Health care utilization, cost burden and coping strategies by disability status: an analysis of the Viet Nam National Health Survey

Access to health insurance amongst people with disabilities and its association with healthcare use, health status and financial protection in low- and middle-income countries: a systematic review

BACKGROUND

People with disabilities often incur higher costs for healthcare, due to higher needs, greater indirect costs, and the need for services not offered by the public system. Yet, people with disabilities are more likely to experience poverty and so have reduced capacity to pay. Health insurance is an important social protection strategy to meet healthcare needs and avoid catastrophic expenditures for this group. This systematic review synthesized evidence on health insurance coverage and potential effects among people with disabilities in low- and middle-income countries (LMICs).

METHODS

This systematic review followed PRISMA Guidelines. We searched English peer-reviewed articles from nine databases (Medline, Embase, CINAHL, Web of Science, Scopus, Cochrane Library, PsyInfo, Global Health, and Econlit) from January 2000 to 24 January 2023. Two independent reviewers conducted the article selection, data extraction, and risk of bias assessment using NIH Guidelines. Studies were eligible for inclusion if they quantitatively assessed at least one of four key outcomes amongst people with disabilities: health insurance coverage/access, the association between health insurance and health care utilization, financial protection, or health status/outcome. Narrative synthesis was deployed due to high variety of outcome measurements.

RESULTS

Out of 8,545 records retrieved and three from hand search, 38 studies covering data from 51 countries met the eligibility criteria. Over two-thirds (68.4%) focused on access/coverage, which was generally limited amongst people with disabilities. Seventeen studies (44.7%) examined healthcare utilization, with a positive association (9/12) found between health insurance and the use of disability-related services. However, its association with general healthcare utilization (5 studies) remained inconclusive. Financial protection, explored by six studies (15.8%), similarly yielded inconclusive results. Only four studies (10.5%) reported on health status, and the findings suggest a favourable association of health insurance with self-reported health among people with disabilities (2/4), despite the limited number of high-quality studies.

CONCLUSIONS

There is considerable variability and limited evidence regarding health insurance coverage and its potential impact among individuals with disabilities in LMICs. This gap highlights the pressing need for further evaluations of health insurance, with a specific focus on people with disabilities, aligning with the broader goal of achieving Universal Health Coverage (UHC).

TRIAL REGISTRATION

PROSPERO CRD42023389533.

Bridging the gap or widening the divide? Exploring the dual role of social capital in healthcare financing in rural Uttar Pradesh, India

Social capital, defined as the nature of the social relationship and the resources embedded within the social network of an individual or community, influences how individuals within a group interact and collaborate within their communities or organizations. While it is acknowledged that social capital can be drawn from as a coping strategy to mitigate financial stress, there is a notable absence of the lived experience in the literature on how social capital influences households to tap resources from their social network. We have investigated the role of social capital in healthcare financing in rural Uttar Pradesh, India, highlighting the challenges faced by households in managing healthcare expenses. We took a qualitative research approach, conducting in-depth interviews with 24 households in the Hardoi District of Uttar Pradesh in August 2017 to explore participants' lived experience of accruing support from their community during their healthcare crisis. Data analysis followed a thematic content analysis approach. The study finds that households leverage social capital for both financial and non-financial support during health crises. Social networks, trust, and community cohesion play critical roles in resource acquisition. However, overreliance on social capital can be coercive, leading to inequity, privacy invasion, and dependency. Though social capital serves as a crucial resource of support in healthcare emergencies, its unequal distribution and potential for misuse highlight the need for more structured health financing policies in India. The findings underscore the importance of integrating community-driven resources into broader health financing strategies, considering local social structures and community dynamics.

Using a biopsychosocial approach to examine parental sense of burden and competency associated with raising a child with a physical disability

BACKGROUND

Parents report both positive and negative experiences associated with raising a child with a physical disability. However, distinctive factors may affect children and families differently.

AIMS

Using a biopsychosocial approach, the current study expands on the existing literature on the general impact of raising a child with a disability.

METHODS

Participants were 98 parents of children/youth with a physical disability. Parents reported on child's level of physical disability, the impact of the disability on the family (financial, social, personal strain and mastery) and their general health. Data were analysed to examine how different biopsychosocial factors are associated with raising a child with a physical disability.

RESULTS

Parents reported that child's disability had a higher social impact, compared with the financial and personal burden, as well as compared with their sense of competency and mastery. Child's level of disability was associated with financial burden, whereas parental emotional distress was associated with parents' personal and social burden, with the latter also associated with parent's religiosity. Total impact was associated with parental emotional distress and educational level.

CONCLUSIONS

Altogether, parental characteristics, but not child's characteristics, were associated with greater caregiver burden. Furthermore, the social impact a child's physical disability has on the family exceeded other sources of burden within the family. Providing parents social and emotional support, tailored to their unique biopsychosocial needs, may mitigate burden and distress, and increase sense of competency among families of children with a physical disability.

Association Between Visual Impairment and Health Care Use

PURPOSE

To determine the association between visual impairment (VI) and medical care use.

DESIGN

Population-based cohort study.

METHODS

The study cohort included individuals from 2007 to 2017. The Disability Registry was used to identify all patients aged ≥20 years who newly developed visual disability. All patients were observed until they became visually impaired (case group). They were then matched with 2 control groups: (1) people with nonvisual disability and (2) people without any disability. The main outcome measures were (1) ophthalmic outpatient and inpatient use and (2) nonophthalmic outpatient and inpatient use.

RESULTS

Compared with people with nonvisual disability, those with visual disability demonstrated a lower nonophthalmic outpatient costs (-NT$42,841, P < .001) and outpatient visits (-2.8 times). However, the opposite was noted for ophthalmic use, where people with visual disability used more medical care compared with people with other types of disability and people without disability. An age-stratified analysis revealed that visual disabilities had an age-related dose-response effect on the reception of nonophthalmic care and a slight nonlinear effect on the receipt of ophthalmic care.

CONCLUSIONS

Studies investigating the effect of VI on medical use should differentiate aggregate use into different types. Use of ophthalmic and nonophthalmic care for people with VI should be compared with that of people with other types of disability and people without disability.

Catastrophic Health Expenditure Associated With Frailty in Community-Dwelling Chinese Older Adults: A Prospective Cohort Analysis

Background: Catastrophic health expenditure (CHE) represents a key indicator for excessive financial burden due to out-of-pocket (OOP) healthcare costs, which could push the household into poverty and is highly pronounced in households with members at an advanced age. Previous studies have been devoted to understanding the determinants for CHE, yet little evidence exists on its association with frailty, an important geriatric syndrome attracting growing recognition. We thus aim to examine the relationship between frailty and CHE and to explore whether this effect is moderated by socioeconomic-related factors. Methods: A total of 3,277 older adults were drawn from two waves (2011 and 2013) of the China Health and Retirement Longitudinal Study (CHARLS). CHE was defined when OOP healthcare expenditure exceeded a specific proportion of the capacity of the household to pay. Frailty was measured following the Fried Phenotype (FP) scale. Mixed-effects logistic regression models were employed to assess the longitudinal relationship between frailty and CHE, and stratification analyses were conducted to explore the moderation effect. Results: The incidence of CHE among Chinese community-dwelling older adults was 21.76% in 2011 and increased to 26.46% in 2013. Compared with non-frail individuals, prefrail or frail adults were associated with higher odds for CHE after controlling for age, gender, residence, education, marriage, income, health insurance, smoking, drinking, and comorbidity (prefrail: odds ratio (OR) = 1.32, 95%CI = 1.14-1.52; frail: OR = 1.67, 95%CI = 1.13-2.47). Three frailty components including weakness, exhaustion, and shrinking contributed to a significantly increased likelihood of CHE (all p < 0.05), while the other two components including slowness and inactivity showed a non-significant effect (all p > 0.05). Similar effects from frailty on CHE were observed across socioeconomic-related subgroups differentiated by gender, residence, education, household income, and social health insurance. Conclusions: Frailty is a significant predictor for CHE in China. Developing and implementing cost-effective strategies for the prevention and management of frailty is imperative to protect households from financial catastrophe.

Health Service Utilization and Out-of-Pocket Expenditure Associated with the Continuum of Disability in Vietnam

Reducing the burden of disability is key priority in many countries where the population is aging rapidly. The relationships between disability, health expenditure and economic burden are complex, particularly when disability is recognized as a continuum rather than a dichotomous phenomenon. However, these complex relationships are not adequately addressed in national health policy and management plans in Vietnam. This paper examines the economic consequences of disability across its continuum or levels of severity. Two-part regression models were applied to assess the relationships between disability, health service use and the out-of-pocket expenditure. We found that Vietnamese adults with disabilities had multiple characteristics of vulnerability, e.g., older, less likely to be employed, lower education, and poorer than adults without disabilities. These characteristics are associated with poorer health and higher need of healthcare utilization but, after controlling for these factors, disability still had an independent association with higher health expenditure and greater economic burden at their household (p < 0.05). Our study provides empirical evidence of the economic burden associated across the continuum of disability in Vietnam. Decisive action is critical for protecting persons with disability from medical impoverishment, and such targeted interventions should include those with moderate disability rather than the current focus on severe disability.

A case-control study of musculoskeletal impairment: association with socio-economic status, time use and quality of life in post-conflict Myanmar

Background

Musculoskeletal impairments (MSI) are a major global contributor to disability. Evidence suggests entrenched cyclical links between disability and poverty, although few data are available on the link of poverty with MSI specifically. More data are needed on the association of MSI with functioning, socio-economic status and quality of life, particularly in resource-poor settings where MSI is common.

Methods

We undertook a case-control study of the association between MSI and poverty, time use and quality of life in post-conflict Myanmar. Cases were recruited from two physical rehabilitation service-centres, prior to the receipt of any services. One age- (+/− 5 years of case’s age) and sex- matched control was recruited per case, from their home community. 108 cases and 104 controls were recruited between July – December 2015. Cases and controls underwent in-depth structured interviews and functional performance tests at multiple time points over a twelve-month period. The baseline characteristics of cases and controls are reported in this manuscript, using multivariate logistic regression analysis and various tests of association.

Results

89% of cases were male, 93% were lower limb amputees, and the vast majority had acquired MSI in adulthood. 69% were not working compared with 6% of controls (Odds Ratio 27.4, 95% Confidence Interval 10.6–70.7). Overall income, expenditure and assets were similar between cases and controls, with three-quarters of both living below the international LMIC poverty line. However, cases’ health expenditure was significantly higher than controls’ and associated with catastrophic health expenditure and an income gap for one fifth and two thirds of cases respectively. Quality of life scores were lower for cases than controls overall and in each sub-category of quality of life, and cases were far less likely to have participated in productive work the previous day than controls.

Conclusion

Adults with MSI in Myanmar who are not in receipt of rehabilitative services may be at increased risk of poverty and lower quality of life in relation to increased health needs and limited opportunities to participate in productive work. This study highlights the need for more comprehensive and appropriate support to persons with physical impairments in Myanmar.

Coping with healthcare costs for chronic illness in low-income and middle-income countries: a systematic literature review

BACKGROUND

Experiencing illness in low-income and middle-income countries (LMICs) can incur very high out-of-pocket (OOP) payments for healthcare and, while the existing literature typically focuses on levels of expenditure, it rarely examines what happens when households do not have the necessary money. Some will adopt one or more 'coping strategies', such as borrowing money, perhaps at exorbitant interest rates, or selling assets, some necessary for their future income, with detrimental long-term effects. This is particularly relevant for chronic illnesses that require consistent, long-term OOP payments. We systematically review the literature on strategies for financing OOP costs of chronic illnesses in LMICs, their correlates and their impacts on households.

METHODS

We searched MEDLINE, EconLit, EMBASE, Global Health and Scopus on 22 October 2018 for literature published on or after 1 January 2000. We included qualitative or quantitative studies describing at least one coping strategy for chronic illness OOP payments in a LMIC context. Our narrative review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

RESULTS

Forty-seven papers were included. Studies identified coping strategies for chronic illness costs that are not traditionally addressed in financial risk protection research (eg, taking children out of school, sending them to work, reducing expenditure on food or education, quitting work to give care). Twenty studies reported socioeconomic or other correlates of coping strategies, with poorer households and those with more advanced disease more vulnerable to detrimental strategies. Only six studies (three cross-sectional and three qualitative) included evidence of impacts of coping strategies on households, including increased labour to repay debts and discontinuing treatment.

CONCLUSIONS

Monitoring of financial risk protection provides an incomplete picture if it fails to capture the effect of coping strategies. This will require qualitative and longitudinal research to understand the long-term effects, especially those associated with chronic illness in LMICs.

The accessibility of health services to young deaf adolescents in Ghana

Quality health care is a fundamental human right, which is enshrined in several international and domestic legislative instruments. In the Ghanaian context, there are reports that adults with disabilities encounter barriers in their attempts to access health care. However, scholarly attention is yet to explore the perspectives of young people and adolescents with disabilities. Therefore, this quantitative study was conducted from the perspective of critical disability studies, where young deaf adolescents (YDAs) were regarded as right bearers, and where they shared their perspectives on health accessibility decisions, barriers, and needs. Sixty-seven participants, made up of 44 male and 23 female students, took part in this quantitative study. Although many YDAs who took part in this study indicated that it was not difficult to access health facilities, they claim to have encountered communication barriers. Sign language interpreters in health facilities and introduction of sign language courses in health training institutions to improve communication between health professionals and deaf patients have been suggested as ways of addressing the barriers faced by YDAs in Ghana.

A Systematic Review of Access to General Healthcare Services for People with Disabilities in Low and Middle Income Countries

Background: A systematic review was undertaken to explore access to general healthcare services for people with disabilities in low and middle-income countries (LMICs). Methods: Six electronic databases were searched in February 2017. Studies comparing access to general healthcare services by people with disabilities to those without disabilities from LMICs were included. Eligible measures of healthcare access included: utilisation, coverage, adherence, expenditure, and quality. Studies measuring disability using self-reported or clinical assessments were eligible. Title, abstract and full-text screening and data extraction was undertaken by the two authors. Results: Searches returned 13,048 studies, of which 50 studies were eligible. Studies were predominantly conducted in sub-Saharan Africa (30%), Latin America (24%), and East Asia/Pacific (12%). 74% of studies used cross-sectional designs and the remaining used case-control designs. There was evidence that utilisation of healthcare services was higher for people with disabilities, and healthcare expenditure was higher. There were less consistent differences between people with and without disabilities in other access measures. However, the wide variation in type and measurement of disability, and access outcomes, made comparisons across studies difficult. Conclusions: Developing common metrics for measuring disability and healthcare access will improve the availability of high quality, comparable data, so that healthcare access for people with disabilities can be monitored and improved.

Inequalities in Household Catastrophic Health Expenditure and Impoverishment Associated With Noncommunicable Diseases in Chi Linh, Hai Duong, Vietnam

A costly modern-day double burden, the expenses of noncommunicable diseases (NCDs) are becoming a devastating epidemic. The World Health Organization estimates $7 trillion in economic losses from NCDs in 2011-2025. Although regarded as affluent diseases, the burden of NCDs is shifting into poorer groups. In this study, we assessed the socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with NCDs in Northern Vietnam. We also identified associated factors for catastrophic health expenditure and impoverishment. Households self-reporting NCD diagnoses had the highest association with both catastrophic health expenditure and impoverishment, followed by those in urban areas. Such households were likely poorer according to our calculations estimating socioeconomic inequalities. Households with at least 1 member older than 60 years were also more likely to suffer catastrophic health expenditures. These findings suggest that targeted policy to prevent or subsidize care for NCDs could prevent catastrophic health expenditure and impoverishment among those already most disadvantaged.

Exploration of the importance of geriatric frailty on health-related quality of life

AIM

The ageing of the population is a demographic trend globally. Promoting the health of elderly persons has become a crucial priority. However, knowledge about the relationship between frailty and quality of life (QoL) remains limited. This research aimed to investigate the association between elderly frailty and QoL, and to identify whether frailty or current health status more significantly affects the QoL of elderly persons.

METHODS

This research began in 2012, and by the end of the study in April 2013, 375 samples had been collected. Structured questionnaires and the face-to-face questionnaire interviews were used. Multiple linear regression, t-test, and one-way anova were administered.

RESULTS

Elderly individuals who were hospitalized performed worse in the physical health QoL domain, whereas those who regularly attended outpatient follow-ups performed worse in the mental health QoL domain. QoL was only partially affected in both groups. All QoL domains were affected in elderly individuals with symptoms of frailty. Age, marital status, and financial status significantly affect health-related QoL.

CONCLUSION

Geriatric frailty significantly affects general QoL. Early screening of frailty-related conditions among the elderly can prompt early and proper intervention for this population.

Medical security and catastrophic health expenditures among households containing persons with disabilities in Korea: a longitudinal population-based study

Background

Although persons with disabilities need access to comprehensive and consistent healthcare services, a significant number of the poor with disabilities do not receive Medical-Aid due to the conditions of eligibility. We aimed to compare the financial burden of healthcare services between two groups of poor persons with disabilities: those not enrolled in Medical-Aid and Medical-Aid enrollees.

Methods

This study used the 1st–8th data (2008–2014 year) of Panel Survey of Employment for the Disabled (PSED) conducted by the Korea Employment Agency for the Disabled. We classified adults who did not exceed 100 % of the poverty level into two groups (N = 3,010). The first group consisted of enrollees in Medical-Aid (n = 1,259) and the second group comprised those not enrolled in Medical-Aid (n = 1,325). We applied generalized estimating equations (GEEs) to assess the independent effect of enrollment in Medical-Aid on catastrophic health expenditures (CHE).

Results

We found that about 4.2 % of the poor not enrolled in the Medical-Aid experienced CHE and the poor not enrolled in Medical-Aid were 2.1 times more likely to experience CHE than Medical-Aid enrollees after applying multivariate models adjusted for several covariates.

Conclusions

Given the additional expenses for treatment and rehabilitation caused by disability-related health problems, persons with disabilities are more likely to face barriers to needed medical services. Thus, policy makers need to expand the number of people receiving Medical-Aid by loosening the strict criteria for those with disabilities.

Catastrophic Health Expenditures for Households with Disabled Members: Evidence from the Korean Health Panel

Persons with disabilities use more health care services due to ill health and face higher health care expenses and burden. This study explored the incidence of catastrophic health expenditures of households with persons with disabilities compared to that of those without such persons. We used the Korean Health Panel (KHP) dataset for the years 2010 and 2011. The final sample was 5,610 households; 800 (14.3%) of these were households with a person with a disability and 4,810 (85.7%) were households without such a person. Households with a person with a disability faced higher catastrophic health expenditures, spending about 1.2 to 1.4 times more of their annual living expenditures for out-of-pocket medical expenses, compared to households without persons with disabilities. Households having low economic status and members with chronic disease were more likely to face catastrophic health expenditures, while those receiving public assistance were less likely. Exemption or reduction of out-of-pocket payments in the National Health Insurance and additional financial support are needed so that the people with disabilities can use medical services without suffering financial crisis.

Determinants of Mental Health Care Utilization in a Suicide High-risk Group With Suicidal Ideation

Objectives:

The suicide rate in Korea is increasing every year, and is the highest among the Organization for Economic Cooperation and Development countries. Psychiatric patients in particular have a higher risk of suicide than other patients. This study was performed to evaluate determinants of mental health care utilization among individuals at high risk for suicide.

Methods:

Korea Health Panel data from 2009 to 2011 were used. Subjects were individuals at high risk of suicide who had suicidal ideation, a past history of psychiatric illness, or had utilized outpatient services for a psychiatric disorder associated with suicidal ideation within the past year. The chi-square test and hierarchical logistic regression were used to identify significant determinants of mental health care utilization.

Results:

The total number of subjects with complete data on the variables in our model was 989. Individuals suffering from three or more chronic diseases used mental health care more frequently. Mental health care utilization was higher in subjects who had middle or high levels of educational attainment, were receiving Medical Aid, or had a large family size.

Conclusions:

It is important to control risk factors in high-risk groups as part of suicide prevention strategies. The clinical approach, which includes community-based intervention, entails the management of reduction of suicidal risk. Our study identified demographic characteristics that have a significant impact on mental health care utilization and should be considered in the development of suicide prevention strategies. Further studies should examine the effect of mental health care utilization on reducing suicidal ideation.

Health care utilization by people with disabilities: A longitudinal analysis of the Korea Welfare Panel Study (KoWePS)

BACKGROUND

Health care is important for people with disabilities in terms of maintaining basic functional status and promoting health. However, empirical studies on health care utilization by this population in South Korea are rare.

OBJECTIVE

The purpose of this study was to examine the characteristics of people with disabilities and to evaluate the relationship between the presence and severity of disabilities and health care utilization.

METHODS

We analyzed the 2005-2011 Korea Welfare Panel Study data, and the final sample included 38,598 observations over seven years. Health care utilization was measured by health screening attendance, number of outpatient physician visits, and inpatient days. To examine the impact of disabilities on health care utilization, random-effects logistic regression and negative binomial regression models were adopted.

RESULTS

About 3.3% of the sample had physical disabilities, as defined by the Korean disability registration system. In the sample, the prevalence of chronic diseases and percentage of poor self-rated health were higher in people with disabilities than in people without disabilities. The results of the regression analyses showed that people with severe disabilities had a lower probability of health screening attendance, and they also had significantly longer inpatient stays for health care services.

CONCLUSIONS

These findings imply poor accessibility of preventive or outpatient health care services for people with severe disabilities in Korea, and suggest that barriers should be removed. Further studies are necessary for effective health care provision to meet the complex needs of people with disabilities.

Out-of-pocket Costs of Disabilities and Their Association with Household Socioeconomic Status Among School-aged Children in Vietnam

Objective: The aim of this study was to assess the economic burden of disability of school-aged children and to evaluate the association between disabilities and household socioeconomic status, as well as the economic burden of disability and household socioeconomic status in Vietnam.

Materials and Methods: Nationally representative data for 9,882 children aged 6 to 17 years from the Vietnam Household Living Standard Survey 2006 were used. Disabilities were measured in six basic functional domains, including vision, hearing, remembering or concentrating, mobility, self-care, and communication. We evaluated the association between area, household income, educational attainment, or occupation of household head, and each difficulty. The ratio of health-care expenditure to per capita household income was compared by presence of a disability as well as household socioeconomic status.

Results: The prevalence of difficulty was 1.9% for vision and 2.3% for at least one of the other five domains. Difficulty in vision was more prevalent in the richer households (p=0.001), whereas difficulty in the other five domains was more prevalent in the poorer households (p=0.002). The ratio of health-care expenditure to per capita household income was greater than 0.05 in 4.6% of children. The adjusted odds ratio of children with difficulty in vision having a health-care expenditure share greater than 0.05 compared with children without difficulty was 4.78 (95% CI: 2.95, 7.73; p<0.001), and that for difficulty in the other five domains was 3.13 (95% CI: 2.04, 4.80; p<0.001). Among children with difficulty in at least one of the five domains other than vision, the proportion of children with a health-care expenditure share greater than 0.05 was higher among children from the poorer households (p=0.033).

Conclusions: Children with a disability spent more on health care relative to their income than those without. Visual disability was more prevalent among children from the richer households, whereas other disabilities were more prevalent among children from the poorer households.

Nonoccupational and occupational injuries to US workers with disabilities

OBJECTIVES

We examined medically treated injuries among US workers with disability.

METHODS

Using 2006-2010 National Health Interview Survey data, we compared 3-month rates of nonoccupational and occupational injuries to workers with disability (n = 7729) and without disability (n = 175 947). We fitted multivariable logistic regression models to calculate odds ratios and 95% confidence intervals of injuries by disability status, controlling for sociodemographic variables. We also compared leading causes of injuries by disability status.

RESULTS

In the 3-month period prior to the survey, workers with disability were more likely than other workers to have nonoccupational injuries (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.04, 2.71) and occupational injuries (OR = 2.39; 95% CI = 1.89, 3.01). For both groups, the leading cause was falls.

CONCLUSIONS

Disability status was strongly associated with risk of nonoccupational and occupational injuries among US workers. The safety issues facing US workers with disability in the workplace warrant future research. Federal agencies with an interest in the employment of workers with disability and their safety in the workplace should take a lead in further assessing injury risk and in promoting a safe working environment for workers with disability.