Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

Background

Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.

Methods

Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.

Results

The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.

Conclusion

Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.     

Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh

Background

Information on health seeking behavior and beneficiaries’ perception of the quality of primary care can help policy makers to set strategies to improve health system. With scarcity of research on this particular field in Iraqi Kurdistan region, we sought to explore the patterns of health seeking behavior and perception of the quality of primary care services of a sample of population.

Methods

This explorative study was carried out in Erbil governorate, Iraq. Data were collected using the novel approach of Q-methodology for eliciting subjective viewpoints and identifying shared patterns among individuals. Forty persons representing different demographic and socioeconomic groups and living in different areas of Erbil governorate sorted 50 statements reflecting different aspects of health-seeking behavior and primary care services into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis through centroid factor extraction and varimax rotation of factors were used to derive latent viewpoints.

Results

Four distinct patterns of health seeking behavior and viewpoints toward the primary care services were identified. People in factor 1 are extremely critical of the services at primary health care centers and are regular users of the private health sector. People in factor 2 positively recognize the services at primary health care centers but mainly turn to inappropriate health seeking behavior. People in factor 3 have satisfaction with the services at primary health care centers with minimal use of these services, but mainly turn to the private sector. People in factor 4 are slightly satisfied with the services at primary health care centers but mainly rely on these services.

Conclusions

This study highlighted the typical characterizations that were associated with each uncovered factor. Informing on the beneficiaries’ concerns about the primary care services can help to improve the system through further exploring the issues raised by the respondents and directing particular action on these issues. The characterizing and distinguishing statements can be used as a set of questions to conduct community-based survey on this important aspect of health services.     

„Primary Health Care“ und Urbanisierung

Background

The world of the twenty-first century will be a predominantly urban world. By the year 2008, for the first time in human history, more people were residing in cities than in rural areas. The process of urbanization was mostly completed in the industrialized countries by the mid-twentieth century. In developing countries, however, both number and proportion of city dwellers are increasing.

Methods

To review the process of urbanization in developing countries, its relevance for the social and health situation of urban populations and the consequences arising thereof for the concept of Primary Health Care (PHC).

Results

A rapid urbanization poses great challenges to city councils, e. g. concerning infrastructure and distribution of societal wealth. Today, the process of urbanization is accompanied by a lack of jobs in the formal sector and a change in lifestyle which is not conducive to health, e.g. high calorie and fatty foods. A disaggregation of the health situation shows strong intra-city differentials between wealthy neighbourhoods and slum areas. Slum dwellers remain exposed to communicable diseases and are in addition at risk for non-communicable, chronic diseases. Many of the most prevalent health problems have social causes. Such health problems will persist as long as their social causes are not mended. Evidence-based interventions for tackling social causes of illness are lacking, however.

Discussion

Urbanization poses new challenges to PHC. The present strategies, e.g. prevention, are often restricted to health symptoms and reach the middle classes rather than the urban poor. Instead, strategies directed towards a more human urbanization are required. They would have to make full use of the primary health care approach.     

Are there geographic and socio-economic differences in incidence, burden and prevention of malaria? A study in southeast Nigeria

Rationale

It is not clearly evident whether malaria affects the poor more although it has been argued that the poor bear a very high burden of the disease. This study explored the socioeconomic and geographic differences in incidence and burden of malaria as well as ownership of mosquito nets.

Methods

Structured questionnaires were used to collect information from 1657 respondents from rural and urban communities in southeast Nigeria on: incidence of malaria, number of days lost to malaria; actions to treat malaria and household ownership of insecticide treated and untreated mosquito nets. Data was compared across socio-economic status (SES) quartiles and between urban and rural dwellers.

Results

There was statistically significant urban-rural difference in malaria occurrence with malaria occurring more amongst urban dwellers. There was more reported occurrence of malaria amongst children and other adult household members in better-off SES groups compared to worse-off SES groups, but not amongst respondents. The average number of days that people delayed before seeking treatment was two days, and both adults and children were ill with malaria for about six days. Better-off SES quartile and urban dwellers owned more mosquito nets (p < 0.05) (treated and untreated).

Conclusion

Malaria occurs more amongst better-off SES groups and urban dwellers in southeast Nigeria. Deployment of malaria control interventions should ensure universal access since targeting the poor and other supposedly vulnerable groups may exclude people that really require malaria control services.     

Dietary patterns and risk of urinary tract tumors: a multilevel analysis of individuals in rural and urban contexts

Introduction

Bladder cancer is the fourth most frequently diagnosed malignancy in males in Córdoba, Argentina. The evidence regarding an association between urinary tract tumors and dietary factors still remains controversial. Argentina has particular dietary habits, which have already been associated with cancer occurrence.

Purposes

(a) To estimate the association of typical dietary patterns in Argentina on the occurrence of urinary tract tumors and (b) to assess the urban–rural context of residence and cancer occurrence dependency.

Methods

A case–control study of urinary tract tumors (n = 123, 41/82 cases/controls) was performed in Córdoba Province (Argentina), 2006–2011. A two-level logistic regression model was fitted, taking into account rural–urban residence. An exhaustive probabilistic sensitivity analysis (bias analysis) was performed.

Results

Southern Cone pattern, characterized by red meat, starchy vegetables and wine consumptions (OR 1.75 high versus low level of adherence to the pattern), and a medium adherence to a high-sugar drinks pattern, with high loadings for soft drinks (OR 2.55), were associated with increasing risk of urinary tract tumors. High adherence to the latter pattern was inversely associated (OR 0.72). The occurrence of urinary tract tumors was also linked to place of residence (urban–rural), explaining more than 20 % of outcome variability and improving the above risk estimations.

Conclusions

A high intake of red meat, starchy vegetables and wine, and a moderate intake of high-sugar drinks seem to be associated with increased risk of urinary tract tumors, with differences related to the context of residence.     

Self-reported health in urban–rural continuum: a grid-based analysis of Northern Finland Birth Cohort 1966

Objectives

To evaluate the association of self-reported health with residential area type defined by the population density in individual??s local environment using a population-based cohort in Finland.

Methods

Young adults of the Northern Finland Birth Cohort 1966 (4,201 women and 3,835 men), surveyed by a postal questionnaire in 1997, were linked to population density of their resident grid (1?km²) depicting different types of residential areas. Self-reported health was regressed on residential area type using ordinal logistic analysis, adjusting for psychosocial well-being, social relationships, health behaviour, education and residence time.

Results

Cumulative odds ratios (COR) for poor health were lowest in high-rise centres, highest in scattered settlement areas and second highest in transitional zones. Adjustments (especially for education and time of residence) reduced the CORs to insignificance except the persistently high COR for women in scattered settlement areas.

Conclusion

Poor self-reported health is associated with individual??s residential area type, with the lowest occurrence in high-rise centres and higher elsewhere. The difference is likely explained, at least partly, by a complex of psychosocial factors, possibly different for women and men.     

Out-of-pocket expenditures on traditional and Western medicine in Taiwan

Objectives

Coexistence of traditional and modern medicine is common in Asian countries. This paper investigates out-of-pocket expenditures on traditional medicine, traditional medical service, and Western medicine by households in Taiwan.

Methods

Using a national sample of 13,765 households, the three expenditure equations are estimated with a censored system procedure. Effects of socio-demographic variables are explored by calculating marginal effects on probabilities and levels of medical expenses.

Results

Different types of medical expenditures are correlated. Households with higher income and more aging members use more traditional medicine than others, as do households in agricultural sector and in urban areas. In addition, households living in rural areas relative to those in the cities are more likely to use and also spend more on traditional service. Regional disparity of health care utilization is found.

Conclusions

Higher income households spend more on traditional medicine, likely due to the fact that patients usually pay out-of-pocket for herbal materials needed in preparation of traditional medicine. To ensure equity in health care utilization, establishment of hospitals and clinics in rural areas should be considered.     

Counteracting brain drain of health professionals from rural areas via teleconsultation: analysis of the barriers and success factors of teleconsultation

Aim

Winning young health professionals for rural areas is a very important challenge against the background of many retiring physicians in the coming decade and a growing unattractiveness of rural areas for future medical professionals. Through teleconsultation, a bridge can be provided between the single physician in the single practice in terms of professional exchange and second opinions. Teleconsultations between GPs and specialists are already in use in other countries (Lamminen et al. J Telemed Telecare 17(8):412–416, 2011; Nordal et al. J Telemed Telecare 7:257–265, 2001) but are not wide spread in Germany. The aim of this investigation is to identify the barriers and success factors for a teleconsultation solution in rural areas of northern Germany.

Subject and methods

A qualitative interview study was conducted among 18 experts from the Schleswig-Holstein health care system using a semi-structured interview guide. Seven representatives of health care institutions, six GPs, and five young health professionals were interviewed and the interviews systematically analysed according to predefined categories.

Results

The results of this study show that the primary barriers preventing the adoption of teleconsultation are the high time-consumption, the physicians’ personality, and the financing possibilities of such solutions. The main factors of a successful adoption of teleconsultation include an easy usability of the system, good training opportunities, voluntary participation, the existence of a model region, and a reasonable financing plan.

Conclusion

A consideration of the results when setting up a teleconsultation solution provides a basis for a working teleconsultation system in rural areas that can help attract more physicians to those regions.     

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.     

Systematic development of a self-regulation weight-management intervention for overweight adults

Background

Little is known about differences in professional care seeking based on marital status. The few existing studies show more professional care seeking among the divorced or separated compared to the married or cohabiting. The aim of this study is to determine whether, in a sample of the European general population, the divorced or separated seek more professional mental health care than the married or cohabiting, regardless of self-reported mental health problems. Furthermore, we examine whether two country-level features--the supply of mental health professionals and the country-level divorce rates--contribute to marital status differences in professional care-seeking behavior.

Methods

We use data from the Eurobarometer 248 on mental well-being that was collected via telephone interviews. The unweighted sample includes 27,146 respondents (11,728 men and 15,418 women). Poisson hierarchical regression models were estimated to examine whether the divorced or separated have higher professional health care use for emotional or psychological problems, after controlling for mental and somatic health, sociodemographic characteristics, support from family and friends, and degree of urbanization. We also considered country-level divorce rates and indicators of the supply of mental health professionals, and applied design and population weights.

Results

We find that professional care seeking is strongly need based. Moreover, the divorced or separated consult health professionals for mental health problems more often than people who are married or who cohabit do. In addition, we find that the gap between the divorced or separated and the married or cohabiting is highest in countries with low divorce rates.

Conclusions

The higher rates of professional care seeking for mental health problems among the divorced or separated only partially correlates with their more severe mental health problems. In countries where marital dissolution is more common, the marital status gap in professional care seeking is narrower, partially because professional care seeking is more common among the married or cohabiting.     

Cameroon mid-level providers offer a promising public health dentistry model

Background

Research on the mal-distribution of health care workers has focused mainly on physicians and nurses. To meet the Millennium Development Goal Five and the reproductive needs of all women, it is predicted that an additional 334,000 midwives are needed. Despite the on-going efforts to increase this cadre of health workers there are still glaring gaps and inequities in distribution. The objectives of this study are to determine the perceived barriers and motivators influencing final year midwifery students?? acceptance of rural postings in Ghana, West Africa.

Methods

An exploratory qualitative study using focus group interviews as the data collection strategy was conducted in two of the largest midwifery training schools in Ghana. All final year midwifery students from the two training schools were invited to participate in the focus groups. A purposive sample of 49 final year midwifery students participated in 6 focus groups. All students were women. Average age was 23.2?years. Glaser??s constant comparative method of analysis was used to identify patterns or themes from the data.

Results

Three themes were identified through a broad inductive process: 1) social amenities; 2) professional life; and 3) further education/career advancement. Together they create the overarching theme, quality of life, we use to describe the influences on midwifery students?? decision to accept a rural posting following graduation.

Conclusions

In countries where there are too few health workers, deployment of midwives to rural postings is a continuing challenge. Until more midwives are attracted to work in rural, remote areas health inequities will exist and the targeted reduction for maternal mortality will remain elusive.     

Availability and structure of primary medical care services and population health and health care indicators in England

Background

It has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding.

Methods

Data for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V.

Results

Higher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15–64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183).

Conclusions

After adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs.     

Privatisation & marketisation of post-birth care: the hidden costs for new mothers

Introduction

Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries.

Methods

Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care.

Results

In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance.

Conclusions

China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.     

The Impact of Rural Health Care Accessibility on Cancer-Related Behaviors and Outcomes

Background

This research seeks to identify the relationship between economic factors related to the ability to receive and pay for health services and adverse cancer outcomes, as well as preventative screening and behavioral factors that influence the risk of cancer. We focus on the Northern High Plains region, where we are able to compare regions with extremely low access to health services with those with relatively high levels of access.

Objective

This study aims to identify health disparities in rural communities, particularly among Native American populations, and, thereby, begin to determine the most effective means by which to deliver health services to areas where geography, economics, and culture might prevent traditional models of health delivery from providing sufficient incentives for the prevention of adverse cancer-related outcomes.

Methods

The Health Care Accessibility Index (HCAI) is computed through the use of principal component analysis and includes economic variables as well as variables concerning institutional and geographic access to health care. Index values are then regressed onto cancer outcomes, cancer-prevention outcomes, and cancer-related risk, using weighted least squares and quantile regressions.

Results

Counties with relatively poor access to health care (low HCAI) also have statistically (1) lower breast cancer screening rates, (2) higher smoking prevalence, (3) higher obesity prevalence, and (4) higher cancer-related mortality rates. Breast cancer screening is found to be especially sensitive to areas of low health accessibility.

Conclusions

Empirical results provide support for policy efforts to increase the accessibility of health care services that are targeted to areas with low mammography screening rates, high obesity rates, high smoking prevalence, as well as areas near Native American reservation territories.     

Is hospital discharge administrative data an appropriate source of information for cancer registries purposes? Some insights from four Spanish registries

Background

Complementary and alternative medicine (CAM) use - of which naturopathy constitutes a significant proportion - accounts for approximately half of all health consultations and half of out-of-pocket expenditure in Australia. Data also suggest CAM use is highest amongst rural Australians. Unfortunately little is known about the grass-roots reality of naturopathy or other CAM use in rural regions.

Methods

Semi-structured interviews were conducted with 20 naturopaths practising in the Darling Downs region of South-East Queensland to assess their perceptions and experiences of rural patients and demand for their services.

Results

Naturopaths described strong demand in rural areas for their services and perceived much of this demand as attributable to cultural traits in rural communities that served as pull factors for their naturopathic services. Such perceived traits included a cultural affinity for holistic approaches to health and disease and the preventive philosophy of naturopathy and an appreciation of the core tenet of naturopathic practice to develop closer therapeutic relationships. However, cost and a rural culture of self-reliance were seen as major barriers to naturopathic practice in rural areas.

Conclusions

Demand for naturopathic services in rural areas may have strong underlying cultural and social drivers. Given the apparent affinity for and increasingly large role played by CAM services, including naturopathic medicine, in rural areas it is imperative that naturopathic medicine and the CAM sector more broadly become a core focus of rural health research.     

Differing mental health practice among general practitioners,private psychiatrists and public psychiatrists

Background

Tuberculosis is still a great challenge to public health in Brazil and worldwide. Early detection followed by effective therapy is extremely important in controlling the disease. Recent studies have investigated reasons for delays in treatment, but there is no agreed definition of what constitutes an "acceptable" delay. This study investigates factors associated with total delay in treatment of tuberculosis.

Methods

A cohort of adult cases of pulmonary tuberculosis diagnosed over a two-year period was studied. Patients were interviewed on entry, reporting the duration of symptoms before the start of treatment, and sputum and blood samples were collected. It was decided that sixty days was an acceptable total delay. Associations were investigated using univariable and multivariable analysis and the population attributable fraction was estimated.

Results

Of 1105 patients, 62% had a delay of longer than 60 days. Age, sex, alcoholism and difficulty of access were not associated with delays, but associations were found in the case of unemployment, having given up smoking, having lost weight and being treated in two of the six health districts. The proportion attributable to: not being an ex-smoker was 31%; unemployment, 18%; weight loss, 12%, and going to the two worst health districts, 25%.

Conclusion

In this urban area, delays seem to be related to unemployment and general attitudes towards health. Although they reflect the way health services are organized, delays are not associated with access to care.     

Who are eating and not eating fruits and vegetables in Malaysia?

Objective

To investigate the roles of sociodemographic factors in fruit and vegetable (FV) consumption in Malaysia.

Methods

Data are obtained from the Malaysia Non-Communicable Disease Surveillance-1. Logistic regressions are conducted using a multiracial (Malay, Chinese, Indian and other ethnic groups) sample of 2,447 observations to examine the factors affecting individual decisions to consume FV on a daily basis.

Results

Based on the binary outcomes of whether individuals consumed FV daily, results indicate that work hours, education, age ethnicity, income, gender, smoking status, and location of residence are significantly correlated with daily fruit consumption. Daily vegetable consumption is significantly correlated with income, gender, health condition, and location of residence.

Conclusions

Our results imply the need for programs to educate and motivate consumers to make healthier dietary choices. Interventions to increase FV consumption by changing behaviors should be considered, as should those that increase public awareness of the dietary benefits of FV. These intervention programs should be targeted at and tailored toward individuals who are less educated, younger, less affluent, males, smokers, and metropolitan dwellers.     

Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study

Background

In family practice depression is a common mental health problem and one with marked gender differences; women are diagnosed as depressed twice as often as men. A more comprehensive explanatory model of depression that can give an understanding of, and tools for changing, this gender difference is called for. This study explores how primary care patients experience, understand and explain their depression.

Methods

Twenty men and women of varying ages and socioeconomic backgrounds diagnosed with depression according to ICD-10 were interviewed in-depth. Data were assessed and analyzed using Grounded Theory.

Results

The core category that emerged from analysis was "Gendered trajectories into depression". Thereto, four categories were identified – "Struck by lightning", "Nagging darkness", "Blackout" and "Slowly suffocating" – and presented as symbolic illness narratives that showed gendered patterns. Most of the men in our study considered that their bodies were suddenly "struck" by external circumstances beyond their control. The stories of study women were more diverse, reflecting all four illness narratives. However, the dominant pattern was that women thought that their depression emanated from internal factors, from their own personality or ways of handling life. The women were more preoccupied with shame and guilt, and conveyed a greater sense of personal responsibility and concern with relationships.

Conclusion

Recognizing gendered narratives of illness in clinical consultation may have a salutary potential, making more visible depression among men while relieving self-blame among women, and thereby encouraging the development of healthier practices of how to be a man or a woman.