Contribution of occupational factors to social inequalities in self-reported health among French employees

Objectives

Social inequalities in health have been widely demonstrated. However, the mechanisms underlying these inequalities are not completely understood. The objective of the study was to examine the contribution of various types of occupational exposures to social inequalities in self-reported health (SRH).

Methods

The study population was based on a random sample of 3,463 men and 2,593 women of the population of employees in west central France (response rate: 85–90 %). Data were collected through a voluntary network of 110 occupational physicians in 2006–2007. Occupational factors included biomechanical, physical, chemical and psychosocial exposures. All occupational factors were collected by occupational physicians, except psychosocial work factors, which were measured using a self-administered questionnaire. Social position was measured using occupational groups.

Results

Strong social gradients were observed for a large number of occupational factors. Marked social gradients were also observed for SRH, manual workers and clerks/service workers being more likely to report poor health. After adjustment for occupational factors, social inequalities in SRH were substantially reduced by 76–134 % according to gender and occupational groups. The strongest impacts in reducing these inequalities were observed for biomechanical exposures and decision latitude. Differences in the contributing occupational factors were observed according to gender and occupational groups.

Conclusion

This study showed that poor working conditions contributed to explain social inequalities in SRH. It also provided elements for developing specific preventive actions for manual workers and clerks/service workers. Prevention towards reducing all occupational exposures may be useful to improve occupational health and also to reduce social inequalities in health.     

Emotional demands and the risks of depression among homecare workers in the USA

Purpose

Homecare workers’ diversity of emotional demands and their relation to mental health problems have not yet been fully explored. The purpose of this study is to investigate the types of emotional demands on homecare workers and the association of these demands with depression.

Method

Data were collected from two surveys of a random sample of 1,599 homecare workers (June 2003–September 2003 and December 2003–February 2004). Depression was assessed using a 20-item RCES-D screening scale.

Results

Homecare workers appeared to have a variety of emotional demands: unfair treatment, client’s family abuse, unmet care needs, client health, and emotional suppression. In general, homecare workers were more likely to be exposed to their client health and emotional suppression (mean scores = 1.46–3.07) than to be exposed to unmet care needs, unfair treatment, and client’s family abuse (mean scores = 1.02–1.38). After adjusting for potential confounders, four emotional-demand factors (excluding the client health factor) were significantly associated with a high risk of subthreshold depression at Wave 1. In particular, the factor “unmet care needs” was an essential predictor of 6-month subthreshold depression at Wave 2.

Conclusion

This study illustrated the diversity of emotional demands among homecare workers and their association with depression. Our mixed findings regarding the cross-sectional and longitudinal analyses suggested that further research should refine the measurement of emotional demands and their relationship with mental health among homecare workers.     

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.     

Socio-economic disparities in mortality due to pandemic influenza in England

Objectives

This study examines variations in mortality between socio-economic groups due to the pandemic Influenza (H1N1) 2009 virus in England.

Methods

We established a system to identify all deaths related to pandemic (H1N1) 2009 influenza. We collected the postcode of every individual who died, and through this determined the socio-economic deprivation, urban–rural characteristics and region of their residence. Across England, we were therefore able to examine how mortality rates varied by socio-economic group, between urban and rural areas, and between regions.

Results

People in the most deprived quintile of England’s population had an age and sex-standardised mortality rate three times that experienced by the least deprived quintile (RR?=?3.1, 95% CI 2.2–4.4). Mortality was also higher in urban areas than in rural areas (RR?=?1.7, 95% CI 1.2–2.3). Mortality rates were similar between regions of the country.

Conclusion

Tackling socio-economic health inequalities is a central concept within public health, but has not always been a part of emergency preparedness plans. These data demonstrate the opportunity to reduce the overall impact and narrow inequalities by considering socio-economic disparities in future pandemic planning.     

Decomposing Kenyan socio-economic inequalities in skilled birth attendance and measles immunization

Introduction

Skilled birth attendance (SBA) and measles immunization reflect two aspects of a health system. In Kenya, their national coverage gaps are substantial but could be largely improved if the total population had the same coverage as the wealthiest quintile. A decomposition analysis allows identifying the factors that influence these wealth-related inequalities in order to develop appropriate policy responses. The main objective of the study was to decompose wealth-related inequalities in SBA and measles immunization into their contributing factors.

Methods

Data from the Kenyan Demographic and Health Survey 2008/09 were used. The study investigated the effects of socio-economic determinants on [1] coverage and [2] wealth-related inequalities of SBA utilization and measles immunization. Techniques used were multivariate logistic regression and decomposition of the concentration index (C).

Results

SBA utilization and measles immunization coverage differed according to household wealth, parent’s education, skilled antenatal care visits, birth order and father’s occupation. SBA utilization further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent’s education (28%), antenatal care (9%), and province (6%). The overall C for measles immunization was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent’s education (28%). Rural residence (?19%) reduced this inequality.

Conclusion

Both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups.     

Targeted versus universal prevention. a resource allocation model to prioritize cardiovascular prevention

Background

Diabetes mellitus brings an increased risk for cardiovascular complications and patients profit from prevention. This prevention also suits the general population. The question arises what is a better strategy: target the general population or diabetes patients.

Methods

A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed.

Results

Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of ?40 per capita, about ?2,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below ?0,000 per QALY. Low or high budgets (below ? or above ?00 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients.

Conclusions

Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.     

Efficacy of integrated school based de-worming and prompt malaria treatment on helminths -Plasmodium falciparum co-infections: A 33 months follow up study

Background

Serbia has proclaimed access to healthcare as a human right. In a context wherein the Roma population are disadvantaged, the aim of this study was to assess whether the Roma population are able to effectively access primary care services, and if not, what barriers prevent them from doing so. The history of the Roma in Serbia is described in detail so as to provide a context for their current vulnerable position.

Methods

Disaggregated data were analyzed from three population groups in Serbia; the general population, the Roma population, and the poorest quintile of the general population not including the Roma. The effective coverage framework, which incorporates availability, affordability, accessibility, acceptability, and effectiveness of health services, was used to structure the secondary data analysis. Acute respiratory infection (ARI) in children less than five years of age was used as an example as this is the leading cause of death in children under 5 years old in Serbia.

Results

Roma children were significantly more likely to experience an ARI than either the general population or the poorest quintile of the general population, not including the Roma. All three population groups were equally likely to not receive the correct treatment regime of antibiotics. An analysis of the factors that affect quality of access to health services reveal that personal documentation is a statistically significant problem; availability of health services is not an issue that disproportionately affects the Roma; however the geographical accessibility and affordability are substantive issues that disproportionately affect the Roma population. Affordability of services affected the Roma and the poorest quintile and affordability of medications significantly affected all three population groups. With regards to acceptability, mothers from all three population groups are equally likely to recognize the importance of seeking treatment.

Conclusions

The Roma should be assisted in applying for personal documentation, the geographical accessibility of clinics needs to be addressed, and the costs of healthcare visits and medications should be reviewed. Areas for improvement specific to ARI are the costs of antibiotics and the diagnostic accuracy of providers. A range of policy recommendations are outlined.     

Domestic gardens and self-reported health: a national population study

Background

There is a growing recognition of the health benefits of the natural environment. Whilst domestic gardens account for a significant proportion of greenspace in urban areas, few studies, and no population level studies, have investigated their potential health benefits. With gardens offering immediate interaction with nature on our doorsteps, we hypothesise that garden size will affect general health—with smaller domestic gardens associated with poorer health.

Methods

A small area ecological design was undertaken using two separate analyses based on data from the 2001 and 2011 UK census. The urban population of England was classified into ‘quintiles’ based on deprivation (Index of Multiple Deprivation) and average garden size (Generalised Land Use Database). Self-reported general health was obtained from the UK population census. We controlled for greenspace exposure, population density, air pollution, house prices, smoking, and geographic location. Models were stratified to explore the associations.

Results

Smaller domestic gardens were associated with a higher prevalence of self-reported poor health. The adjusted prevalence ratio of poor self-reported general health for the quintile with smallest average garden size was 1.13 (95% CI 1.12–1.14) relative to the quintile with the largest gardens. Additionally, the analysis suggested that income-related inequalities in health were greater in areas with smaller gardens. The adjusted prevalence ratio for poor self-reported general health for the most income deprived quintile compared against the least deprived was 1.72 (95% CI 1.64–1.79) in the areas with the smallest gardens, compared to 1.31 (95% CI 1.21–1.42) in areas with the largest gardens.

Conclusions

Residents of areas with small domestic gardens have the highest levels of poor health/health inequality related to income deprivation. Although causality needs to be confirmed, the implications for new housing are that adequate garden sizes may be an important means of reducing socioeconomic health inequalities. These findings suggest that the trend for continued urban densification and new housing with minimal gardens could have adverse impacts on health.

     

Looking at Graduates of Title V MCHB-Funded Training Programs Through the Lens of the MCH Pyramid

Objectives

To examine the distribution of professional responsibilities as reflected in each level of the MCH Pyramid for 208 graduates of five Maternal and Child Health Bureau (MCHB)-funded training programs—Leadership Education in Neurodevelopmental and Related Disabilities, nutrition, pediatric dentistry, public health, and social work—at the University of North Carolina at Chapel Hill.

Methods

Graduates completed a web-based survey, 1–8 years after graduation. For each program, we constructed means of the reported percentages of total work time spent in infrastructure-building, population-based, enabling, and direct health care services.

Results

Although generally consistent with the goals of the training programs, the percentages of time spent in each level of the Pyramid varied substantially among the five programs. For example, for a clinically focused program like pediatric dentistry, 80.2 % of time is spent in direct care services in contrast to 14.8 % for public health graduates. For each program, however, graduates report responsibilities among the different levels of the Pyramid.

Conclusions

Reporting job responsibilities within the MCH Pyramid provides a more informative picture of the contributions of training program graduates than do conventional metrics such as institutional or agency appointments. The fact that graduates from all five programs engage multiple roles is consistent with the MCHB workforce training goal to develop leaders in the field of MCH. Given the central role of the MCH Pyramid in planning and reporting for the MCH Services Block Grant, MCH training programs should include metrics such as graduates’ roles according to the MCH Pyramid to assure that training goals are more closely aligned with workforce needs.     

Health and human rights of women imprisoned in Zambia

Background

The healthcare needs and general experience of women in detention in sub-Saharan Africa are rarely studied and poorly understood.

Methods

A mixed-methods study was conducted including in-depth interviews with 38 adult female prisoners and 21 prison officers in four Zambian prisons to assess the health and human rights concerns of female detainees. Key informant interviews with 46 officials from government and non-governmental organizations and a legal and policy review were also conducted.

Results

Despite special protection under international and regional law, incarcerated women's health needs–including prenatal care, prevention of mother-to-child transmission of HIV, and nutritional support during pregnancy and breastfeeding–are not being adequately met in Zambian prisons. Women are underserved by general healthcare programs including those offering tuberculosis and HIV testing, and reported physical and sexual abuse conducted by police and prison officers that could amount to torture under international law.

Conclusions

There is an urgent need for women's healthcare services to be expanded, and for general prison health campaigns, including HIV and tuberculosis testing and treatment, to ensure the inclusion of female inmates. Abuses against women in Zambian police and prison custody, which violate their rights and compromise their health, must be halted immediately.     

Healthcare Use and Voluntary Health Insurance After Retirement in Thailand

Background

The dramatic changes occurring in the age structure of the Thai population make providing healthcare services for the elderly a major challenge for decision makers. Because the number of the elderly will be increasing, together with the number of retired workers, under the Social Health Insurance (SHI) scheme, there will be the unmet needs for healthcare use after retirement. The SHI scheme does not cover workers after retirement unless they could use free healthcare for the elderly. In addition, the government budget is tight regarding the support of universal healthcare and long-term care services for all of the elderly. Therefore, the government could support retired workers who have the ability to pay by facilitating voluntary health insurance.

Objective

The main objectives of the present study are to analyze the characteristics of workers that need health insurance after retirement and to identify the factors explaining healthcare use to offer healthcare services to meet the workers’ needs and expectations.

Methods

Four hundred insured workers under the Social Health Insurance (SHI) Scheme in Thailand were interviewed using a structured questionnaire. The Anderson–Newman model of healthcare use is the conceptual framework used in this study to understand the factors that explain healthcare use patterns of workers. Multiple regressions are employed extensively to evaluate the variables that predict healthcare use.

Results

According to the survey, a person that purchases voluntary health insurance is likely to be female, have a higher personal income, and healthy. The characteristics related to healthcare use were poor health status, a high personal income, and peeople afflicted by chronic illness.

Conclusions

There is a gap between healthcare service use and the demand for voluntary health insurance. People that have a high income are more likely to purchase voluntary health insurance, while people in worse health and afflicted by chronic illness may have greater difficulty purchasing voluntary health insurance because they face higher premiums or are denied coverage by insurers.     

Factors enabling community health workers and volunteers to overcome socio-cultural barriers to behaviour change: meta-synthesis using the concept of social capital

Background

Community-based health workers and volunteers are not just low-level health workforce; their effectiveness is also due to their unique relationship with the community and is often attributed to social capital, an area not well studied or acknowledged in the literature.

Methods

A qualitative meta-synthesis was conducted using the SPIDER framework and based on critical interpretive synthesis. The protocol was registered with PROSPERO, ID = CRD42018084130. This article reports on the qualitative data extracted from the final 33 articles selected from 147 full-text articles on social capital and community-based health systems.

Results

Three constructs were identified that enable community health workers to bring about changes in behaviour in the community: seeing their role as a service or a calling motivated by altruistic values, accompanying community members on their journey and the aim of the journey being empowerment rather than health. Community health workers feel under-resourced to provide for expectations from the community, to fulfil their non-health needs, to meet the expectations of their employers and to be able to deliver health services.

Conclusion

The dichotomy of needs between the community and health services can be resolved if policy makers and programme designers examine the possibility of two cadres of community-based health workforce: full-time workers and part-time volunteers, with clear scopes of practice and supervision. Community health workers would primarily be concerned with task shifting roles demanded by programmes, and volunteers can focus on the wider empowerment-based needs of communities.

     

Human rights violations among sexual and gender minorities in Kathmandu, Nepal: a qualitative investigation

Background

As part of a comprehensive study on the primary health care system in Iraq, we sought to explore primary care providers?? perspectives about the main problems influencing the provision of primary care services and opportunities to improve the system.

Methods

A qualitative study based on four focus groups involving 40 primary care providers from 12 primary health care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October 2010. A topic guide was used to lead discussions and covered questions on positive aspects of and current problems with the primary care system in addition to the priority needs for its improvement. The discussions were fully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis.

Results

Problems facing the primary care system included inappropriate health service delivery (irrational use of health services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforce challenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of training and educational opportunities and discrepancies in the salary system), shortage in resources (shortage and low quality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly the irrational use of health services and the related overcrowding and overload on primary care providers and health facilities. Suggestions for improving the system included application of a family medicine approach and ensuring effective planning and monitoring.

Conclusions

This study has provided a comprehensive understanding of the factors that negatively affect the primary care system in Iraq??s Kurdistan region from the perspective of primary care providers. From their experience, primary care providers have a role in informing the community and policy makers about the main problems affecting this system, though improvements to the health care system must be taken up at the national level and involve other key stakeholders.     

Illustrating a “consequential” shift in the study of health inequalities: a decomposition of racial differences in the distribution of body mass

Purpose

We present a conceptual introduction to “distributional inequalities”—differences in distributions of risk factors or other outcomes between social groups—as a consequential shift for research on health inequalities. We also review a companion analytical methodology, “distributional decomposition”, which can assess the population characteristics that explain distributional inequalities.

Time trends in health inequalities due to care in the context of the Spanish Dependency Law

Objective

In Spain, responsibility for care of old people and those in situations of dependency is assumed by families, and has an unequal social distribution according to gender and socioeconomic level. This responsibility has negative health effects on the carer. In 2006, the Dependency Law recognised the obligation of the State to provide support. This study analyses time trends in health inequalities attributable to caregiving under this new law.

Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence

Background

Enhancing the effectiveness of the community and aged care workforce to prevent malnutrition and functional decline is important in reducing hospital and aged care facility demand.

Objective

To investigate the impact of nutrition-related interventions delivered to or by informal carers and non-clinical community care workers on malnutrition-related health outcomes of community-dwelling older adults (≥65years).

Methods

Intervention studies were searched for using six electronic databases for English-language publications from January 1980 to 30 May 2012.

Results

Nine studies were eligible for inclusion. The strength and quality of the evidence was moderate (six studies with level II intervention evidence, five with positive quality). Types of interventions used were highly varied. The majority of interventions were delivered to informal carers (6 studies), with three of these studies also involving older adult care recipients. Five interventions were targeted at identifying, preventing and/or treating malnutrition specifically (two positive quality, three neutral quality, n=2368). As a result of these interventions, nutritional status improved or stabilized (two positive quality, two neutral quality, n=2333). No study reported an improvement in functional status but two successfully prevented further decline in their participants (two neutral quality, n=1097).

Conclusion

Interventions targeted at identifying, preventing and/or treating malnutrition were able to improve or prevent decline in nutritional and functional status, without increasing informal carer burden. The findings of this review support the involvement of non-clinical community care workers and informal carers as part of the nutritional care team for community-dwelling older adults.     

Socioeconomic inequalities in mental health and health-related quality of life (HRQOL) in children and adolescents from 11 European countries

Objectives

To assess the presence and magnitude of social inequalities in mental health and health-related quality of life (HRQOL) in the population aged 8–18 years in 11 European countries.

Methods

Cross-sectional surveys were carried out in representative samples of children/adolescents (8–18 years) from the participating countries of the KIDSCREEN project. Mental health was assessed using the Strengths and Difficulties Questionnaire (SDQ), and HRQOL by means of the KIDSCREEN-10. Socioeconomic status (SES) was assessed using the Family Affluence Scale and parental level of education. The association between health outcomes and SES was analyzed with the regression-based relative index of inequalities (RII) and population attributable risk.

Results

A total of 16,210 parent–child pairs were included. The SDQ showed inequalities in mental health according to family level of education in all countries (RII = 1.45; 1.37–1.53). The RII for HRQOL was 2.15 (1.79–2.59) in the whole sample, with less consistent results by age and country.

Conclusions

Socioeconomic inequalities in mental health were consistently found across Europe. Future research should clarify the causes of these inequalities and define initiatives which prevent them continuing into adulthood.     

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland

Background

Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment.

Methods

An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning.

Results

378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion.

Conclusions

Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.