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Ssali SN, Morgan R, Nakiranda S, Opio CK, Otmani del Barrio M. Gendered lives, gendered Vulnerabilities: An intersectional gender analysis of exposure to and treatment of schistosomiasis in Pakwach district, Uganda. PLoS Negl Trop Dis 2023; 17:e0010639. [PMID: 37948453 PMCID: PMC10684070 DOI: 10.1371/journal.pntd.0010639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/28/2023] [Accepted: 08/17/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Schistosomiasis is a neglected tropical disease (NTD) that is endemic in Uganda, despite several interventions to eliminate it. It is transmitted when people infected with it pass on their waste matter into fresh water bodies used by others, consequently infecting them. Several studies have demonstrated gender and age differences in prevalence of schistosomiasis and NTDs such as lymphatic filariasis and soil transmitted helminths. However, few intersectional gender analysis studies of schistosomiasis have been undertaken. Using the World Health Organisation (WHO)'s intersectional gender analysis toolkit, this study was undertaken to identify which social stratifiers most intersected with gender to influence vulnerability to and access to treatment for schistosomiasis disease, to understand how best to implement interventions against it. METHODOLOGY This was a qualitative study comprising eight focus group discussions (FGDs) of community members, disaggregated by age, sex and location, and 10 key informant interviews with health care providers and community leaders. The Key informants were selected purposively while the community members were selected using stratified random sampling (to cater for age, sex and location). The data was analysed manually to identity key themes around gender, guided by a gender and intersectionality lens. RESULTS The study established that while the River Nile provided livelihoods it also exposed the community to schistosomiasis infection. Gender relations played a significant role in exposure to and access to treatment for schistosomiasis. Traditional gender roles determined the activities men and women performed in the private and public spheres, which in turn determined their exposure to schistosomiasis and treatment seeking behaviour. Gender relations also affected access to treatment and decision making over family health care. Men and some women who worked outside the home were reported to prioritise their income earning activities over seeking health care, while women who visited the health facilities more regularly for antenatal care and to take sick children were reported to have higher chance of being tested and treated in time, although this was undermined by the irregular and infrequent provision of praziquantel (PZQ) mass drug administration. These gender relations were further compounded by underdevelopment and limited economic opportunities, insufficient health care services, as well as the respondent's age and location. CONCLUSIONS The study concludes that vulnerability to schistosomiasis disease and treatment occurred within a complex web of gender relations, culture, poverty, limited economic opportunities and insufficient health services delivery, which together undermined efforts to eliminate schistosomiasis. This study recommends the following: a) increased public health campaigns around schistosomiasis prevention and treatment; b) more regular PZQ MDA at home and schools; c) improved health services delivery and integration of services to include vector control; d) prioritising NTDs; e) providing alternative economic activities; and f) addressing negative gender norms that promote social behaviours which negatively influence vulnerability, treatment seeking and decision making for health.
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Affiliation(s)
- Sarah N. Ssali
- Makerere University School of Women and Gender Studies, Kampala, Uganda
| | - Rosemary Morgan
- Department of International Health, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Salama Nakiranda
- Makerere University School of Women and Gender Studies, Kampala, Uganda
| | | | - Mariam Otmani del Barrio
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
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Dahal PK, Rawal L, Ademi Z, Mahumud RA, Paudel G, Vandelanotte C. Estimating the Health Care Expenditure to Manage and Care for Type 2 Diabetes in Nepal: A Patient Perspective. MDM Policy Pract 2023; 8:23814683231216938. [PMID: 38107033 PMCID: PMC10725113 DOI: 10.1177/23814683231216938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/05/2023] [Indexed: 12/19/2023] Open
Abstract
Background. This study aimed to estimate the health care expenditure for managing type 2 diabetes (T2D) in the community setting of Nepal. Methods. This is a baseline cross-sectional study of a heath behavior intervention that was conducted between September 2021 and February 2022 among patients with T2D (N = 481) in the Kavrepalanchok and Nuwakot districts of Nepal. Bottom-up and micro-costing approaches were used to estimate the health care costs and were stratified according to residential status and the presence of comorbid conditions. A generalized linear model with a log-link and gamma distribution was applied for modeling the continuous right-skewed costs, and 95% confidence intervals were obtained from 10,000 bootstrapping resampling techniques. Results. Over 6 months the mean health care resource cost to manage T2D was US $22.87 per patient: 61% included the direct medical cost (US $14.01), 15% included the direct nonmedical cost (US $3.43), and 24% was associated with productivity losses (US $5.44). The mean health care resource cost per patient living in an urban community (US $24.65) was about US $4.95 higher than patients living in the rural community (US $19.69). The health care costs per patient with comorbid conditions was US $22.93 and was US $22.81 for those without comorbidities. Patients living in rural areas had 16% lower health care expenses compared with their urban counterparts. Conclusion. T2D imposes a substantial financial burden on both the health care system and individuals. There is a need to establish high-value care treatment strategies for the management of T2D to reduce the high health care expenses. Highlights More than 60% of health care expenses comprise the direct medical cost, 15% direct nonmedical cost, and 24% patient productivity losses. The costs of diagnosis, hospitalization, and recommended foods were the main drivers of health care costs for managing type 2 diabetes.Health care expenses among patients living in urban communities and patients with comorbid conditions was higher compared with those in rural communities and those with without comorbidities.The results of this study are expected to help integrate diabetes care within the existing primary health care systems, thereby reducing health care expenses and improving the quality of diabetes care in Nepal.
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Affiliation(s)
- Padam Kanta Dahal
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney Campus, Sydney, NSW, Australia
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Queensland, Australia
| | - Lal Rawal
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney Campus, Sydney, NSW, Australia
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Queensland, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Sydney, NSW, Australia
| | - Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashidul Alam Mahumud
- NHRMC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Grish Paudel
- School of Health, Medical and Applied Sciences, Central Queensland University, Sydney Campus, Sydney, NSW, Australia
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Queensland, Australia
| | - Corneel Vandelanotte
- Appleton Institute, Physical Activity Research Group, Central Queensland University, Queensland, Australia
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Loewenson R, Mhlanga G, Gotto D, Chayikosa S, Goma F, Walyaro C. Equity dimensions in initiatives promoting urban health and wellbeing in east and southern Africa. Front Public Health 2023; 11:1113550. [PMID: 37113184 PMCID: PMC10128861 DOI: 10.3389/fpubh.2023.1113550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
Urbanisation in east and southern Africa (ESA) has brought opportunity and wealth together with multiple dimensions of deprivation. Less well documented in published literature on the ESA region are features of urban practice that promote health equity. This work thus aimed to explore features of urban initiatives aimed at improving health and wellbeing in ESA countries and their contribution to different dimensions of health equity. A thematic analysis was implemented on evidence gathered from 52 documents from online searches and 10 case studies from Harare, Kampala, Lusaka, and Nairobi. Most of the initiatives found focused on social determinants affecting low income communities, particularly water, sanitation, waste management, food security and working and environmental conditions, arising from longstanding urban inequalities and from recent climate and economic challenges. The interventions contributed to changes in social and material conditions and system outcomes. Fewer reported on health status, nutrition, and distributional outcomes. The interventions reported facing contextual, socio-political, institutional, and resource challenges. Various enablers contributed to positive outcomes and helped to address challenges. They included investments in leadership and collective organisation; bringing multiple forms of evidence to planning, including from participatory assessment; building co-design and collaboration across multiple sectors, actors and disciplines; and having credible brokers and processes to catalyse and sustain change. Various forms of mapping and participatory assessment exposed often undocumented shortfalls in conditions affecting health, raising attention to related rights and duties to promote recognitional equity. Investment in social participation, organisation and capacities across the initiatives showed participatory equity to be a consistent feature of promising practice, with both participatory and recognitional equity acting as levers for other dimensions of equity. There was less evidence of distributional, structural and intergenerational equity. However, a focus on low income communities, links made between social, economic and ecological benefit, and investment in women and young people and in urban biodiversity indicated a potential for gains in these areas. The paper discusses learning on local process and design features to strengthen to promote these different dimensions of equity, and issues to address beyond the local level to support such equity-oriented urban initiatives.
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Affiliation(s)
- Rene Loewenson
- Training and Research Support Centre, Harare, Zimbabwe
- *Correspondence: Rene Loewenson,
| | | | - Danny Gotto
- Innovations for Development, Kampala, Uganda
| | | | - Fastone Goma
- Centre for Primary Care Research, Lusaka, Zambia
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Zanganeh A, Ziapour A, Naderlou R, Teimouri R, Janjani P, Yenneti K. Evaluating the access of slum residents to healthcare centers in Kermanshah Metropolis, Iran (1996-2016): A spatial justice analysis. Heliyon 2022; 9:e12731. [PMID: 36685373 PMCID: PMC9849978 DOI: 10.1016/j.heliyon.2022.e12731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022] Open
Abstract
Background Proper access to health care centres and services is one of the key indicators of health justice, and it is more than ever important in slums. Objective This aim of this research is to evaluate the accessibility of health care centres to slum residents in the Kermanshah metropolis, Iran during the period 1996-2016. Methods In this cross-sectional study, data was obtained from the Census of Iran for the periods 1996, 2006 and 2016. Information on the number and location of health care centres was collected from the Kermanshah University of Medical Sciences. Network Analysis modelling method in Arc/GIS10.6 software was used to evaluate the accessibility of people to health centres. Results The results show that the spatial pattern of health centres in Kermanshah was random during 1996, 2006 and 2016, but the spatial pattern of poverty in the metropolis was clustered. In addition, the distribution of health centres was not consistent with the population densities. However, the overall population with inappropriate access to health centres in the slums of Kermanshah metropolis decreased over the study period (1996-54.02%, 2006-51.09%, and 2016-34.71%). Conclusions The findings of the study reveal that access to health care services by the slum population is not consistent with the increase of health care centres. This means that health policymakers were unsuccessful to provide the required health care services for the slums.
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Affiliation(s)
- Alireza Zanganeh
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Arash Ziapour
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran,Corresponding author.
| | | | - Raziyeh Teimouri
- UniSA Creative, University of South Australia, Adelaide, Australia
| | - Parisa Janjani
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Komali Yenneti
- School of Architecture and the Built Environment, University of Wolverhampton, UK
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Uddin MF, Molyneux S, Muraya K, Jemutai J, Berkley JA, Walson JL, Hossain MA, Islam MA, Zakayo SM, Njeru RW, Ahmed T, Chisti MJ, Sarma H. Treatment-seeking and recovery among young undernourished children post-hospital discharge in Bangladesh: A qualitative study. PLoS One 2022; 17:e0274996. [PMID: 36149880 PMCID: PMC9506605 DOI: 10.1371/journal.pone.0274996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries. Although a number of quantitative studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, few studies have explored family and provider perspectives of the post-discharge period in-depth. METHODS This work was part of a large, multi-country prospective cohort study, the Childhood Acute Illness and Nutrition (CHAIN) Network. We conducted a qualitative sub-study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in a rural and urban icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospital. Methods included repeat in-depth interviews (73 interviews in total) with 29 family members of 17 purposively selected children. These data were supplemented by interviews with 33 health workers, and by observations in hospitals and homes. RESULTS Important drivers of treatment-seeking perceived to support recovery included advice provided to family members while in hospital, media campaigns on hygiene practice, availability of free treatment, and social and financial support from family members, relatives and neighbours. Key perceived challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the sick child, lack of support (sometimes violence) from the child's father, and family members' preference for relatively accessible drug shops, physicians or healers over hospital admission. CONCLUSION Development of interventions that address the challenges that families face is essential to support post-discharge adherence to medical advice and recovery. Potential interventions include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other 'significant others' in post-discharge advice, and building mobile phone-based support for follow-up care.
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Affiliation(s)
- Md. Fakhar Uddin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sassy Molyneux
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Julie Jemutai
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Judd L. Walson
- Department of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Md. Alamgir Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Aminul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
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Eze P, Lawani LO, Agu UJ, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis. Bull World Health Organ 2022; 100:337-351J. [PMID: 35521041 PMCID: PMC9047424 DOI: 10.2471/blt.21.287673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods We 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. Findings We 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; I 2 = 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; I 2 = 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. Conclusion Although 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.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA 16802, United States of America
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Ujunwa Justina Agu
- Department of Community Medicine, Enugu State University Teaching Hospital, Parklane, Nigeria
| | - Yubraj Acharya
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA 16802, United States of America
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Adamu AL, Karia B, Bello MM, Jahun MG, Gambo S, Ojal J, Scott A, Jemutai J, Adetifa IM. The cost of illness for childhood clinical pneumonia and invasive pneumococcal disease in Nigeria. BMJ Glob Health 2022; 7:bmjgh-2021-007080. [PMID: 35101861 PMCID: PMC8804652 DOI: 10.1136/bmjgh-2021-007080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/03/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pneumococcal disease contributes significantly to childhood morbidity and mortality and treatment is costly. Nigeria recently introduced the pneumococcal conjugate vaccine (PCV) to prevent pneumococcal disease. The aim of this study is to estimate health provider and household costs for the treatment of pneumococcal disease in children aged <5 years (U5s), and to assess the impact of these costs on household income. METHODS We recruited U5s with clinical pneumonia, pneumococcal meningitis or pneumococcal septicaemia from a tertiary level hospital and a secondary level hospital in Kano, Nigeria. We obtained resource utilisation data from medical records to estimate costs of treatment to provider, and household expenses and income loss data from caregiver interviews to estimate costs of treatment to households. We defined catastrophic health expenditure (CHE) as household costs exceeding 25% of monthly household income and estimated the proportion of households that experienced it. We compared CHE across tertiles of household income (from the poorest to least poor). RESULTS Of 480 participants recruited, 244 had outpatient pneumonia, and 236 were hospitalised with pneumonia (117), septicaemia (66) and meningitis (53). Median (IQR) provider costs were US$17 (US$14-22) for outpatients and US$272 (US$271-360) for inpatients. Median household cost was US$51 (US$40-69). Overall, 33% of households experienced CHE, while 53% and 4% of the poorest and least poor households, experienced CHE, respectively. The odds of CHE increased with admission at the secondary hospital, a diagnosis of meningitis or septicaemia, higher provider costs and caregiver having a non-salaried job. CONCLUSION Provider costs are substantial, and households incur treatment expenses that considerably impact on their income and this is particularly so for the poorest households. Sustaining the PCV programme and ensuring high and equitable coverage to lower disease burden will reduce the economic burden of pneumococcal disease to the healthcare provider and households.
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Affiliation(s)
- Aishatu Lawal Adamu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Boniface Karia
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Musa M Bello
- Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
- Community Medicine, Bayero University Faculty of Medicine, Kano, Nigeria
| | - Mahmoud G Jahun
- Paediatrics, Bayero University Faculty of Medicine, Kano, Nigeria
- Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Paediatrics, Murtala Muhammed Specialist Hospital, Kano, Nigeria
| | - John Ojal
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Anthony Scott
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Jemutai
- Health System & Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ifedayo M Adetifa
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Virhia J. Contextualising health seeking behaviours for febrile illness: Lived experiences of farmers in northern Tanzania. Health Place 2021; 73:102710. [PMID: 34801785 DOI: 10.1016/j.healthplace.2021.102710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 01/09/2023]
Abstract
Understanding how people seek treatment for febrile illness can provide important insights into when care is sought and under what circumstances. This is includes examining how people engage with health facilities and the barriers to care they experience. However, a focus on individual actions runs the risk of overemphasising the agency of individuals to make apt health decisions while underestimating the ways which health behaviours are circumscribed by their place-specific social, historic and political contexts. Drawing on the experiences of approximately 100 farmers in a small livestock keeping community in northern Tanzania, this study uses biosocial theory of health to better understand how febrile illness is managed among individuals. The paper draws attention to the ways in which health decisions are mediated by individual, intrinsic and extrinsic health system factors. Some extrinsic factors (such as hospital user fees) are legacies of neoliberal healthcare reform policies which continue to have consequences for how people manage febrile illness in Tanzania. The findings highlight the need for considerations of health behaviours to look beyond the individual and to appreciate the role of the wider health landscape in influencing individual choice and agency when seeking treatment for illness.
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Affiliation(s)
- Jennika Virhia
- Institute of Health & Wellbeing/School of Social & Political Sciences, 27 Bute Gardens, University of Glasgow, G12 8RS, UK.
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Pavlinac PB, Singa BO, Tickell KD, Brander RL, McGrath CJ, Amondi M, Otieno J, Akinyi E, Rwigi D, Carreon JD, Tornberg-Belanger SN, Nduati R, Babigumira JB, Meshak L, Bogonko G, Kariuki S, Richardson BA, John-Stewart GC, Walson JL. Azithromycin for the prevention of rehospitalisation and death among Kenyan children being discharged from hospital: a double-blind, placebo-controlled, randomised controlled trial. LANCET GLOBAL HEALTH 2021; 9:e1569-e1578. [PMID: 34559992 PMCID: PMC8638697 DOI: 10.1016/s2214-109x(21)00347-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/23/2021] [Accepted: 07/21/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mass drug administration of azithromycin to children in sub-Saharan Africa has been shown to improve survival in high-mortality settings. The period after hospital discharge is a time of elevated risk unaddressed by current interventions and might provide an opportunity for targeting empirical azithromycin administration. We aimed to assess the efficacy of azithromycin administered at hospital discharge on risk of death and rehospitalisation in Kenyan children younger than 5 years. METHODS In this double-blind, placebo-controlled randomised trial, children were randomly assigned (1:1) to receive a 5-day course of azithromycin (oral suspension 10 mg/kg on day 1, followed by 5mg/kg per day on days 2-5) or identically appearing and tasting placebo at discharge from four hospitals in western Kenya. Children were eligible if they were aged 1-59 months at hospital discharge, weighed at least 2 kg, and had been admitted to hospital for any medical reason other than trauma, poisoning, or congenital anomaly. The primary outcome was death or rehospitalisation in the subsequent 6-month period in a modified intention-to-treat population, compared by randomisation group with Cox proportional hazards regression and Kaplan-Meier. Azithromycin resistance in Escherichia coli isolates from a random subset of children was compared by randomisation group with generalised estimating equations. This trial is registered with ClinicalTrials.gov, NCT02414399. FINDINGS Between June 28, 2016, and Nov 4, 2019, 1400 children were enrolled in the trial at discharge from hospital, with 703 (50·2%) randomly assigned to azithromycin and 697 (49·8%) to placebo. Among the 1398 children included in the modified intention-to-treat analysis (702 in the azithromycin group and 696 in the placebo group), the incidence of death or rehospitalisation was 20·4 per 100 child-years in the azithromycin group and 22·5 per 100 child-years in the placebo group (adjusted hazard ratio 0·91, 95·5% CI 0·64-1·29, p=0·58). Azithromycin resistance was common in commensal E coli isolates from enrolled children before randomisation (37·7% of 406 isolates) despite only 3·7% of children having received a macrolide antibiotic during the hospitalisation. Azithromycin resistance was slightly higher at 3 months after randomisation in the azithromycin group (26·9%) than in the placebo group (19·1%; adjusted prevalence ratio 1·41, 95% CI 0·95-2·09, p=0·088), with no difference observed at 6 months (1·17, 0·78-1·76, p=0·44). INTERPRETATION We did not observe a significant benefit of a 5-day course of azithromycin delivered to children younger than 5 years at hospital discharge despite the overall high risk of mortality and rehospitalisation. These findings highlight the need for more research into mechanisms and interventions for prevention of morbidity and mortality in the post-discharge period. FUNDING Eunice Kennedy Shriver National Institute of Child Health & Human Development.
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Affiliation(s)
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Mary Amondi
- International AIDS Vaccine Initiative, Nairobi, Kenya
| | - Joyce Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Akinyi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Doreen Rwigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Ruth Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Liru Meshak
- Homa Bay Teaching and Referral Hospital, Homa Bay, Kenya
| | | | - Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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10
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Tadokera R, Huo S, Theron G, Timire C, Manyau-Makumbirofa S, Metcalfe JZ. Health care seeking patterns of rifampicin-resistant tuberculosis patients in Harare, Zimbabwe: A prospective cohort study. PLoS One 2021; 16:e0254204. [PMID: 34270593 PMCID: PMC8284678 DOI: 10.1371/journal.pone.0254204] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Delays in seeking and accessing treatment for rifampicin-resistant tuberculosis (RR-TB) and multi-drug resistant (MDR-TB) are major impediments to TB control in high-burden, resource-limited settings. Method We prospectively determined health-seeking behavioural patterns and associations with treatment outcomes and costs among 68 RR-TB patients attending conveniently selected facilities in a decentralised system in Harare, Zimbabwe. Results From initial symptoms to initiation of effective treatment, patients made a median number of three health care visits (IQR 2–4 visits) at a median cost of 13% (IQR 6–31%) of their total annual household income (mean cost, US$410). Cumulatively, RR-TB patients most frequently first visited private facilities, i.e., private pharmacies (30%) and other private health care providers (24%) combined. Median patient delay was 26 days (IQR 14–42 days); median health system delay was 97 days (IQR 30–215 days) and median total delay from symptom onset to initiation of effective treatment was 132 days (IQR 51–287 days). The majority of patients (88%) attributed initial delay in seeking care to “not feeling sick enough.” Total delay, total cost and number of health care visits were not associated with treatment or clinical outcomes, though our study was not adequately powered for these determinations. Conclusions Despite the public availability of rapid molecular TB tests, patients experienced significant delays and high costs in accessing RR-TB treatment. Active case finding, integration of private health care providers and enhanced service delivery may reduce treatment delay and TB associated costs.
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Affiliation(s)
- Rebecca Tadokera
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, NRF/DST Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Stella Huo
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | - Grant Theron
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, NRF/DST Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Collins Timire
- Ministry of Health and Child Care, National Tuberculosis Control Programme, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease Zimbabwe Office, Centre for Operational Research, Harare, Zimbabwe
| | - Salome Manyau-Makumbirofa
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
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11
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Kayiba NK, Yobi DM, Devleesschauwer B, Mvumbi DM, Kabututu PZ, Likwela JL, Kalindula LA, DeMol P, Hayette MP, Mvumbi GL, Lusamba PD, Beutels P, Rosas-Aguirre A, Speybroeck N. Care-seeking behaviour and socio-economic burden associated with uncomplicated malaria in the Democratic Republic of Congo. Malar J 2021; 20:260. [PMID: 34107960 PMCID: PMC8191196 DOI: 10.1186/s12936-021-03789-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 05/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to estimate the socio-economic costs of uncomplicated malaria and to explore health care-seeking behaviours that are likely to influence these costs in the Democratic Republic of Congo (DRC), a country ranked worldwide as the second most affected by malaria. Methods In 2017, a cross-sectional survey included patients with uncomplicated malaria in 64 healthcare facilities from 10 sentinel sites of the National Malaria Control Programme (NMCP) in the DRC. A standard questionnaire was used to assess health care-seeking behaviours of patients. Health-related quality of life (HRQL) and disutility weights (DW) of illness were evaluated by using the EuroQol Group’s descriptive system (EQ-5D-3L) and its visual analogue scale (EQ VAS). Malaria costs were estimated from a patient’s perspective. Probabilistic sensitivity analyses (PSA) evaluated the uncertainty around the cost estimates. Generalized regression models were fitted to assess the effect of potential predictive factors on the time lost and the DW during illness. Results In total, 1080 patients (age: 13.1 ± 14 years; M/F ratio: 1.1) were included. The average total costs amounted to US$ 36.3 [95% CI 35.5–37.2] per malaria episode, including US$ 16.7 [95% CI 16.3–17.1] as direct costs and US$ 19.6 [95% CI 18.9–20.3] indirect costs. During care seeking, economically active patients and their relatives lost respectively 3.3 ± 1.8 and 3.4 ± 2.1 working days. This time loss occurred mostly at the pre-hospital stage and was the parameter associated the most with the uncertainty around malaria cost estimates. Patients self-rated an average 0.36 ± 0.2 DW and an average 0.62 ± 0.3 EQ-5D index score per episode. A lack of health insurance coverage (896 out of 1080; 82.9%) incurred substantially higher costs, lower quality of life, and heavier DW while leading to longer time lost during illness. Residing in rural areas incurred a disproportionally higher socioeconomic burden of uncomplicated malaria with longer time lost due to illness and limited access to health insurance mechanisms. Conclusion Uncomplicated malaria is associated with high economic costs of care in the DRC. Efforts to reduce the cost-of-illness should target time lost at the pre-hospital stage and social disparities in the population, while reinforcing measures for malaria control in the country. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03789-w.
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Affiliation(s)
- Nadine Kalenda Kayiba
- Research Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium. .,School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo. .,School of Public Health, Faculty of Medicine, University of Mbujimayi, Mbujimayi, Democratic Republic of the Congo.
| | - Doudou Malekita Yobi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Brecht Devleesschauwer
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.,Department of Veterinary Public Health and Food Safety, Ghent University, Ghent, Belgium
| | - Dieudonné Makaba Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo.,Department of Quality of Laboratories, Sciensano, Brussels, Belgium
| | - Pius Zakayi Kabututu
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | | | - Patrick DeMol
- Laboratory of Clinical Microbiology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium
| | - Marie-Pierre Hayette
- Laboratory of Clinical Microbiology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium
| | - Georges Lelo Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Paul Dikassa Lusamba
- School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases, University of Antwerp, Antwerp, Belgium
| | - Angel Rosas-Aguirre
- Research Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
| | - Niko Speybroeck
- Research Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
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12
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Otieno PO, Kiroro F, Runyenje C, Kamau P. Unmet need for primary healthcare and associated individual and household-level factors in Kenya: results from a national survey. BMJ Open 2021; 11:e041032. [PMID: 34049900 PMCID: PMC8166634 DOI: 10.1136/bmjopen-2020-041032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 05/02/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the prevalence of unmet need for primary healthcare and associated individual and household-level factors in Kenya. DESIGN The data for this study are drawn from the 2016 Kenya Integrated Household Budget Survey (KIHBS). A multistage sampling technique involving a systematic selection of clusters at the national level and final selection of households was used. SETTING This study was conducted in Kenya. The KIHBS is a nationally representative survey on a wide range of indicators to assess the progress made in improving the living standards of the population at the national level. PARTICIPANTS A total of 9447 households comprising 15 539 household members who reported a sickness or injury over the 4 weeks preceding this survey were included in this study. The study respondents comprised of the household heads. PRIMARY OUTCOME MEASURE The primary outcome of this study is unmet need for primary healthcare defined as an unexpressed demand for primary healthcare following a reported sickness or injury over the 4 weeks preceding this survey. RESULTS About one in every five study participants experienced an unexpressed demand for primary care. The odds of having unmet need for primary healthcare were 68% higher among participants without health insurance coverage compared with those with health insurance (adjusted OR 1.68; p<0.001; 95% CI 1.34 to 2.09) and 45% higher among households headed by single or unmarried persons compared with the those who were in a marital union (adjusted OR 1.45; p<0.05; 95% CI 1.06 to 1.98). CONCLUSIONS Our findings show that there is still a considerable unexpressed demand for primary care services despite widespread implementation of Universal Health Coverage (UHC) in Kenya, with households without a health insurance cover bearing the highest burden. Therefore, the design of UHC reforms in Kenya should focus on embedding social health protection to escalate the demand for primary healthcare services.
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Affiliation(s)
- Peter O Otieno
- African Population and Health Research Center, Nairobi, Kenya
| | - Francis Kiroro
- African Population and Health Research Center, Nairobi, Kenya
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13
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Majamanda MD, Joshua Gondwe M, Makwero M, Chalira A, Lufesi N, Dube Q, Desmond N. Capacity Building for Health Care Workers and Support Staff in Pediatric Emergency Triage Assessment and Treatment (ETAT) at Primary Health Care Level in Resource Limited Settings: Experiences from Malawi. Compr Child Adolesc Nurs 2021:1-16. [PMID: 34029495 DOI: 10.1080/24694193.2021.1916127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
Primary health care facilities offer an entry point to the health care system in Malawi. Challenges experienced by these facilities include limited resources (both material and human), poor or inadequate knowledge, skills and attitudes of health care workers in emergency management, and delay in referral from primary care level to other levels of care. These contribute to poor outcomes including children dying within the first 24 hours of hospital admission. Training of health care workers and support staff in Emergency Triage Assessment and Treatment (ETAT) at primary care levels can help improve care of children with acute and severe illnesses. Health care workers and support staff in the primary care settings were trained in pediatric ETAT. The training package for health care workers was adapted from the Ministry of Health ETAT training for district and tertiary health care. Content for support staff focused on non-technical responsibility for lifesaving in emergency situations. The primary health care facilities were provided with a minimum treatment package comprising emergency equipment, supplies and drugs. Supportive supervisory visits were conducted quarterly. The training manual for health care workers was adapted from the Ministry of Health package and the support staff training manual was developed from the adapted package. Eight hundred and seventy-seven participants were trained (336 health care workers and 541 support staff). Following the training, triaging of patients improved and patients were managed as emergency, priority or non-urgent. This reduced the number of referral cases and children were stabilized before referral. Capacity building of health care workers and support staff in pediatric ETAT and the provision of a basic health center package improved practice at the primary care level. The practice was sustained through institutional mentorship and pre-service and in-service training. The practice of triage and treatment including stabilization of children with dangerous signs at the primary health care facility improves emergency care of patients, reduces the burden of patients on referral hospitals and increases the number of successful referrals.
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Affiliation(s)
- Maureen Daisy Majamanda
- Department of Medical and Surgical Nursing, Kamuzu College of Nursing, University of Malawi, Blantyre, Malawi
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
| | - Mtisunge Joshua Gondwe
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Behaviour and Health Group, Malawi-Liverpool Wellcome Trust, Clinical Research Programme, Blantyre, Malawi
| | - Martha Makwero
- Department of Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Alfred Chalira
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Nicola Desmond
- Behaviour and Health Group, Malawi-Liverpool Wellcome Trust, Clinical Research Programme, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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14
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Ng G, Raskin E, Wirtz VJ, Banks KP, Laing RO, Kiragu ZW, Rockers PC, Onyango MA. Coping with access barriers to non-communicable disease medicines: qualitative patient interviews in eight counties in Kenya. BMC Health Serv Res 2021; 21:417. [PMID: 33941177 PMCID: PMC8094552 DOI: 10.1186/s12913-021-06433-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background There is rich literature on barriers to medicines access for the treatment of non-communicable diseases (NCDs) in high-income countries. Less is known about low- and middle-income countries, in particular the differences in coping with medicines access barrier by household wealth and disease. The aim of this study was to compare the coping mechanisms of patients with the lack of availability and affordability of cardio-vascular diseases, diabetes and asthma medicines in Kenya. Methods This qualitative study was part of a larger mixed methods evaluation study conducted in eight counties of Kenya from 2016 to 2019. Forty-nine patient interviews at study end line explored their NCD journey, perceptions of availability, stockouts and affordability of NCD medicines, their enrollment in health insurance, and their relationship with the private chemists. Transcribed interviews were coded using Nvivo software. A two-step thematic approach was used, first conducting a priority coding which was followed by coding emerging and divergent themes. Results Overall, we found that patients across all disease types and wealth level faced frequent medicine stock-outs at health facilities. In the absence of NCD medicines at health facilities, patients coped by purchasing medicines from local chemists, switching health facilities, requesting a different prescription, admitting oneself to an inpatient facility, establishing connections with local staff to receive notifications of medicine stock, stocking up on medicines, utilizing social capital to retrieve medicines from larger cities and obtaining funds from a network of friends and family. Categorizing by disease revealed patterns in coping choices that were based on the course of the disease, severity of the symptoms and the direct and indirect costs incurred as a result of stockouts of NCD medicines. Categorizing by wealth highlight differences in households’ capacity to cope with the unavailability and unaffordability of NCD medicines. Conclusions The type of coping strategies to access barriers differ by NCD and wealth group. Although Kenya has made important strides to address NCD medicines access challenges, prioritizing enrollment of low wealth households in county health insurance programs and ensuring continuous availability of essential NCD medicines at public health facilities close to the patient homes could improve access.
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Affiliation(s)
- Gloria Ng
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
| | - Elizabeth Raskin
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA.
| | - Kathleen P Banks
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
| | - Richard O Laing
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA.,School of Public Health, Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Zana W Kiragu
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
| | - Monica A Onyango
- Department of Global Health, Boston University School of Public Health, Crosstown, 3rd floor, 801 Massachusetts Avenue, MA, 02118, Boston, USA
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15
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Socioeconomic Impact of Hospitalization Expenditure for Treatment of Noncommunicable Diseases in India: A Repeated Cross-Sectional Analysis of National Sample Survey Data, 2004 to 2018. Value Health Reg Issues 2021; 24:199-213. [PMID: 33845450 DOI: 10.1016/j.vhri.2020.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/17/2020] [Accepted: 12/27/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This article explores the consequences of hospitalization expenditure on noncommunicable diseases (NCD) and its impact on out-of-pocket expenditure (OOPE), catastrophic health expenditure, impoverishment, and hardship financing of households in India. METHODS Data on hospitalized cases of NCDs from the 3 rounds of National Sample Surveys (NSS) (2004, 2014, 2018) were used. Bivariate and multivariate analyses were conducted to investigate the socioeconomic differentials of the impact of OOPE on catastrophic health expenditure, impoverishment, and exposure to hardship financing. RESULTS Rural households had greater exposure to catastrophic health expenditure but urban households had higher risk of impoverishment due to OOPE. Older patients (aged ≥60 years) had the highest hospitalization rate per 100 000, including increase in average healthcare expenditure from 2004 to 2018. At 10% and 30% thresholds, 50% and 25% of the households, respectively, faced catastrophic health expenditure across all the 3 rounds. Due to OOPE on hospitaliation treatment for NCDs, about 3.8%, 7.4% and 4.8% of households fell below poverty line, and percentage shortfall in income for the population from the poverty line was 3%, 4.9% and 3%, in 2004, 2014 and 2018 respectively. Percentage of households facing hardship financing reduced from 49.2% in 2004 to 24.4% 2014 and 12.7% in 2018. CONCLUSION OOPE by households are still very high and hence the higher effects of CHE, impoverishment and exposure to hardship financing due to health expenditure in India. This study proposes that along with increase in budgetary allocations for healthcare, the government should develop suitable policies to expand the effectiveness of government-sponsored health insurance, such as developing a specific NCD service package to be included in the health insurance program.
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16
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Diagnostic validity of the pre-diabetes scale among at-risk rural Iranian adults for screening for pre-diabetes. J Diabetes Metab Disord 2021; 19:823-828. [PMID: 33520805 DOI: 10.1007/s40200-020-00568-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/08/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022]
Abstract
Background An intense increase in pre-diabetes has taken place among the worldwide population each year. The purpose of this study was to assess the diagnostic validity of the American Diabetes Association (ADA) screening questionnaire for identifying pre-diabetes in the Iranian rural population. Methods This study was conducted in Ahar County, East Azarbaijan, Iran. The participants (n = 440) were randomly recruited via trained community health care workers. The ADA questionnaire including six items (age, gender, having family members with diabetes, obesity, hypertension, and physical activity) is the screening tool used to identify people at high risk for developing type 2 diabetes. The World Health Organization (WHO) forward/backward translation protocol was used for translating the assessment tool. The diagnosis of pre-diabetes was defined based on the fasting blood glucose (FBG, as a gold standard) cut-points of 100 mg/dl to 125 mg/dl. We assessed the criterion validity and diagnosis characteristics of the ADA questionnaire in the diagnosis of pre-diabetes using the measures of sensitivity, specificity, and receiver operating characteristics (ROC) curves. In addition, the optimal cut-point of the ADA questionnaire for the diagnosis of pre-diabetes was computed using Youden's index. Results A total of 440 adults ages 30-65 years (Mage = 48.8 years, SDage = 11.2 years) were included in the study. Around half of the participants were women (50%), illiterate (51.4%), and married (85.2). In the pre-diabetes diagnosis scale, the present cut-point yielded a sensitivity of 98.7 (95% CI:96.6-99.6), specificity of 53.1 (95% CI: 44.6-61.5), positive predictive value (PPV) of 81.4 (95% CI:77-85.3), positive predictive value (NPV) of 95.0 (95% CI:87.7-98.6), and accuracy of 83.9 (95% CI:81.4-89.2) with an area under curve (AUC) of 0.84 (95% CI: 0.80 - 0.89). Conclusions The Persian version of the ADA questionnaire had good sensitivity and fair specificity for pre-diabetes diagnosis among rural adults at high risk for developing type 2 diabetes. The study provided evidence for the ADA questionnaire as a valid and reliable tool for identifying pre-diabetes in a rural area. Identifying rural residents in the early stage of developing diabetes with a simple and accurate instrument without the need for a FBG test contributes to controlling the disease in areas with limited access to health services. Trial registration The study is not a trial; the registration number is not applicable.
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17
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Myers K, Redere A, Fefferman NH. How resource limitations and household economics may compromise efforts to safeguard children during outbreaks. BMC Public Health 2020; 20:270. [PMID: 32093663 PMCID: PMC7041186 DOI: 10.1186/s12889-019-7968-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Epidemiological models have been employed with great success to explore the efficacy of alternative strategies at combating disease outbreaks. These models have often incorporated an understanding of age-based susceptibility and severity of outcome, considering how to limit the adverse outcomes or disease burden relative to an age structure. Such models frequently recommend the preferential treatment/vaccination of children or the elderly, demonstrating how prevention of serious disease within these etiological subgroups can provide both protection within the subgroup itself and indirect protection to the broader population. However, it is most frequently the case that these target populations are consumers, rather than providers, of household resources. In areas of the globe where continued health of household members relies on continued provision of resources, these models may fail to provide the most effective overall strategies for health outcomes in both target populations and overall. This is particularly important for tropical diseases impacting rural and low-income areas in which the disease may be endemic or newly emergent, particularly in the wake of natural disasters.
Methods
We propose a modified epidemiological model with targeted treatment in resource-limited populations. We evaluate the model over a broad parameter space.
Results
This model demonstrates how economic limitations may shift the optimal strategy. It may be advantageous to treat populations at lesser direct risk if they are responsible for providing secondary protection to higher-risk population(s) by producing household resources. Evaluation of this model over the parameter space reveals that, in some cases, targeting treatment towards consumers may result in greater numbers of consumer infections.
Conclusions
Our results demonstrate how household resource limitation can drastically affect the impact of targeted treatment strategies for limiting epidemics. Depending on the economic circumstances, it is possible that focusing treatment on consumers such as children can produce a counter-intuitive outcome in which more children contract the disease.
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Do S, Lohmann J, Brenner S, Koulidiati JL, Souares A, Kuunibe N, Hamadou S, Hien H, Winkler V, De Allegri M. Patterns of healthcare seeking among people reporting chronic conditions in rural sub-Saharan Africa: findings from a population-based study in Burkina Faso. Trop Med Int Health 2020; 25:1542-1552. [PMID: 32981177 DOI: 10.1111/tmi.13500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso. METHODS Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care. RESULTS 1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care. CONCLUSION Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.
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Affiliation(s)
- Stefanie Do
- Leibniz Institute for Prevention Research and Epidemiology, Bremen, Germany.,Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephan Brenner
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Aurelia Souares
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Naasegnibe Kuunibe
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany.,University for Development Studies, Tamale, Ghana
| | - Saidou Hamadou
- The World Bank, Health, Nutrition, Population Global Practice, Washington, DC, USA
| | - Hervé Hien
- Centre Muraz, National Public Health Institute (NPHI), Bobo-Dioulasso, Hauts-Bassins, Burkina Faso.,Research and Heath Science Institute (IRSS), Ouagadougou, Burkina Faso
| | - Volker Winkler
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
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Donfouet HPP, Mohamed SF, Otieno P, Wambiya E, Mutua MK, Danaei G. Economic valuation of setting up a social health enterprise in urban poor-resource setting in Kenya. Soc Sci Med 2020; 266:113294. [PMID: 32927381 DOI: 10.1016/j.socscimed.2020.113294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
The failure of the market and government to provide quality healthcare services have been the motivation to set up social health enterprise. However, the value for money associated with setting up a social health enterprise in sub-Sahara African countries has been relatively unexplored in the literature. The study presents the first empirical estimates of the mean willingness-to-pay (WTP) for setting up a social health enterprise that will simultaneously run a health center and provide health insurance scheme in an urban resource-poor setting and explores whether the benefits outweigh the costs. The contingent valuation method is used to estimate the mean WTP for the health insurance scheme proposed by the social health enterprise in Viwandani slum (Nairobi, Kenya). The survey was conducted between June and July 2018 on 300 households. We find that the feasibility of setting up a social health enterprise could be promising with 97 percent of respondents willing to pay about US$ 2 per person per month for a scheme that would provide quality healthcare services. More importantly, setting up the social health enterprise will yield a positive net profit, and investors could expect US$ 1.11 in benefits for each US$ 1 of costs of investment in setting up the social health enterprise. We, therefore, conclude that this health policy in this urban resource-poor setting could be a viable solution to reach the neglected urban households in the Kenyan slums.
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Affiliation(s)
- Hermann Pythagore Pierre Donfouet
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya; University of Rennes 1, CREM UMR-CNRS 6211, 7 Place Hoche, 35065, RENNES Cedex, France.
| | - Shukri F Mohamed
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Peter Otieno
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Elvis Wambiya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Martin Kavao Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Goodarz Danaei
- Harvard T.H. Chan School of Public Health, United States.
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Zakayo SM, Njeru RW, Sanga G, Kimani MN, Charo A, Muraya K, Sarma H, Uddin MF, Berkley JA, Walson JL, Kelley M, Marsh V, Molyneux S. Vulnerability and agency across treatment-seeking journeys for acutely ill children: how family members navigate complex healthcare before, during and after hospitalisation in a rural Kenyan setting. Int J Equity Health 2020; 19:136. [PMID: 32778121 PMCID: PMC7418306 DOI: 10.1186/s12939-020-01252-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Child mortality rates during hospitalisation for acute illness and after discharge are unacceptably high in many under-resourced settings. Childhood vulnerability to recurrent illness, and death, is linked to their families' situations and ability to make choices and act (their agency). We examined vulnerability and agency across treatment-seeking journeys for acutely ill children and considered the implications for policy and practice. METHOD A qualitative sub-study was embedded within the prospective CHAIN Network cohort study, which is investigating mechanisms of inpatient and post-hospital discharge mortality among acutely ill young children across a spectrum of nutritional status. Primary data were collected from household members of 20 purposively selected cohort children over 18 months through formal interviews (total n = 74), complemented by informal discussions and observations. Data were analysed using narrative and thematic approaches. RESULTS Treatment-seeking pathways were often long and complex, particularly for children diagnosed as severely malnourished. Family members' stories reveal that children's carers, usually mothers, navigate diverse challenges related to intersecting vulnerabilities at individual, household and facility levels. Specific challenges include the costs of treatment-seeking, confusing and conflicting messaging on appropriate care and nutrition, and poor continuity of care. Strong power inequities were observed between family members and health staff, with many mothers feeling blamed for their child's condition. Caregivers' agency, as demonstrated in decision-making and actions, often drew on the social support of others but was significantly constrained by their situation and broader structural drivers. CONCLUSION To support children's care and recovery, health systems must be more responsive to the needs of families facing multiple and interacting vulnerabilities. Reducing incurred treatment costs, improving interpersonal quality of care, and strengthening continuity of care across facilities is essential. Promising interventions need to be co-designed with community representatives and health providers and carefully tested for unintended negative consequences and potential for sustainable scale-up.
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Affiliation(s)
| | - Rita W Njeru
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
| | - Gladys Sanga
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
| | - Mary N Kimani
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
| | - Anderson Charo
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
| | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
| | - Haribondhu Sarma
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh
| | - Md Fakhar Uddin
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Judd L Walson
- Department of Global Health, University of Washington, Washington, USA
| | - Maureen Kelley
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Vicki Marsh
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- KEMRI-Wellcome Trust Research Programme, P.O Box 230, Kilifi, 80108, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Otieno PO, Wambiya EOA, Mohamed SM, Mutua MK, Kibe PM, Mwangi B, Donfouet HPP. Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. BMC Public Health 2020; 20:981. [PMID: 32571277 PMCID: PMC7310125 DOI: 10.1186/s12889-020-09106-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. Methods The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. Results The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001). Conclusion In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.
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Affiliation(s)
- Peter O Otieno
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Elvis O A Wambiya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Shukri M Mohamed
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Martin Kavao Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Peter M Kibe
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Bonventure Mwangi
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Hermann Pythagore Pierre Donfouet
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
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Njagi P, Arsenijevic J, Groot W. Cost-related unmet need for healthcare services in Kenya. BMC Health Serv Res 2020; 20:322. [PMID: 32303244 PMCID: PMC7164162 DOI: 10.1186/s12913-020-05189-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 04/06/2020] [Indexed: 11/17/2022] Open
Abstract
Background The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations. Methods We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level. Results Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need. Conclusion The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.
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Affiliation(s)
- Purity Njagi
- United Nations University-MERIT, Maastricht Graduate School of Governance, Maastricht University, Maastricht, The Netherlands.
| | - Jelena Arsenijevic
- Utrecht University School of Governance, Faculty of Law, Economics and Governance, Utrecht University, Utrecht, the Netherlands
| | - Wim Groot
- United Nations University-MERIT, Maastricht Graduate School of Governance, Maastricht University, Maastricht, The Netherlands.,Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Katana PV, Abubakar A, Nyongesa MK, Ssewanyana D, Mwangi P, Newton CR, Jemutai J. Economic burden and mental health of primary caregivers of perinatally HIV infected adolescents from Kilifi, Kenya. BMC Public Health 2020; 20:504. [PMID: 32299411 PMCID: PMC7161196 DOI: 10.1186/s12889-020-8435-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/28/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Eighty per cent of perinatally HIV infected (PHI) adolescents live in sub-Saharan Africa (sSA), a setting also characterized by huge economic disparities. Caregiving is crucial to the management of chronic illness such as HIV/AIDS, but the economic costs and mental disorders borne by caregivers of PHI adolescents often go unnoticed. In this study, we evaluated economic costs, coping strategies and association between economic cost and mental health functioning of caregivers of perinatally HIV infected adolescents in Kilifi, Kenya. METHODS We used a cost of illness descriptive analysis approach to determine the economic burden and Patient Health Questionnaire (PHQ-9) to assess the caregivers' mental health. Cross-sectional data were collected from 121 primary caregivers of PHI adolescents in Kilifi using a structured cost questionnaire. Economic costs (direct and indirect costs) were measured from primary caregivers' perspective. We used descriptive statistics in reporting the results of this study. RESULTS Average monthly direct and indirect costs per primary caregiver was Ksh 2784.51 (USD 27.85). Key drivers of direct costs were transportation (66.5%) and medications (13.8%). Total monthly costs represented 28.8% of the reported caregiver monthly earnings. Majority of the caregivers borrowed resources to cope with high economic burden. About 10.7% of primary caregivers reported depressive symptoms. Caregivers with positive depression screen (PHQ-9 score ≥ 10) had high average monthly direct and indirect costs. However, this was not statistically different compared to costs incurred by caregivers who screened negative for depressive symptoms. CONCLUSION Our study indicates that HIV/AIDS is associated with a significant economic burden for caregivers of adolescents living with HIV. Results underscore the need for developing economic empowerment and social support programmes that reduce the economic burden of caring for perinatally infected adolescent. These efforts may improve the mental health and quality of life of caregivers of adolescents living with HIV.
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Affiliation(s)
- Patrick V Katana
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya. .,Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya.
| | - Amina Abubakar
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK.,Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Moses K Nyongesa
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya
| | - Derrick Ssewanyana
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya.,Child and Adolescent Studies, Utrecht University, Utrecht, Netherlands
| | - Paul Mwangi
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya
| | - Charles R Newton
- Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Box, Kilifi, PO Box 230-80108, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK.,Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Julie Jemutai
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
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Treatment-Seeking Behavior Among Male Civil Servants in Northeastern Malaysia: A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082713. [PMID: 32326447 PMCID: PMC7216173 DOI: 10.3390/ijerph17082713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 02/05/2023]
Abstract
Background: Men's health in Malaysia is slowly gaining more attention, but minimal research has examined how Malaysian men behave and seek treatment. While few studies have investigated men's treatment-seeking behavior (TSB), those that have been conducted seem to be inconclusive and tend to yield contradictory findings. Objectives: This paper aims to determine the proportion of inappropriate TSB and to explore in-depth treatment-seeking behavior among male civil servants in northeastern Malaysia. Methods: This paper adopted a mixed-methods approach, specifically a concurrent parallel study design. A quantitative study using a self-administered questionnaire was performed to identify the proportion of appropriate and inappropriate TSB among male civil servants in northeastern Malaysia. Concurrently, a qualitative study was conducted involving six focus group discussion sessions, and the results of both parts were integrated to provide a detailed explanation of TSB among the participants. Results: A total of 381 participants were involved in the quantitative study, yielding a response rate of 94.8%; 246 (64.6%) engaged in inappropriate TSB. Some of the reported morbidities among the participants were hypertension (26.5%) and diabetes mellitus (26.2%). From the qualitative study, a main theme related to TSB emerged with several sub-themes, which were health literacy, stage of seeking treatment, preference for alternative treatment, perceived threat of illness, self-treatment, and the influence of family members and others. Conclusions: TSB among male civil servants in northeastern Malaysia is poor, and the factors contributing to it are multidimensional. This study has provided new valuable evidence on men's TSB in northeastern Malaysia. The findings can be used to facilitate and improve current policies and the implementation of men's health services throughout the country.
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Mishra S, Mohanty SK. Out-of-pocket expenditure and distress financing on institutional delivery in India. Int J Equity Health 2019; 18:99. [PMID: 31238928 PMCID: PMC6593606 DOI: 10.1186/s12939-019-1001-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/10/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Despite large investment in central and state sponsored schemes for maternal care, out-of-pocket expenditure (OOPE) and catastrophic health spending (CHS) on institutional delivery remain high over time, across states and across socio-economic groups. Though many studies have examined the OOPE and CHS, few studies have examined the nature and extent of distress financing on institutional delivery in India. DATA Data from the fourth round of National Family Health Survey (NFHS 4), 2015-16 was used for the analysis. Distress financing was defined as borrowing money or selling assets to meet the OOPE on delivery care. Composite variables, descriptive analyses, concentration index (CI), concentration curve (CC) and predicted probability were used to estimate the extent of distress financing for institutional delivery in India. RESULTS The OOPE on institutional delivery has strong economic and educational gradient. One in four mothers resorted to borrowing or selling to meet the OOPE on institutional delivery. The extent of distress financing on institutional delivery was high in poorer state of Bihar and Odisha and in the state of Telangana that had highest prevalence of caesarean delivery. Savings was more prevalent among mothers compared to those who met the OOPE by borrowing/selling of assets. Finding are robust across the states of India. The predicted probability of incurring distress financing was 0.31 among mothers belonging to the poorest wealth quintile compared to 0.09 in the richest quintile, and 0.40 for those who incurred OOPE of more than INR 20,000. The probability of incurring distress financing was higher for mothers who had caesarean birth, delivered in private health centers and incurred high OOPE on institutional delivery. CONCLUSION Distress financing on institutional delivery was higher among the less educated, poor and in private health centers. Increasing use of public health centers, reducing caesarean births, improving the availability of medicine and diagnostic services can reduce the extent of distress financing in India.
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Affiliation(s)
- Suyash Mishra
- International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088 India
| | - Sanjay K. Mohanty
- Department of Fertility Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088 India
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Karinja M, Pillai G, Schlienger R, Tanner M, Ogutu B. Care-Seeking Dynamics among Patients with Diabetes Mellitus and Hypertension in Selected Rural Settings in Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16112016. [PMID: 31174248 PMCID: PMC6603942 DOI: 10.3390/ijerph16112016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus and hypertension are two common non-communicable diseases (NCDs) that often coexist in patients. However, health-seeking behaviour in patients with diabetes mellitus or hypertension has not been extensively studied especially in low- and middle-income countries. This study aimed to examine care-seeking dynamics among participants diagnosed with diabetes and/or hypertension across nine counties in rural Kenya. We conducted a cross-sectional study among adults diagnosed with diabetes and/or hypertension through face-to-face interviews. Of the 1100 participants, 69.9% had hypertension, 15.5% diabetes while 14.7% had both. The mean age of the respondents was 64 years. The majority of the respondents (86%) were on allopathic treatment. Hospital admission, having a good self-rated health status and having social support for illness, were positively associated with appropriate health-seeking behaviour while use of alcohol and pharmacy or chemist as source of treatment were negatively associated with appropriate health-seeking behaviour. Our study found a high prevalence of appropriate health-seeking behaviour among respondents with the majority obtaining care from government facilities. The results are evidence that improving public health care services can promote appropriate health-seeking behaviour for non-communicable diseases and thus improve health outcomes.
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Affiliation(s)
- Miriam Karinja
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland.
- University of Basel, 4001 Basel, Switzerland.
- Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi 00100, Kenya.
| | - Goonaseelan Pillai
- CP+ Associates GmbH, 4102 Basel, Switzerland.
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town 7701, South Africa.
| | - Raymond Schlienger
- Quantitative Safety and Epidemiology, Chief Medical Office & Patient Safety, Novartis Pharma AG, 4033 Basel, Switzerland.
| | - Marcel Tanner
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland.
- University of Basel, 4001 Basel, Switzerland.
| | - Bernhards Ogutu
- Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi 00100, Kenya.
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi 00100, Kenya.
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Hailemichael Y, Hailemariam D, Tirfessa K, Docrat S, Alem A, Medhin G, Lund C, Chisholm D, Fekadu A, Hanlon C. Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia. Int J Ment Health Syst 2019; 13:39. [PMID: 31164919 PMCID: PMC6544918 DOI: 10.1186/s13033-019-0294-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 05/23/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are limited data on healthcare spending by households containing a person with severe mental disorder (SMD) in low- and middle-income countries (LMIC). This study aimed to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) payments and coping strategies implemented by households with and without a person with SMD in a rural district of Ethiopia. METHODS A comparative cross-sectional community household survey was carried out from January to November 2015 as part of the Emerald programme (emerging mental health systems in low- and middle-income countries). A sample of 290 households including a person with SMD and 289 comparison households without a person with SMD participated in the study. An adapted and abbreviated version of the World Health Organization SAGE (Study on global Ageing and adult health) survey instrument was used. Households were considered to have incurred catastrophic health expenditure if their annual OOP health expenditures exceeded 40% of their annual non-food expenditure. Multiple logistic regression was used to explore factors associated with catastrophic expenditure and types of coping strategies employed. RESULTS The incidence of catastrophic OOP payments in the preceding 12 months was 32.2% for households of a person with SMD and 18.2% for comparison households (p = 0.006). In households containing a person with SMD, there was a significant increase in the odds of hardship financial coping strategies (p < 0.001): reducing medical visits, cutting down food consumption, and withdrawing children from school. Households of a person with SMD were also less satisfied with their financial status and perceived their household income to be insufficient to meet their livelihood needs (p < 0.001). CONCLUSIONS Catastrophic OOP health expenditures in households of a person with SMD are high and associated with hardship financial coping strategies which may lead to poorer health outcomes, entrenchment of poverty and intergenerational disadvantage. Policy interventions aimed at financial risk pooling mechanisms are crucial to reduce the intensity and impact of OOP payments among vulnerable households living with SMD and support the goal of universal health coverage.
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Affiliation(s)
- Yohannes Hailemichael
- Department of Reproductive Health and Health Services Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Damen Hailemariam
- Department of Reproductive Health and Health Services Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kebede Tirfessa
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sumaiyah Docrat
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Dan Chisholm
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
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Levenets O, Stepurko T, Polese A, Pavlova M, Groot W. Coping strategies of cancer patients in Ukraine. Int J Health Plann Manage 2019; 34:1423-1438. [PMID: 31095792 DOI: 10.1002/hpm.2802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/12/2019] [Accepted: 04/14/2019] [Indexed: 11/06/2022] Open
Abstract
This case study explores the coping strategies of oncology patients and their family members in Ukraine. These coping strategies are seen as an individual-level response to the organizational and financial failures of the Ukrainian health care system. Based on semistructured interviews with medical doctors, patients, representatives of charitable foundations, and policy makers, we identify a variety of coping strategies, including personal connections and informal payments. Unequal access to diagnostic and treatment services is observed: coping strategies are developed by patients and their families taking into account the available financial and social capital. Importantly, we could not identify a typical path for cancer patients as cancer patients act in an environment of great uncertainty-in terms of their prognosis and in terms of the cost of treatment. With a weak state and financial uncertainty, patients and physicians perceive coping strategies rather positively as it may contribute to the chance of life.
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Affiliation(s)
- Olena Levenets
- Tallinn School of Business and Governance, Tallinn University of Technology, Tallinn, Estonia
| | - Tetiana Stepurko
- School of Public Health, National University of Kyiv-Mohyla Academy, Kyiv, Ukraine
| | - Abel Polese
- Tallinn School of Business and Governance, Tallinn University of Technology, Tallinn, Estonia
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Wim Groot
- Top Institute Evidence-Based Education Research (TIER), Maastricht University, Maastricht, The Netherlands
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Radovich E, Dennis ML, Barasa E, Cavallaro FL, Wong KL, Borghi J, Lynch CA, Lyons-Amos M, Abuya T, Benova L. Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya. BMJ Open 2019; 9:e022414. [PMID: 30787074 PMCID: PMC6398787 DOI: 10.1136/bmjopen-2018-022414] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics. DESIGN, SETTING AND PARTICIPANTS Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values. MAIN OUTCOME Respondent's self-reported source and payment to obtain their current modern contraceptive method. METHODS We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth. RESULTS Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users. CONCLUSIONS More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mardieh L Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Francesca L Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Lm Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Borghi
- Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Lyons-Amos
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Belgium
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Oyando R, Njoroge M, Nguhiu P, Kirui F, Mbui J, Sigilai A, Bukania Z, Obala A, Munge K, Etyang A, Barasa E. Patient costs of hypertension care in public health care facilities in Kenya. Int J Health Plann Manage 2019; 34:e1166-e1178. [PMID: 30762904 PMCID: PMC6618067 DOI: 10.1002/hpm.2752] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/09/2022] Open
Abstract
Background Hypertension in low‐ and middle‐income countries, including Kenya, is of economic importance due to its increasing prevalence and its potential to present an economic burden to households. In this study, we examined the patient costs associated with obtaining care for hypertension in public health care facilities in Kenya. Methods We conducted a cross‐sectional study among adult respondents above 18 years of age, with at least 6 months of treatment in two counties. A total of 212 patients seeking hypertension care at five public facilities were interviewed, and information on care seeking and the associated costs was obtained. We computed both annual direct and indirect costs borne by these patients. Results Overall, the mean annual direct cost to patients was US$ 304.8 (95% CI, 235.7‐374.0). Medicines (mean annual cost, US$ 168.9; 95% CI, 132.5‐205.4), transport (mean annual cost, US$ 126.7; 95% CI, 77.6‐175.9), and user charges (mean annual cost, US$ 57.7; 95% CI, 43.7‐71.6) were the highest direct cost categories. Overall mean annual indirect cost was US$ 171.7 (95% CI, 152.8‐190.5). The incidence of catastrophic health care costs was 43.3% (95% CI, 36.8‐50.2) and increased to 59.0% (95% CI, 52.2‐65.4) when transport costs were included. Conclusions Hypertensive patients incur substantial direct and indirect costs. High rates of catastrophic costs illustrate the urgency of improving financial risk protection for these patients and strengthening primary care to ensure affordability of hypertension care.
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Affiliation(s)
- Robinson Oyando
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Martin Njoroge
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter Nguhiu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Fredrick Kirui
- Clinical Unit, KEMRI Centre for Clinical Research, Nairobi, Kenya
| | - Jane Mbui
- Clinical Unit, KEMRI Centre for Clinical Research, Nairobi, Kenya
| | - Antipa Sigilai
- Epidemiology and Demography, KEMRI Centre for Geographic Medicine Research, Coast, Kilifi, Kenya
| | - Zipporah Bukania
- Public health nutrition, maternal and child health unit, KEMRI Centre for Public Health Research, Nairobi, Kenya
| | - Andrew Obala
- Medical Microbiology and Parasitology, Moi University, Eldoret, Kenya
| | - Kenneth Munge
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Anthony Etyang
- Epidemiology and Demography, KEMRI Centre for Geographic Medicine Research, Coast, Kilifi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Robertson NM, Nagourney EM, Pollard SL, Siddharthan T, Kalyesubula R, Surkan PJ, Hurst JR, Checkley W, Kirenga BJ. Urban-Rural Disparities in Chronic Obstructive Pulmonary Disease Management and Access in Uganda. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2019; 6:17-28. [PMID: 30775421 PMCID: PMC6373590 DOI: 10.15326/jcopdf.6.1.2018.0143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 11/21/2022]
Abstract
Introduction: Almost 90% of chronic obstructive pulmonary disease (COPD) deaths occur in low- and middle-income countries (LMICs), where there are large rural populations and access to health care for COPD is poor. The purpose of this study was to compare urban-rural provider experiences regarding systemic facilitators and barriers to COPD management and treatment access. Methods: We conducted a qualitative study using direct observations and in-depth semi-structured interviews with 16 and 10 health care providers in urban Kampala and rural Nakaseke, Uganda, respectively. We analyzed interviews by performing inductive coding using generated topical codes. Results: In both urban and rural districts, exposure to evidence-based practices for COPD diagnosis and treatment was limited. The biomedical definition of COPD is not well distinguished in rural communities and was commonly confused with asthma and other respiratory diseases. Urban and rural participants alike described low availability of medications, limited access to diagnostic tools, poor awareness of the disease, and lack of financial means for medical care as common barriers to seeking and receiving care for COPD. While there was greater access to COPD treatment in urban areas, rural populations faced more pronounced barriers in access to diagnostic equipment, following standard treatment guidelines, and training medical personnel in non-communicable disease (NCD) management and treatment. Conclusion: Our results suggest that health system challenges for the treatment of COPD may disproportionately affect rural areas in Uganda. Implementation of diagnostic and treatment guidelines and training health professionals in COPD, with a special emphasis on rural communities, will assist in addressing these barriers.
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Affiliation(s)
- Nicole M Robertson
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Emily M Nagourney
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert Kalyesubula
- Department of Physiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Pamela J Surkan
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - John R Hurst
- UCL Respiratory, University College London, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Bruce J Kirenga
- Department of Medicine and Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Determinants of Health Seeking Behavior among Caregivers of Infants Admitted with Acute Childhood Illnesses at Kenyatta National Hospital, Nairobi, Kenya. Int J Pediatr 2018; 2018:5190287. [PMID: 30643520 PMCID: PMC6311279 DOI: 10.1155/2018/5190287] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/05/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background Poor, delayed, or inappropriate health seeking for a sick infant with acute childhood illness is associated with high morbidity/mortality. Delay in health seeking is implicated with fatal complications and prolonged hospital stay. Thus, caregivers ought to identify danger signs and promptly seek professional help for a sick infant. Objective Establish determinants of health seeking behavior among caregivers of infants admitted with acute childhood illnesses in Kenyatta National Hospital. Methods A mixed method cross-sectional study involving caregivers (n=130) of sick infants. Semistructured questionnaire and two focused group discussions were used to gather data on caregiver knowledge on danger signs, health care seeking options, and decision-making regarding health care seeking. Data was analyzed with SPSS V. 22. Results Knowledge of danger signs of infancy was poor. Immediate health seeking was associated with tertiary [P=0.009] and secondary [P=0.030] education, knowledgeability on danger signs [P=0.002], and being married [P=0.019]. Respondents who resided in urban [P=0.034] or less than a kilometer [P=0.042] from a health facility sought care immediately. Those who rated services as excellent (P=0.005) and satisfactory (P=0.025) sought care promptly. Conclusion Poor knowledge on danger signs of infancy was common among caregivers blurring the magnitude of acute illness resulting in delayed health seeking. Knowledgeability of danger signs of infancy, high educational level, and being married were associated with immediate health care seeking. Caregivers who resided in urban setting and/or near a health facility were linked to immediate health seeking. Additionally, satisfaction and perception of quality health care services were associated with immediate health seeking. Interventions with caregivers should involve capacity building through partnership with families and communities to raise awareness of danger signs of infancy. Strengthening of health care system to offer quality basic health services could improve health seeking behavior. Provision of a seamless supply system, infrastructural support, and technical support for soft skills minimize the turnaround time which is critical.
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Keats EC, Akseer N, Bhatti Z, Macharia W, Ngugi A, Rizvi A, Bhutta ZA. Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya. JAMA Netw Open 2018; 1:e185152. [PMID: 30646326 PMCID: PMC6324360 DOI: 10.1001/jamanetworkopen.2018.5152] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Previous work has underscored subnational inequalities that could impede additional health gains in Kenya. OBJECTIVE To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018. EXPOSURES Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered. MAIN OUTCOMES AND MEASURES Absolute and relative measures of inequality in coverage of RMNCAH interventions. RESULTS For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations. CONCLUSIONS AND RELEVANCE Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.
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Affiliation(s)
- Emily Catherine Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Aga Khan University, Karachi, Pakistan
- Aga Khan University, Nairobi, Kenya
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Neke N, Reifferscheid A, Buchberger B, Wasem J. Time and cost associated with utilization of services at mobile health clinics among pregnant women. BMC Health Serv Res 2018; 18:920. [PMID: 30509269 PMCID: PMC6276179 DOI: 10.1186/s12913-018-3736-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022] Open
Abstract
Background Antenatal care (ANC) is provided for free in Tanzania in all public health facilities. Yet surveys suggested that long distances to the facilities limit women from accessing these services. Mobile health clinics (MHC) were introduced to address this problem; however, little is known about the client cost and time associated with utilizing ANC at MHC and whether these costs deter women from using the provided services. Methods Client-exit interviews were conducted by interviewing 293 pregnant women who visited the MHC in rural Tanzania. Two subgroups were created, one with women who travelled more than 1.5 h to the MHC, and the other with women who travelled within 1.5 h. For each subgroup we estimated the direct cost in US$ and time in hours for utilizing services and they hinder service utilization. The Wilcoxon–Mann–Whitney rank sum test was performed to compare the differences between the estimated mean values in the two groups. Result Total direct cost per visit was: US$2.27 (SD = 0.90) for overall, US$2.29 (SD = 1.03) for those women who travelled less than 1.5 h and US$2.53 (SD = 0.63) for those who travelled more than 1.5 h (p = 0.08). Laboratory and medicine cost accounted for 70 and 16% of the total direct cost and were similar across the groups. Total time cost per visit (in hours) was: 3.75 (SD = 1.83), 2.88 (SD = 1.27) for those women who travelled less than 1.5 h and 5.02 (SD = 1.81) for those who travelled more than 1.5 h (p < 0.01). The major contributor of time cost was waiting time; 1.89 (SD = 1.29) for overall, 1.68 (SD = 1.02) for those women who travelled less than 1.5 h and 2.17 (SD = 1.57) for those who travelled more than 1.5 h (p = 0.07). Participants reported having missed their scheduled visit due to lack of money (15%) and time (9%). Conclusion Women receiving nominally free ANC incur considerable time and direct cost, which may result in an unsteady use of maternal care. Improving availability of essential medicine and supplies at health facilities, as well as focusing on efficient utilization of community health workers may reduce these costs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3736-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nyasule Neke
- National Institute for Medical Research, Mwanza Centre, Isamilo Street, P O BOX 1462, Mwanza, Tanzania. .,Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany.
| | - Antonius Reifferscheid
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Barbara Buchberger
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Jürgen Wasem
- Alfried Krupp von Bohlen und Halbach, Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
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Rijal A, Adhikari TB, Khan JAM, Berg-Beckhoff G. The economic impact of non-communicable diseases among households in South Asia and their coping strategy: A systematic review. PLoS One 2018; 13:e0205745. [PMID: 30462648 PMCID: PMC6248902 DOI: 10.1371/journal.pone.0205745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 10/01/2018] [Indexed: 12/31/2022] Open
Abstract
Background Out of pocket payment (OOPP), is the major health financing mechanism in South Asia region. With the rising burden of non-communicable diseases (NCDs), the region is facing a high financial burden. However, the extent and nature of economic impact caused by treatment and management of NCDs at the household level is yet unknown. Method We conducted a systematic review using Medline and Embase databases. Only peer-reviewed quantitative studies published between January 2000 to December 2016 assessing OOPP or catastrophic health expenditure or impoverishment or financial coping strategy due to at least one of the four major NCDs—cardiovascular diseases(CVDs), diabetes, cancer, chronic respiratory disease in South Asia region was included in the review. The review is registered in PROSPERO no: CRD42017059345. Results A total of 21 studies (of 2693 records identified) met the inclusion criteria. The economic impact was most frequently studied in CVDs and in terms of OOPP. The studies collectively indicated high OOPP, higher likelihood of catastrophic expenditure and impoverishment for inpatient care for these major NCDs which was visible in all income levels. Borrowing and selling off assets were the most common forms of coping strategies adopted and varied inconsistently between urban and rural households. The true extent of the economic impact, however, remains difficult to determine due to methodological heterogeneity regarding outcomes reported and measures employed for calculation of OOPP, catastrophic expenditure, and impoverishment across these four major NCDs and between nations. Conclusion The economic impact due to treatment and management of CVDs, diabetes, cancer and chronic respiratory diseases among households in South Asia seems dire. Given the lack of sufficient evidence the review stresses the need for further research in the region to develop evidence-informed nationally tailored prepayment mechanisms covering NCDs to reduce economic vulnerability and standardization of tools measuring the economic impact for generating comparable estimates.
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Affiliation(s)
- Anupa Rijal
- Young Earth, Kathmandu, Nepal
- Nepal Development Society, Chitwan, Nepal
- * E-mail:
| | - Tara Ballav Adhikari
- Nepal Development Society, Chitwan, Nepal
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Jahangir A. M. Khan
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden
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Pacheco Barzallo D. Place of residence & financial hardship: the situation of people with spinal cord injury. Int J Equity Health 2018; 17:115. [PMID: 30089482 PMCID: PMC6083562 DOI: 10.1186/s12939-018-0818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Even with universal health coverage, people with long-term medical conditions can face financial hardship. However, financial hardship can be not only the result of an increase in health care costs; it has other socio-economic determinants that can cause social inequalities in terms of health. This study aims to estimate the impact of the place of residence on the financial hardship of people with spinal cord injury (SCI) in Switzerland. Switzerland is an interesting case to analyze because of its political system, where each of the 26 cantons is autonomous and responsible for raising its own income (through taxes) and providing public services. METHODS Using cross-sectional data from the Swiss Spinal Cord Injury Cohort Study (SwiSCI), this paper estimates the probability of financial hardship by place of residence. The data set, recorded between 2011 and 2013, comprises information from 1549 participants aged 16 years and older, living with SCI. RESULTS The results show that people face different probabilities of financial hardship, depending on their place of residence. In general, people in the French-speaking cantons have a higher probability of financial hardship compared with people living in the German- or Italian-speaking cantons. People in the cantons of Geneva and Graubünden have almost five times the probability of financial hardship, compared with people in the canton with the lowest probability of financial hardship, Zug. CONCLUSIONS The place of residence is a determinant of the financial situation of a household where a member deals with a long-term health condition. The differences might arise due to variations in health care costs, the tax burden and social support system, which are regulated and administered by each canton.
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Affiliation(s)
- Diana Pacheco Barzallo
- Swiss Paraplegic Research, Health Services Statistics & Economics Group, Guido A. Zach Strasse 4., 6207, Nottwil, Switzerland.
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Wang Q, Tian W. Prevalence, awareness, and treatment of depressive symptoms among the middle‐aged and elderly in China from 2008 to 2015. Int J Health Plann Manage 2018; 33:1060-1070. [DOI: 10.1002/hpm.2581] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/29/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Qun Wang
- Faculty of Humanities and Social SciencesDalian University of Technology Dalian China
| | - Wenyao Tian
- School of Political StudiesUniversity of Ottawa Ottawa Canada
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Yaya S, Ghose B. Patterns of computer and Internet use and its association with HIV knowledge in selected countries in sub-Saharan Africa. PLoS One 2018; 13:e0199236. [PMID: 29949601 PMCID: PMC6021052 DOI: 10.1371/journal.pone.0199236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 06/04/2018] [Indexed: 11/19/2022] Open
Abstract
Background Healthcare systems in Sub-Saharan Africa (SSA) are fraught with numerous governance and infrastructural issues including lack of access to quality care and health worker shortage. Policy makers are becoming increasingly interested in adopting novel technologies such as web-based interventions within the scope of e-Health to bridge the gaps in care delivery in a cost-effective and sustainable manner. Successful implementation of these policies is reliant on evidences regarding people’s access to these technologies, which are scarce for countries in SSA. Objectives To 1) investigate the variation in the prevalence of accessing computer and internet across regional and socioeconomic groups, and 2) assess association between ever accessing computer and internet and knowledge of routes and risk factors of HIV transmission in selected SSA countries. Methods We analyzed cross-sectional datasets from UNICEF Multiple Indicator Cluster Surveys. Participants were16,194 men and 39,121 women from Ghana, Guinea Bissau, Malawi and Zimbabwe. Main outcome variable was ever-accessing computer and Internet for any purpose. Associations were assessed by multivariable regression methods. Results Lifetime computer usage in Ghana, Guinea Bissau, Malawi and Zimbabwe was respectively 21.5%, 13.4%, 12.3%, 28.4% among men, and 12.5%, 8.3%, 4.8%, 20.5% among women, and that of internet was 14.9%, 11.7%, 10.8%, 34% among men, and 6.4%, 6.9%, 4.2%, 21.6% among women in the aforementioned order. Participants who reported ever using computer and Internet were more likely to have higher knowledge regarding the transmission of HIV compared to those who did not. Conclusions Prevalence of lifetime access to computer and Internet was considerably low in all four countries. Several socioeconomic factors appeared to be associated with the access to computer and Internet, addressing which might prove beneficial for the successful expansion e-Health in these countries.
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Affiliation(s)
- Sanni Yaya
- School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
| | - Bishwajit Ghose
- School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario, Canada
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Prevalence of Smoking among Men in Ethiopia and Kenya: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15061232. [PMID: 29891795 PMCID: PMC6025624 DOI: 10.3390/ijerph15061232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/31/2018] [Accepted: 06/09/2018] [Indexed: 11/20/2022]
Abstract
While tobacco use remains the largest single cause of premature death in the industrialized countries, low-and-middle income countries are also experiencing a rising burden of the tobacco epidemic and are making various programmatic efforts to tackle the issue. Evidence-based policy making is critical to the long-term success of tobacco intervention programs and is reliant on regular monitoring of the trends and prevalence rates of tobacco use though population-based surveys, which are sparse for countries in eastern Africa. Therefore, in the present study we aimed to (1) estimate the trends in the prevalence of self-reported smoking status; and (2) explore the sociodemographic factors associated with smoking among adult men in Ethiopia and Kenya. Methods: Subjects were 26,919 adult men aged between 15 and 59 years from Ethiopia and Kenya. Nationally representative cross-sectional data on self-reported smoking and relevant sociodemographic indicators were collected from the Demographic and Health Surveys (DHS) conducted in these two countries. Data analysis was performed by descriptive, bivariate, and multivariable methods. Results: In Ethiopia, the prevalence rate of smoking increased from 8.5% in 2005 to 11.7% in 2011. While in Kenya, the rate declined albeit slowly from 22.9% in 2003 to 18.8% in 2008–2009 and 17% in 2014. The prevalence was significantly different in urban and rural areas. In majority of the surveys, prevalence of smoking was highest in the age group of 25–34 years. The prevalence of smoking varied widely across several socioeconomic characteristics. Conclusions: The findings indicate a high rate of smoking among men especially in urban areas, and call for policy actions to address the socioeconomic factors as a part of the policy to strengthen tobacco-control efforts.
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Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, Trujillo A, Khan J, Peters DH. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; 391:2036-2046. [PMID: 29627160 DOI: 10.1016/s0140-6736(18)30482-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 07/24/2017] [Accepted: 01/17/2018] [Indexed: 12/01/2022]
Abstract
Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.
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Affiliation(s)
- Louis W Niessen
- Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan K Akuoku
- Department of Health, Nutrition and Population Global Practice, The World Bank, Washington, DC, USA
| | | | - Sayem Ahmed
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Health Economics and Policy Research Group, Department of Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Tracey P Koehlmoos
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Antonio Trujillo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jahangir Khan
- Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Health Economics and Policy Research Group, Department of Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Abuya T, Obare F, Matanda D, Dennis ML, Bellows B. Stakeholder perspectives regarding transfer of free maternity services to
N
ational
H
ealth
I
nsurance
F
und in
K
enya: Implications for universal health coverage. Int J Health Plann Manage 2018; 33:e648-e662. [DOI: 10.1002/hpm.2515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | | | - Mardieh L. Dennis
- Department of Epidemiology and Population HealthLondon School of Hygiene and Tropical Medicine London UK
| | - Ben Bellows
- Reproductive HealthPopulation Council Lusaka Zambia
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Brent AJ, Nyundo C, Langat J, Mulunda C, Wambua J, Bauni E, Sande J, Park K, Williams TN, Newton CRJ, Levin M, Scott JAG. Prospective Observational Study of Incidence and Preventable Burden of Childhood Tuberculosis, Kenya. Emerg Infect Dis 2018; 24:514-523. [PMID: 29460738 PMCID: PMC5823335 DOI: 10.3201/eid2403.170785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Muraya KW, Jones C, Berkley JA, Molyneux S. "If it's issues to do with nutrition…I can decide…": gendered decision-making in joining community-based child nutrition interventions within rural coastal Kenya. Health Policy Plan 2017; 32:v31-v39. [PMID: 29244104 PMCID: PMC5886246 DOI: 10.1093/heapol/czx032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2017] [Indexed: 11/13/2022] Open
Abstract
Gender roles and relations play an important role in child health and nutritional status. While there is increasing recognition of the need to incorporate gender analysis in health planning and programme development, there has been relatively little attention paid to the gendered nature of child nutrition interventions. This qualitative study undertaken in rural Coastal Kenya aimed to explore the interaction between household gender relations and a community-based child nutrition programme, with a focus on household decision-making dynamics related to joining the intervention. Fifteen households whose children were enrolled in the programme were followed up over a period of 12 months. Over a total of 60 household visits, group and individual in-depth interviews were conducted with a range of respondents, supplemented by non-participant observations. Data were analysed using a framework analysis approach. Engagement with the intervention was highly gendered with women being the primary decision-makers and engagers. Women were responsible for managing child feeding and minor child illnesses in households. As such, involvement in community-based nutrition interventions and particularly one that targeted a condition perceived as non-serious, fell within women's domain. Despite this, the nutrition programme of interest could be categorized as gender-blind. Gender was not explicitly considered in the design and implementation of the intervention, and the gender roles and norms in the community with regards to child nutrition were not critically examined or challenged. In fact, the intervention might have inadvertently reinforced existing gender divisions and practices in relation to child nutrition, by (unintentionally) excluding men from the nutrition discussions and activities, and thereby supporting the notion of child feeding and nutrition as "women's business". To improve outcomes, community-based nutrition interventions need to understand and take into account gendered household dynamics, and incorporate strategies that promote behaviour change and attitude shifts in relation to gendered norms and child nutrition.
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Affiliation(s)
- Kelly W Muraya
- Health Systems & Research Ethics Department, P.O Box 230-80108, Kilifi, Kenya
- Corresponding author. Health Systems & Research Ethics Department, P.O Box 230-80108, Kilifi, Kenya; E-mail:
| | - Caroline Jones
- Health Systems & Research Ethics Department, P.O Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
| | - James A Berkley
- Health Systems & Research Ethics Department, P.O Box 230-80108, Kilifi, Kenya
| | - Sassy Molyneux
- Health Systems & Research Ethics Department, P.O Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
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Mudzengi D, Sweeney S, Hippner P, Kufa T, Fielding K, Grant AD, Churchyard G, Vassall A. The patient costs of care for those with TB and HIV: a cross-sectional study from South Africa. Health Policy Plan 2017; 32:iv48-iv56. [PMID: 28204500 PMCID: PMC5886108 DOI: 10.1093/heapol/czw183] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This study describes the post-diagnosis care-seeking costs incurred by people living with TB and/or HIV and their households, in order to identify the potential benefits of integrated care. METHODS We conducted a cross-sectional study with 454 participants with TB or HIV or both in public primary health care clinics in Ekurhuleni North Sub-District, South Africa. We collected information on visits to health facilities, direct and indirect costs for participants and for their guardians and caregivers. We define 'integration' as receipt of both TB and HIV services at the same facility, on the same day. Costs were presented and compared across participants with TB/HIV, TB-only and HIV-only. Costs exceeding 10% of participant income were considered catastrophic. RESULTS Participants with both TB and HIV faced a greater economic burden (US$74/month) than those with TB-only (US$68/month) or HIV-only (US$40/month). On average, people with TB/HIV made 18.4 visits to health facilities, more than TB-only participants or HIV-only participants who made 16 and 5.1 visits, respectively. However, people with TB/HIV had fewer standalone TB (10.9) and HIV (2.2) visits than those with TB-only (14.5) or HIV-only (4.4). Although people with TB/HIV had access to 'integrated' services, their time loss was substantially higher than for other participants. Overall, 55% of participants encountered catastrophic costs. Access to official social protection schemes was minimal. CONCLUSIONS People with TB/HIV in South Africa are at high risk of catastrophic costs. To some extent, integration of services reduces the number of standalone TB and HIV of visits to the health facility. It is however unlikely that catastrophic costs can be averted by service integration alone. Our results point to the need for timely social protection, particularly for HIV-positive people starting TB treatment.
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Affiliation(s)
- Don Mudzengi
- The Aurum Institute, Johannesburg, 29 Queens Road, Parktown Johannesburg, Gauteng, 2193 South Africa
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Piotr Hippner
- The Aurum Institute, Johannesburg, 29 Queens Road, Parktown Johannesburg, Gauteng, 2193 South Africa
| | - Tendesayi Kufa
- The Aurum Institute, Johannesburg, 29 Queens Road, Parktown Johannesburg, Gauteng, 2193 South Africa
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Alison D Grant
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, 29 Queens Road, Parktown Johannesburg, Gauteng, 2193 South Africa
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Brock AR, Ross JV, Greenhalgh S, Durham DP, Galvani A, Parikh S, Esterman A. Modelling the impact of antimalarial quality on the transmission of sulfadoxine-pyrimethamine resistance in Plasmodium falciparum. Infect Dis Model 2017; 2:161-187. [PMID: 29928735 PMCID: PMC6001968 DOI: 10.1016/j.idm.2017.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 12/26/2022] Open
Abstract
Background The use of poor quality antimalarial medicines, including the use of non-recommended medicines for treatment such as sulfadoxine-pyrimethamine (SP) monotherapy, undermines malaria control and elimination efforts. Furthermore, the use of subtherapeutic doses of the active ingredient(s) can theoretically promote the emergence and transmission of drug resistant parasites. Methods We developed a deterministic compartmental model to quantify the impact of antimalarial medicine quality on the transmission of SP resistance, and validated it using sensitivity analysis and a comparison with data from Kenya collected in 2006. We modelled human and mosquito population dynamics, incorporating two Plasmodium falciparum subtypes (SP-sensitive and SP-resistant) and both poor quality and good quality (artemether-lumefantrine) antimalarial use. Findings The model predicted that an increase in human malaria cases, and among these, an increase in the proportion of SP-resistant infections, resulted from an increase in poor quality SP antimalarial use, whether it was full- or half-dose SP monotherapy. Interpretation Our findings suggest that an increase in poor quality antimalarial use predicts an increase in the transmission of resistance. This highlights the need for stricter control and regulation on the availability and use of poor quality antimalarial medicines, in order to offer safe and effective treatments, and work towards the eradication of malaria.
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Affiliation(s)
- Aleisha R Brock
- School of Nursing & Midwifery, University of South Australia, Adelaide, SA, Australia
| | - Joshua V Ross
- School of Mathematical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Scott Greenhalgh
- Department of Mathematics and Statistics, Queen's University, Kingston, ON, Canada
| | - David P Durham
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Alison Galvani
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Sunil Parikh
- Yale School of Public Health, New Haven, CT, USA
| | - Adrian Esterman
- Sansom Institute for Research Health, University of South Australia, Adelaide, SA, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
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Islam MR, Rahman MS, Islam Z, Nurs CZB, Sultana P, Rahman MM. Inequalities in financial risk protection in Bangladesh: an assessment of universal health coverage. Int J Equity Health 2017; 16:59. [PMID: 28376808 PMCID: PMC5381038 DOI: 10.1186/s12939-017-0556-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/30/2017] [Indexed: 01/31/2023] Open
Abstract
Background Financial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. We investigated progress towards UHC financial risk indicators and assessed variability of inequalities in financial risk protection indicators by wealth quintile. We further examined the determinants of different financial hardship indicators related to healthcare costs. Methods A cross-sectional, three-stage probability survey was conducted in Bangladesh, which collected information from 1600 households from August to November 2011. Catastrophic health payments, impoverishment, and distress financing (borrowing or selling assets) were treated as financial hardship indicators in UHC. Poisson regression models were used to identify the determinants of catastrophic payment, impoverishment and distress financing separately. Slope, relative and concentration indices of inequalities were used to assess wealth-based inequalities in financial hardship indicators. Results The study found that around 9% of households incurred catastrophic payments, 7% faced distress financing, and 6% experienced impoverishing health payments in Bangladesh. Slope index of inequality indicated that the incidence of catastrophic health payment and distress financing among the richest households were 12 and 9 percentage points lower than the poorest households respectively. Multivariable Poisson regression models revealed that all UHC financial hardship indicators were significantly higher among household that had members who received inpatient care or were in the poorest quintile. The presence of a member with chronic illness in a household increased the risk of impoverishment by nearly double. Conclusion This study identified a greater inequality in UHC financial hardship indicators. Rich households in Bangladesh were facing disproportionately less financial hardship than the poor ones. Households can be protected from financial hardship associated with healthcare costs by implementing risk pooling mechanism, increasing GDP spending on health, and properly monitoring subsidized programs in public health facilities. Electronic supplementary material The online version of this article (doi:10.1186/s12939-017-0556-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Md Rashedul Islam
- Department of Computer Science, Uttara Commerce College, Dhaka, Bangladesh
| | - Md Shafiur Rahman
- Department of Global Health Policy, The University of Tokyo, Tokyo, Japan
| | - Zobida Islam
- Department of Public Health, First Capital University of Bangladesh, Chuadanga, Bangladesh
| | | | - Papia Sultana
- Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh
| | - Md Mizanur Rahman
- Department of Global Health Policy, The University of Tokyo, Tokyo, Japan. .,Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, 6205, Bangladesh.
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Hutchison C, Khan MS, Yoong J, Lin X, Coker RJ. Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China. BMC Public Health 2017; 17:221. [PMID: 28222724 PMCID: PMC5320743 DOI: 10.1186/s12889-017-4089-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden. METHODS Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding. RESULTS Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable. CONCLUSIONS Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.
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Affiliation(s)
- C Hutchison
- London School of Hygiene and Tropical Medicine, London, UK
| | - M S Khan
- London School of Hygiene and Tropical Medicine, London, UK.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - J Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Centre for Economic and Social Research, University of Southern California, Los Angeles, USA
| | - X Lin
- Yunnan Center for Disease Control and Prevention, Kunming, China.
| | - R J Coker
- London School of Hygiene and Tropical Medicine, London, UK.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Faculty of Public Health, Mahidol University, Bangkok, Thailand
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The Financial Burden of Non-Communicable Chronic Diseases in Rural Nigeria: Wealth and Gender Heterogeneity in Health Care Utilization and Health Expenditures. PLoS One 2016; 11:e0166121. [PMID: 27832107 PMCID: PMC5104487 DOI: 10.1371/journal.pone.0166121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022] Open
Abstract
Objectives Better insights into health care utilization and out-of-pocket expenditures for non-communicable chronic diseases (NCCD) are needed to develop accessible health care and limit the increasing financial burden of NCCDs in Sub-Saharan Africa. Methods A household survey was conducted in rural Kwara State, Nigeria, among 5,761 individuals. Data were obtained using biomedical and socio-economic questionnaires. Health care utilization, NCCD-related health expenditures and distances to health care providers were compared by sex and by wealth quintile, and a Heckman regression model was used to estimate health expenditures taking selection bias in health care utilization into account. Results The prevalence of NCCDs in our sample was 6.2%. NCCD-affected individuals from the wealthiest quintile utilized formal health care nearly twice as often as those from the lowest quintile (87.8% vs 46.2%, p = 0.002). Women reported foregone formal care more often than men (43.5% vs. 27.0%, p = 0.058). Health expenditures relative to annual consumption of the poorest quintile exceeded those of the highest quintile 2.2-fold, and the poorest quintile exhibited a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2% to 6.7%). Long travel distances to the nearest provider, highest for the poorest quintile, were a significant deterrent to seeking care. Using distance to the nearest facility as instrument to account for selection into health care utilization, we estimated out-of-pocket health care expenditures for NCCDs to be significantly higher in the lowest wealth quintile compared to the three upper quintiles. Conclusions Facing potentially high health care costs and poor accessibility of health care facilities, many individuals suffering from NCCDs—particularly women and the poor—forego formal care, thereby increasing the risk of more severe illness in the future. When seeking care, the poor spend less on treatment than the rich, suggestive of lower quality care, while their expenditures represent a higher share of their annual household consumption. This calls for targeted interventions that enhance health care accessibility and provide financial protection from the consequences of NCCDs, especially for vulnerable populations.
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Ewing VL, Tolhurst R, Kapinda A, Richards E, Terlouw DJ, Lalloo DG. Increasing understanding of the relationship between geographic access and gendered decision-making power for treatment-seeking for febrile children in the Chikwawa district of Malawi. Malar J 2016; 15:521. [PMID: 27776549 PMCID: PMC5078939 DOI: 10.1186/s12936-016-1559-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/06/2016] [Indexed: 11/20/2022] Open
Abstract
Background This study used qualitative methods to investigate the relationship between geographic access and gendered intra-household hierarchies and how these influence treatment-seeking decision-making for childhood fever within the Chikwawa district of Malawi. Previous cross-sectional survey findings in the district indicated that distance from facility and associated costs are important determinants of health facility attendance in the district. This paper uses qualitative data to add depth of understanding to these findings by exploring the relationship between distance from services, anticipated costs and cultural norms of intra-household decision-making, and to identify potential intervention opportunities to reduce challenges experienced by those in remote locations. Qualitative data collection included 12 focus group discussions and 22 critical incident interviews conducted in the local language, with primary caregivers of children who had recently experienced a febrile episode. Results Low geographic accessibility to facilities inhibited care-seeking, sometimes by extending the ‘assessment period’ for a child’s illness episode, and led to delays in seeking formal treatment, particularly when the illness occurred at night. Although carers attempted to avoid incurring costs, cash was often needed for transport and food. Whilst in all communities fathers were normatively responsible for treatment costs, mothers generally had greater access to and control over resources and autonomy in decision-making in the matrilineal and matrilocal communities in the central part of the district, which were also closer to formal facilities. Conclusions This study illustrates the complex interplay between geographic access and gender dynamics in shaping decisions on whether and when formal treatment is sought for febrile children in Chikwawa District. Geographic marginality and cultural norms intersect in remote areas both to increase the logistical and anticipated financial barriers to utilising services and to reduce caretakers’ autonomy to act quickly once they recognize the need for formal care. Health education campaigns should be based within communities, engaging all involved in treatment-seeking decision-making, including men and grandmothers, and should aim to promote the ability of junior women to influence the treatment-seeking process. Both mothers’ financial autonomy and fathers financial contributions are important to enable timely access to effective healthcare for children with malaria.
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Affiliation(s)
- Victoria L Ewing
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi. .,Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
| | - Rachel Tolhurst
- Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
| | - Andrew Kapinda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi
| | - Esther Richards
- Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
| | - Dianne J Terlouw
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi.,Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
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Pavel MS, Chakrabarty S, Gow J. Cost of illness for outpatients attending public and private hospitals in Bangladesh. Int J Equity Health 2016; 15:167. [PMID: 27724955 PMCID: PMC5057498 DOI: 10.1186/s12939-016-0458-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 10/03/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND A central aim of Universal Health Coverage (UHC) is protection for all against the cost of illness. In a low income country like Bangladesh the cost burden of health care in tertiary facilities is likely to be significant for most citizens. This cost of an episode of illness is a relatively unexplored policy issue in Bangladesh. The objective of this study was to estimate an outpatient's total cost of illness as result of treatment in private and public hospitals in Sylhet, Bangladesh. METHODS The study used face to face interviews at three hospitals (one public and two private) to elicit cost data from presenting outpatients. Other socio-economic and demographic data was also collected. A sample of 252 outpatients were randomly selected and interviewed. The total cost of outpatients comprises direct medical costs, non-medical costs and the indirect costs of patients and caregivers. Indirect costs comprise travel and waiting times and income losses associated with treatment. RESULTS The costs of illness are significant for many of Bangladesh citizens. The direct costs are relatively minor compared to the large indirect cost burden that illness places on households. These indirect costs are mainly the result of time off work and foregone wages. Private hospital patients have higher average direct costs than public hospital patients. However, average indirect costs are higher for public hospital patients than private hospital patients by a factor of almost two. Total costs of outpatients are higher in public hospitals compared to private hospitals regardless of patient's income, gender, age or illness. CONCLUSION Overall, public hospital patients, who tend to be the poorest, bear a larger economic burden of illness and treatment than relatively wealthier private hospital patients. The large economic impacts of illness need a public policy response which at a minimum should include a national health insurance scheme as a matter of urgency.
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Affiliation(s)
- Md Sadik Pavel
- Department of Economics, Shahjalal University of Science & Technology, Sylhet, 3114 Bangladesh
| | - Sayan Chakrabarty
- Department of Economics, Shahjalal University of Science & Technology, Sylhet, 3114 Bangladesh
- Institute for Resilient Regions (IRR), University of Southern Queensland, Springfield, 4300 QLD Australia
| | - Jeff Gow
- School of Commerce, University of Southern Queensland, Toowoomba, 4350 QLD Australia
- School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, 4000 South Africa
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