Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

ObjectiveTo estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.MethodsWe systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.FindingsWe identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9–20.4; 50 datapoints; 462 151 households; I² = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2–10.3; 84 datapoints; 795 355 households; I² = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.ConclusionAlthough data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.     

Survival after out-of-hospital cardiac arrest,Viet Nam: multicentre prospective cohort study

ObjectiveTo investigate factors associated with survival after out-of-hospital cardiac arrest in Viet Nam.MethodsWe did a multicentre prospective observational study of people (> 18 years) presenting with out-of-hospital cardiac arrest (not caused by trauma) to three tertiary hospitals in Viet Nam from February 2014 to December 2018. We collected data on characteristics, management and outcomes of patients with out-of-hospital cardiac arrest and compared these data by type of transportation to hospital and survival to hospital admission. We assessed factors associated with survival to admission to and discharge from hospital using logistic regression analysis.FindingsOf 590 eligible people with out-of-hospital cardiac arrest, 440 (74.6%) were male and the mean age was 56.1 years (standard deviation: 17.2). Only 24.2% (143/590) of these people survived to hospital admission and 14.1% (83/590) survived to hospital discharge. Most cardiac arrests (67.8%; 400/590) occurred at home, 79.4% (444/559) were witnessed by bystanders and 22.3% (124/555) were given cardiopulmonary resuscitation by a bystander. Only 8.6% (51/590) of the people were taken to hospital by the emergency medical services and 32.2% (49/152) received pre-hospital defibrillation. Pre-hospital defibrillation (odds ratio, OR: 3.90; 95% confidence interval, CI: 1.54–9.90) and return of spontaneous circulation in the emergency department (OR: 2.89; 95% CI: 1.03–8.12) were associated with survival to hospital admission. Hypothermia therapy during post-resuscitation care was associated with survival to discharge (OR: 5.44; 95% CI: 2.33–12.74).ConclusionImprovements are needed in the emergency medical services in Viet Nam such as increasing bystander cardiopulmonary resuscitation and public access defibrillation, and improving ambulance and post-resuscitation care.     

The effects of medical tourism: Thailand's experience

Objective

To explore the positive and negative effects of medical tourism on the economy, health staff and medical costs in Thailand.

Methods

The financial repercussions of medical tourism were estimated from commerce ministry data, with modifications and extrapolations. Survey data on 4755 foreign and Thai outpatients in two private hospitals were used to explore how medical tourism affects human resources. Trends in the relative prices of caesarean section, appendectomy, hernia repair, cholecystectomy and knee replacement in five private hospitals were examined. Focus groups and in-depth interviews with hospital managers and key informants from the public and private sectors were conducted to better understand stakeholders’ motivations and practices in connection with these procedures and learn more about medical tourism.

Findings

Medical tourism generates the equivalent of 0.4% of Thailand’s gross domestic product but has exacerbated the shortage of medical staff by luring more workers away from the private and public sectors towards hospitals catering to foreigners. This has raised costs in private hospitals substantially and is likely to raise them in public hospitals and in the universal health-care insurance covering most Thais as well. The “brain drain” may also undermine medical training in future.

Conclusion

Medical tourism in Thailand, despite some benefits, has negative effects that could be mitigated by lifting the restrictions on the importation of qualified foreign physicians and by taxing tourists who visit the country solely for the purpose of seeking medical treatment. The revenue thus generated could then be used to train physicians and retain medical school professors.     

Treatment outcomes of acute streptococcal tonsillitis according to antibiotic treatment. A retrospective analysis of 242,366 cases treated in the community

BackgroundAcute upper respiratory infections are the most common reason for primary physician visits in the community. This study investigated whether the type of antibiotic used to treat streptococcal tonsillitis can reduce the burden by affecting the number of additional visits.ObjectivesTo assess the effect of different antibiotic treatments for tonsillitis on the number of additional primary physician visits and the development of infectious or inflammatory sequels.MethodsThis retrospective study included first cases of culture-confirmed streptococcal tonsillitis (n = 242,366, 55.3% females, 57.6% aged 3–15 years) treated in primary clinics throughout Israel between the years 2010 and 2019. Primary outcomes were the number of additional primary physician visits, due to any cause or due to specific upper airway infections. Secondary outcomes were the number of developed complications, such as peritonsillar abscess, post-streptococcal glomerulonephritis, rheumatic fever, post-streptococcal arthritis, chorea and death.ResultsCompared to penicillin-V, adjusted incidence rate ratios (IRR) for additional primary physician visits at 30–days were highest for IM benzathine-benzylpenicillin (IRR = 1.46, CI 1.33–1.60, p < .001) and cephalosporin treatment (IRR = 1.27, CI 1.24–1.30, p < .001). Similar results were noted for visits due to specific diagnoses such as recurrent tonsillitis, otitis media and unspecified upper respiratory tract infection. Amoxicillin showed decreased adjusted odds ratio (aOR) of developing complications (aOR = 0.68, CI 0.52–0.89, p < .01 for any complication. aOR = 0.75, CI 0.55–1.02, p = .07 for peritonsillar or retropharyngeal abscess).ConclusionPenicillin-V treatment is associated with fewer additional primary physician visits compared to other antibiotic treatments. Amoxicillin and penicillin-V are associated with fewer complications. These findings are limited by the retrospective nature of the study and lack of adjustment for illness severity. Further prospective studies may be warranted to validate results.     

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

ObjectivesEngland has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.DesignHistorical cohort study.SettingA total of 330 English primary care practices, 2010–2017, using UK Clinical Practice Research Datalink.ParticipantsA total of 84,441 adults with type 2 diabetes.Main Outcome MeasuresThe primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.ResultsThere were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89–0.92; p < 0.001 and 0.87; 95% CI 0.86–0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96–0.99; p = 0.001). Strong associations were found between completing 7–9 (vs. either 4–6 or 0–3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7–9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.ConclusionsAttaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.     

Effects of Welfare and Maternal Work on Recommended Preventive Care Utilization Among Low-Income Children

Objectives. We examined how maternal work and welfare receipt are associated with children receiving recommended pediatric preventive care services.Methods. We identified American Academy of Pediatrics–recommended preventive care visits from medical records of children in the 1999–2004 Illinois Families Study: Child Well-Being. We used Illinois administrative data to identify whether mothers received welfare or worked during the period the visit was recommended, and we analyzed the child visit data using random-intercept logistic regressions that adjusted for child, maternal, and visit-specific characteristics.Results. The 485 children (95%) meeting inclusion criteria made 41% of their recommended visits. Children were 60% more likely (adjusted odds ratios [AOR` = 1.60; 95% confidence interval [CI] = 1.27, 2.01) to make recommended visits when mothers received welfare but did not work compared with when mothers did not receive welfare and did not work. Children were 25% less likely (AOR = 0.75; 95% CI = 0.60, 0.94) to make preventive care visits during periods when mothers received welfare and worked compared with welfare only periods.Conclusion. The Temporary Assistance for Needy Families maternal work requirement may be a barrier to receiving recommended preventive pediatric health care.The Personal Responsibility and Work Opportunity Reconciliation Act was enacted in 1996, replacing Aid to Families With Dependent Children with a new program, Temporary Assistance for Needy Families (TANF). Sometimes called “welfare reform,” TANF is now in its 15th year, and another reauthorization is anticipated in 2013. Whereas Aid to Families With Dependent Children provided welfare cash assistance (“welfare”) for low-income mothers with young children and did not permit receipt of additional income through work, TANF requires most mothers receiving welfare to work or to participate in job-training programs.The impact of welfare reform on children’s health care access, utilization, and outcomes has been much debated. Several studies examined the consequences of welfare reform on children’s health and reported that TANF’s maternal employment requirements may negatively affect children’s health.1–5 In a previous study, we found that mothers working during periods when mothers were receiving welfare resulted in negative effects on the timely administration of childhood immunizations.6aWe sought to understand the association of welfare receipt and maternal work with recommended preventive pediatric health care visits. The American Academy of Pediatrics (AAP) provides recommendations for the ages at which a child should receive preventive care visits and, for each recommended visit, a “window,” or period of time, when the visit should be received.6b Preventive pediatric health care visits are critical during the vulnerable first years of a child’s life for monitoring growth and development and for providing timely immunizations.7–9 Also, previous research has shown that receipt of preventive pediatric health care is associated with reduced avoidable hospitalizations, reduced emergency department visits, and better health outcomes.10–12 Nevertheless, there is good evidence that many preventive care visits are delayed or missed entirely and, among low-income children, this is of particular concern because of their increased risks for poor growth and development.13–15 We hypothesized that maternal work required for welfare receipt was associated with reduced preventive health care visits.     

Improving outcomes for caregivers through treatment of young people affected by war: a randomized controlled trial in Sierra Leone

ObjectiveTo measure the benefits to household caregivers of a psychotherapeutic intervention for adolescents and young adults living in a war-affected area.MethodsBetween July 2012 and July 2013, we carried out a randomized controlled trial of the Youth Readiness Intervention – a cognitive–behavioural intervention for war-affected young people who exhibit depressive and anxiety symptoms and conduct problems – in Freetown, Sierra Leone. Overall, 436 participants aged 15–24 years were randomized to receive the intervention (n = 222) or care as usual (n = 214). Household caregivers for the participants in the intervention arm (n = 101) or control arm (n = 103) were interviewed during a baseline survey and again, if available (n = 155), 12 weeks later in a follow-up survey. We used a burden assessment scale to evaluate the burden of care placed on caregivers in terms of emotional distress and functional impairment. The caregivers’ mental health – i.e. internalizing, externalizing and prosocial behaviour – was evaluated using the Oxford Measure of Psychosocial Adjustment. Difference-in-differences multiple regression analyses were used, within an intention-to-treat framework, to estimate the treatment effects.FindingsCompared with the caregivers of participants of the control group, the caregivers of participants of the intervention group reported greater reductions in emotional distress (scale difference: 0.252; 95% confidence interval, CI: 0.026–0.4782) and greater improvements in prosocial behaviour (scale difference: 0.249; 95% CI: 0.012–0.486) between the two surveys.ConclusionA psychotherapeutic intervention for war-affected young people can improve the mental health of their caregivers.     

Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication

BackgroundCommunicating about medications across transitions of care is important in older patients who frequently move between health care settings. While there is increasing interest in understanding patient communication across transitions of care, little is known about older patients'' involvement in formal and informal modes of communication regarding managing medications.ObjectiveThe aim of this paper was to explore how older patients participated in managing their medications across transitions of care through formal and informal modes of communication.MethodsThe study was conducted across two metropolitan hospitals: an acute hospital and a geriatric rehabilitation hospital in metropolitan Melbourne, Australia. A focused ethnographic design was used involving semi‐structured interviews (n = 50), observations (203 h) and individual interviews or focus groups (n = 25). Following thematic analysis, data were analysed using Fairclough''s Critical Discourse Analysis.ResultsData analysis revealed two major discursive practices, which comprised of an interplay between formal and informal communication and environmental influences on formal and informal communication. Self‐created patient notes were used by older patients to initiate informal discussion with health professionals about medication decisions, which challenged traditional unequal power relations between health professionals and patients. Formal prompts on electronic medication administration records facilitated the continuous information discourse about patients'' medications across transitions of care and encouraged health professionals to seek out older patients'' preferences through informal bedside interactions. Environmental influences on communication comprised health professionals'' physical movements across private and public spaces in the ward, their distance from older patients at the bedside and utilization of the computer systems during patient encounters.ConclusionOlder patients'' self‐created medication notes enabled them to take on a more active role in formal and informal medication communication across transitions of care. Older patients and family members did not have continuous access to information about medication changes during their hospital stay and systems often failed to address older patients'' key concerns about their medications, which hindered their active involvement in formal and informal communication.Patient or Public ContributionOlder adults, family members and health professionals volunteered to be interviewed and observed.     

The cost of type?1 diabetes: a nationwide multicentre study in Brazil

Objective

To determine the direct medical costs of type 1 diabetes mellitus (T1DM) to the National Brazilian Health-Care System (NBHCS) and quantify the contribution of each individual component to the total cost.

Methods

A retrospective, cross-sectional, nationwide multicentre study was conducted between 2008 and 2010 in 28 public clinics in 20 Brazilian cities. The study included 3180 patients with T1DM (mean age 22 years ± 11.8) who were surveyed while receiving health care from the NBHCS. The mean duration of their diabetes was 10.3 years (± 8.0). The costs of tests and medical procedures, insulin pumps, and supplies for administration, and supplies for self-monitoring of blood glucose (SMBG) were obtained from national and local health system sources for 2010–2011. Annual direct medical costs were derived by adding the costs of medications, supplies, tests, medical consultations, procedures and hospitalizations over the year preceding the interview.

Findings

The average annual direct medical cost per capita was 1319.15 United States dollars (US$). Treatment-related expenditure – US$ 1216.33 per patient per year – represented 92.20% of total direct medical costs. Insulin administration supplies and SMBG (US$ 696.78 per patient per year) accounted for 52.82% of these total costs. Together, medical procedures and haemodialysis accounted for 5.73% (US$ 75.64 per patient per year) of direct medical costs. Consultations accounted for 1.94% of direct medical costs (US$ 25.62 per patient per year).

Conclusion

Health technologies accounted for most direct medical costs of T1DM. These data can serve to reassess the distribution of resources for managing T1DM in Brazil’s public health-care system.     

Impact of the 2004 Tsunami on Self-Reported Physical Health in Thailand for the Subsequent 2 Years

Objectives. We examined self-reported physical health during the first 2 years following the 2004 tsunami in Thailand.Methods. We assessed physical health with the revised Short Form Health Survey. We evaluated 6 types of tsunami exposure: personal injury, personal loss of home, personal loss of business, loss of family member, family member’s injury, and family’s loss of business. We examined the relationship between tsunami exposure and physical health with multivariate linear regression.Results. One year post-tsunami, we interviewed 1931 participants (97.2% response rate), and followed up with 1855 participants 2 years after the tsunami (96.1% follow-up rate). Participants with personal injury or loss of business reported poorer physical health than those unaffected (P < .001), and greater health impacts were found for women and older individuals.Conclusions. Exposure to the tsunami disaster adversely affected physical health, and its impact may last for longer than 1 year, which is the typical time when most public and private relief programs withdraw.At the end of Boxing Day in 2004, more than 5 million people were affected by one of the world’s worst natural disasters.1–3 An earthquake triggered a tsunami that affected 14 countries. In Thailand, the geographical focus of this study, more than 60 000 people in 6 southern provinces (Phuket, Phang Nga, Krabi, Ranong, Trang, and Satun) were directly affected.2,3 There were 3980 deaths and 6065 injuries.3,4Studies of the impact of a tsunami have focused primarily on mental health of those affected,5–10 with limited information on health service utilization11–13 and physical health.8,14 Previous investigations of physical health have focused on general physical health status, mortality, and nutritional status.14–19 Of those, there were 2 studies conducted in post-tsunami settings of Thailand.14,15 Two months after the tsunami, one study found that displaced individuals (those whose homes were affected by the disaster) reported significantly poorer physical health than unaffected individuals.14 The other study focused on Scandinavian tourists (from Norway, Denmark, and Sweden) who were in Thailand during the tsunami.15 The results indicated that, 14 months post-tsunami, being directly affected by the tsunami led to increased risk of musculoskeletal, cardiorespiratory, neurologic, and gastrointestinal health problems.The longer-term impact of the tsunami on Thai residents has not been previously examined. Hence, it is unclear whether the impacts of the tsunami on health are similar for those living in Thailand as for those who visited, and how long such physical impacts last. We report, here, the findings of a comparative study of self-reported physical health of those directly affected and those unaffected 1 and 2 years following the 2004 tsunami. Our findings could help public health officials in Thailand as well as add to the limited literature on the impacts of a disaster more than 1 year after it occurred.8,20–22     

Aids in Thailand: A medical student's perspective

Acquired Immunodeficiency Syndrome (AIDS) has become the biggest problem facing the health profession of Thailand today. The Ministry of Public Health reports that there are 400,000 individuals in Thailand already infected with the Human Immunodeficiency Virus (HIV) and is predicting that 4 million will be infected by the year 2000. This explosive epidemic first occurred among intravenous drug abusers (IVDAs) and subsequently spread to other high risk groups, especially prostitutes. The heterosexual population was next affected.The AIDS problem in Thailand was seen close-up by this writer, then a fourth year medical student, studying during an international health elective. At all three hospitals where I worked, I encountered large numbers of AIDS related admissions. Ten percent of medical beds at a Bangkok hospital were occupied by patients with AIDS related problems. In comparison, two hospitals located in the northern province of Chiang Mai had 15–20% and 30–40% of their beds occupied by patients with AIDS complications. Opportunistic infections were the primary reason for admissions. This paper describes the current AIDS epidemic in Thailand and the preventive measures being undertaken to combat it.Strategies to combat AIDS focus on preventive measures. The current program in Thailand emphasizes AIDS education and awareness, the promotion of condom usage, decreasing needle sharing, the screening of donated blood, and the development of the GP160 vaccine. The program, however, has been undermined by the country's well organized sex industry. Without a clear commitment from the Thai government, Thailand faces serious health and economic consequences from this epidemic in the coming decade.     

Frequency of visits to health facilities and HIV services offered to men,Malawi

ObjectiveTo determine how often men in Malawi attend health facilities and if testing for human immunodeficiency virus (HIV) is offered during facility visits.MethodsWe conducted a cross-sectional, community-representative survey of men (15–64 years) from 36 villages in Malawi. We excluded men who ever tested HIV-positive. Primary outcomes were: health facility visits in the past 12 months (for their own health (client visit) or to support the health services of others (guardian visit)); being offered HIV testing during facility visits; and being tested that same day. We disaggregated all results by HIV testing history: tested ≤ 12 months ago, or in need of testing (never tested or tested > 12 months before).FindingsWe included 1116 men in the analysis. Mean age was 34 years (standard deviation: 13.2) and 55% (617/1116) of men needed HIV testing. Regarding facility visits, 82% (920/1116) of all men and 70% (429/617) of men in need of testing made at least one facility visit in the past 12 months. Men made a total of 1973 visits (mean two visits): 39% (765/1973) were as guardians and 84% (1657/1973) were to outpatient departments. Among men needing HIV testing, only 7% (30/429) were offered testing during any visit. The most common reason for not testing was not being offered services (37%; 179/487).ConclusionMen in Malawi attend health facilities regularly, but few of those in need of HIV testing are offered testing services. Health screening services should capitalize on men’s routine visits to outpatient departments as clients and guardians.     

Community surveillance of COVID-19 by village health volunteers,Thailand

ProblemTo control the increasing spread of coronavirus disease 2019 (COVID-19), the government of Thailand enforced the closure of public and business areas in Bangkok on 22 March 2020. As a result, large numbers of unemployed workers returned to their hometowns during April 2020, increasing the risk of spreading the virus across the entire country.ApproachIn anticipation of the large-scale movement of unemployed workers, the Thai government trained existing village health volunteers to recognize the symptoms of COVID-19 and educate members of their communities. Provincial health offices assembled COVID-19 surveillance teams of these volunteers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant symptoms.Local settingDespite a significant and recent expansion of the health-care workforce to meet sustainable development goal targets, there still exists a shortage of professional health personnel in rural areas of Thailand. To compensate for this, the primary health-care system includes trained village health volunteers who provide basic health care to their communities.Relevant changesVillage health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020.Lessons learntThe timely mobilization of Thailand’s trusted village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country to the COVID-19 pandemic. The virus was initially contained without the use of a costly country-wide lockdown or widespread testing.     

The implementation cost of a safety‐net hospital program addressing social needs in Atlanta

ObjectiveTo describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers.Data Sources/Study SettingCosts for a heart failure health care program based in a safety‐net hospital were reported by program staff for the program year May 2018–April 2019. Additional data sources included hospital records, invoices, and staff survey.Study DesignWe conducted a retrospective, cross‐sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities.Data CollectionProgram cost data were collected using a activity‐based, micro‐costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation.Principal FindingsProgram costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30‐day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities.DiscussionHistorically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.     

Change in Mean Height of Thai Military Recruits From 1972 Through 2006

Background

Records in Western countries reveal that adult height has been increasing over the last 250 years. These height gains have been biologically associated with healthier childhoods, less illness, and longer life spans—a health-risk transition. To measure such progress in Thailand we studied height change over the last 3 decades.

Methods

We analyzed height records for 33 000 21-year-old male military recruits, sampling 1000 per year from 1972 through 2006. We compared the height trend in Thailand to those noted in Europe, and discuss the former in the context of improvements in living circumstances in Thailand.

Results

Over 35 years, mean height increased from 164.4 to 169.2 cm, an increment of nearly 5 cm. The height increase was negligible in the first decade (1972–1981), but substantially accelerated after that. In the period after 1990 the increase exceeded 3 cm. A similar overall height gain in Britain occurred over a much longer period (1750–1886).

Conclusions

The increase in height among Thai men is biological evidence that a Thai health-risk transition—defined by both changing risks and outcomes—is well underway for height. Military recruits born during the 1960s through the 1980s had progressively healthier childhoods. Over this period child nutrition improved, infection and mortality rates declined, and preventive health services expanded. The combined effect of these factors is indicated by the increased adult height of Thai military recruits.Key words: adult height, Thailand, military recruits, health transition     

Catastrophic health expenditure on acute coronary events in Asia: a prospective study

Objective

To estimate out-of-pocket costs and the incidence of catastrophic health expenditure in people admitted to hospital with acute coronary syndromes in Asia.

Methods

Participants were enrolled between June 2011 and May 2012 into this observational study in China, India, Malaysia, Republic of Korea, Singapore, Thailand and Viet Nam. Sites were required to enrol a minimum of 10 consecutive participants who had been hospitalized for an acute coronary syndrome. Catastrophic health expenditure was defined as out-of-pocket costs of initial hospitalization > 30% of annual baseline household income, and it was assessed six weeks after discharge. We assessed associations between health expenditure and age, sex, diagnosis of the index coronary event and health insurance status of the participant, using logistic regression models.

Findings

Of 12 922 participants, 9370 (73%) had complete data on expenditure. The mean out-of-pocket cost was 3237 United States dollars. Catastrophic health expenditure was reported by 66% (1984/3007) of those without insurance versus 52% (3296/6366) of those with health insurance (P < 0.05). The occurrence of catastrophic expenditure ranged from 80% (1055/1327) in uninsured and 56% (3212/5692) of insured participants in China, to 0% (0/41) in Malaysia.

Conclusion

Large variation exists across Asia in catastrophic health expenditure resulting from hospitalization for acute coronary syndromes. While insurance offers some protection, substantial numbers of people with health insurance still incur financial catastrophe.     

Unequal coverage of nutrition and health interventions for women and children in seven countries

ObjectiveTo examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries.MethodsWe used data from the most recent (2015–2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms.FindingsOnly 15% of 231 113 mother–child pairs received all eight health interventions (weighted percentage). The percentage of mother–child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points.ConclusionCo-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.     

Interruptions in Mental Health Care,Cannabis Use,Depression, and Anxiety during the COVID-19 Pandemic: Findings from a Cohort of HIV-Positive and HIV-Negative MSM in Los Angeles,California

The objective was to examine the impact of the COVID-19 pandemic on mental health care, cannabis use, and behaviors that increase the risk of STIs among men living with or at high risk for HIV. Data were from mSTUDY — a cohort of men who have sex with men in Los Angeles, California. Participants who were 18 to 45 years and a half were HIV-positive. mSTUDY started in 2014, and at baseline and semiannual visits, information was collected on substance use, mental health, and sexual behaviors. We analyzed data from 737 study visits from March 2020 through August 2021. Compared to visits prior to the COVID-19 pandemic, there were significant increases in depressive symptomatology (CES-D ≥ 16) and anxiety (GAD-7 ≥ 10). These increases were highest immediately following the start of the pandemic and reverted to pre-pandemic levels within 17 months. Interruptions in mental health care were associated with higher substance use (especially cannabis) for managing anxiety/depression related to the pandemic (50% vs. 31%; p-value < .01). Cannabis use for managing pandemic-related anxiety/depression was higher among those reporting changes in sexual activity (53% vs. 36%; p-value = 0.01) and was independently associated with having more than one sex partner in the prior 2 weeks (adjusted OR = 1.5; 95% CI 1.0–2.4). Our findings indicate increases in substance use, in particular cannabis, linked directly to experiences resulting from the COVID-19 pandemic and the associated interruptions in mental health care. Strategies that deliver services without direct client contact are essential for populations at high risk for negative sexual and mental health outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-022-00607-9.