in 2014 (p > 0.05).In both surveys, uptake among subjects with a chronic disease was three times higher than uptake in subjects who did not have these diseases.In 2011/12 and 2014, 20% and 27.6% of health workers were vaccinated. Subjects born outside Spain were vaccinated less frequently than Spanish-born subjects (9.3% vs 20.4% and 8.9% vs 20%).Within the diseases studied, the best uptake was for patients with heart disease (52.5% in 2011/12 and 51.1% in 2014) and patients with diabetes (50.5% and 51.8%).Multivariate analysis showed that older age, having a chronic disease or being a HCW increases the possibility of being vaccinated whereas being born outside Spain decreased it.ConclusionsSeasonal influenza vaccine uptake rates in the recommended target groups, patients with chronic conditions and health care workers, in Spain are unacceptably low and seem to be stable in the post pandemic seasons. This finding should alert health authorities to the need to work directly with health care providers on the indications for this vaccine and to study strategies that make it possible to increase vaccination uptake.     

EQ-5D-3L health status and health state utilities of the oldest-old (85 +) in Germany: results from the AgeCoDe-AgeQualiDe study

Quality of Life Research - To describe health status and health state utilities measured by the EQ-5D-3L in a population-based sample of individuals aged 85?+?in Germany, and to analyze...     

Psychiatric institutions and communities: a study of the demand for mental health care in the State of São Paulo, Brazil

Psychiatric hospitals have been accused of being both ineffective institutions and the main parties responsible for the chronic status of the mentally ill. However, there is a lack of research on the influence of mental health care facilities on either the communities in which they are located or the nearby out-patient services. Their presence may be a cause for increased psychiatric demand. This study investigates a possible association between the existence of such hospitals in given communities and an increase in hospitalization and demand for primary care services. The author compares the demand and client profile of out-patient services in similar communities, both with and without psychiatric hospitals Some evidence was found that in communities with such hospitals there is an increase in both hospital admittance and consultations in mental health care.     

The effects of neck–shoulder pain development on sensory–motor interactions among female workers in the poultry and fish industries. A prospective study

OBJECTIVES: The purpose of this prospective laboratory study was to follow newly employed workers in the fish or poultry industry for 6 months and investigate possible changes in sensory manifestations and motor performance during low load, repetitive work simulation. It was investigated whether the changes were an effect of employment duration and of development of neck-shoulder complaints. METHODS: Twelve newly employed female filleting employees without any sign of neck-shoulder tenderness/pain at the time of employment of 0 months took part in two laboratory recording sessions planned within 1 month of employment and after 6 months of employment at the plant. After 6 months, six workers out of 12 had developed pain and/or tenderness in the neck-shoulder region. The recording sessions evaluated sensory-motor aspects by measuring pressure pain threshold, work-task timing, cutting forces, surface electromyographic activity of four shoulder muscles, displacement of the centre of pressure, and 3D movements of the arm and trunk during simulation of low load, repetitive filleting. RESULTS: Effects due to the duration of employment were observed in both groups, i.e. decreased sensibility to pressure, decrease in the duration of the work cycle, increased arm starting position with respect to the upright position, and decreased range of motion of the arm and trunk (P<0.05) after 6 months. Among the workers with neck-shoulder complaints, increased sensibility to pressure, lower force level, higher electromyographic activity, decreased amplitude of arm movement, and increased trunk posture and movement amplitude (P<0.05) were observed, compared with workers without complaints. CONCLUSIONS: Differences in terms of sensory manifestations and motor control strategy were seen after 6 months of employment with or without neck-shoulder complaints. In general, changes in sensory manifestations and motor control strategy after 6 months work were most likely of importance, as they underlined a learning process as employment duration increased. Moreover, the present sensory-motor changes observed among workers with neck-shoulder complaints highlighted the potential physical risk factors associated with low load, repetitive work.     

The incursion of ‘Big Food’ in middle-income countries: a qualitative documentary case study analysis of the soft drinks industry in China and India

Public health research is only just beginning to explore the myriad ways in which the food and beverage industry, or ‘Big Food’, has sought to influence policy and increase consumption of energy-dense products high in sugar, salt, and fat in middle-income countries. In particular, very little research has focused on Asia-Pacific markets, including China and India. This article uses the soft drink sector as a case study, and focuses on The Coca-Cola Company – the largest soft drinks company in both China and India. Documentary data from company reports, news articles, industry analyst reports, and industry magazines are analyzed to explore how the company successfully re-entered these markets following liberalization of their economies, and how it subsequently sought to influence government and key organizations in order to increase consumption and challenge public health policy. Applying a framework previously used in an analysis of Big Food in high income countries like the United States, I find that Coca-Cola has used the same strategies in China and India. Findings reveal that Coca-Cola lobbied US Government officials (in order to influence international issues); made political contributions; participated in a ‘revolving door’ between government and industry; funded professional organizations; and generally lobbied to resist regulation or urge weak regulation. The findings of this study could help to inform public health debates about Big Food in other emerging markets, including the Middle East and Africa.     

The establishment of bonds between professional and patient in TB treatment: the performance of primary health care services in a city in the interior of São Paulo

This study evaluated the performance of health care services implementing TB control actions in relation to the establishment of bonds between health professionals and patients in S?o José do Rio Preto, SP, Brazil from the perspective of patients, health professionals, and managers. A total of 108 patients, 37 health professionals and 15 managers were interviewed through a questionnaire containing 10 indicators of bond-establishment based on the instruments of the Primary Care Assessment Tool, adapted to evaluate tuberculosis control in Brazil. The three groups of actors considered the establishment of bonds satisfactory, though opinions of patients and managers differed in almost all indicators. This fact indicates that the view of managers is still predominantly focused on bureaucratic and administrative aspects, which shows the need for managers to integrate more management and care actions.     

The standard of care debate: can research in developing countries be both ethical and responsive to those countries' health needs?

To avoid exploitation of host communities, many commentators argue that subjects must receive the best methods available worldwide. Others worry that this requirement may block important research intended to improve health care, especially in developing countries.To resolve this dilemma, we propose a framework for the conditions under which it is acceptable to provide subjects with less than the best methods. Specifically, institutional review boards should assume a default of requiring the "worldwide best" methods, meaning the best methods available anywhere in the world, in all cases.However, institutional review boards should be willing to grant exceptions to this default for research studies that satisfy the following 4 conditions: (1) scientific necessity, (2) relevance for the host community, (3) sufficient host community benefit, and (4) subject and host community non-maleficence.     

Mental Vitality @ Work: The effectiveness of a mental module for workers’ health surveillance for nurses and allied health professionals,comparing two approaches in a cluster-randomised controlled trial

Purpose

The aim of this study was to compare two approaches for a worker’s health surveillance (WHS) mental module on work functioning and work-related mental health.

Methods

Nurses and allied health professionals from one organisation were cluster-randomised at ward level to e-mental health care (EMH) (N = 579) or occupational physician care (OP) (N = 591). Both groups received screening and personalised feedback on impaired work functioning and mental health. Positively screened participants received an invitation to follow a self-help EMH intervention, or for a consultation with an OP. The primary outcome was impaired work functioning. Follow-up was performed after 3 and 6 months. Linear mixed models were applied to determine differences. Non-inferiority of the EMH-care approach was demonstrated if the mean absolute improvement on work functioning in the OP-care group was ≤10 points higher than the EMH-care group.

Results

Analyses were performed on the positively screened participants (almost 80 %) (EMH N = 75; OP N = 108) and all participants (EMH N = 98; OP N = 142). Both groups improved over time regarding impaired work functioning. A considerable percentage of participants had improved relevantly at follow-up regarding work functioning (3 months: EMH 30 %, OP 46 %; 6 months: EMH 36 %, OP 41 %) compared to baseline. No statistically significant differences were found between the groups, and the difference did not exceed the pre-defined criterion for non-inferiority.

Conclusion

The OP-care approach for a WHS mental module trended towards better performance in targeting work functioning, but our findings indicate that the EMH-care approach was non-inferior. However, the high dropout rate and low compliance to EMH interventions should be taken into account.