Primary care, infant mortality, and low birth weight in the states of the USA

Early-life access to primary healthcare and educational attainment: Evidence from community health centers in China

This paper uses the rollout of community health centers (CHCs) from the 1950s to the 1970s in China to study the long-term effects of early-life access to primary healthcare on educational attainment. By leveraging the variation across birth cohorts and communities in the establishment of CHCs, we find that exposure to CHCs in early life significantly increases children's completed years of education in later life. Event study estimates confirm that the beneficial effects of CHC exposure are concentrated in early life. Mechanism analysis reveals that early-life exposure to CHCs improves birth health and childhood health. The results remain robust after considering a series of robustness checks, such as ruling out confounding factors and placebo tests. Our findings underscore the significance of early-life primary healthcare in building human capital and indicate that the returns on accessing primary healthcare may be significantly underestimated.

Prevention of maternal mortality with interventions in primary care services: What can we do?

Despite global progress and a marked reduction in maternal mortality ratio worldwide, the burden of maternal death and morbidity remains a huge challenge, especially among low- and middle-income settings. Maternal mortality is determined by multiple components. As a result, sustainable strategies require not only the implementation of effective health policies but also social development. In this narrative review, we discuss strategies to improve the maternal mortality ratio based on recent advances in public health. Primary care plays a key role in identifying background conditions, risk factors and early signs of some major causes of maternal mortality and morbidity. Antenatal care also addresses other conditions that influence outcomes: unwanted pregnancies, nutrition, sexually transmitted illnesses, family planning, immunization, and child health. Therefore, awareness about major causes of maternal mortality, direct and indirect targeted interventions to adequately identify risk factors, implement prophylactic interventions when available and guarantee early diagnosis, can certainly impact outcomes.

Racial and ethnic differences in infant survival for hydrocephaly-Texas, 1999-2017

BACKGROUND

Congenital hydrocephaly, an abnormal accumulation of fluid within the ventricular spaces at birth, can cause disability or death if untreated. Limited information is available about survival of infants born with hydrocephaly in Texas. Therefore, the purpose of the study was to calculate survival estimates among infants born with hydrocephaly without spina bifida in Texas.

METHODS

A cohort of live-born infants delivered during 1999-2017 with congenital hydrocephaly without spina bifida was identified from the Texas Birth Defects Registry. Deaths within 1 year of delivery were identified using vital and medical records. One-year infant survival estimates were generated for multiple descriptive characteristics using the Kaplan-Meier method. Crude hazard ratios (HRs) for one-year survival among infants with congenital hydrocephaly by maternal and infant characteristics and adjusted HRs for maternal race and ethnicity were estimated using Cox proportional hazard models.

RESULTS

Among 5709 infants born with congenital hydrocephaly without spina bifida, 4681 (82%) survived the first year. The following characteristics were associated with infant survival: maternal race and ethnicity, clinical classification (e.g., chromosomal or syndromic), preterm birth, birth weight, birth year, and maternal education. In the multivariable Cox proportional hazards model, differences in survival were observed by maternal race and ethnicity after adjustment for other maternal and infant characteristics. Infants of non-Hispanic Black (HR: 1.28, 95% CI: 1.04-1.58) and Hispanic (HR: 1.31, 95% CI: 1.12-1.54) women had increased risk for mortality, compared with infants of non-Hispanic White women.

CONCLUSIONS

This study showed infant survival among a Texas cohort differed by maternal race and ethnicity, clinical classification, gestational age, birth weight, birth year, and maternal education in infants with congenital hydrocephaly without spina bifida. Findings confirm that mortality continues to be common among infants with hydrocephaly without spina bifida. Additional research is needed to identify other risk factors of mortality risk.

The effect of primary healthcare on mortality: Evidence from Costa Rica

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

The distribution of child physicians and early academic achievement

OBJECTIVE

To describe the distribution of pediatricians and family physicians (child physicians) across school districts and examine the association between physician supply and third-grade test scores.

DATA SOURCES AND STUDY SETTING

Data come from the January 2020 American Medical Association Physician Masterfile, the 2009-2013 and 2014-2018 waves of American Community Survey 5-Year Data, and the Stanford Education Data Archive (SEDA), which uses test scores from all U.S. public schools. We use covariate data provided by SEDA to describe student populations.

STUDY DESIGN

This descriptive analysis constructs a physician-to-child-population ratio for every school district in the country and describes the child population served by the current distribution of physicians. We fit a set of multivariable regression models to estimate the associations between district test score outcomes and district physician supply. Our model includes state fixed effects to control for unobservable state-level factors, as well as a covariate vector of sociodemographic characteristics.

DATA COLLECTION

Public data from three sources were matched by district ID.

PRINCIPAL FINDINGS

Physicians are highly unequally distributed across districts: nearly 3640 (29.6%) of 12,297 districts have no child physician, which includes 49% of rural districts. Rural children of color in particular have very little access to pediatric care, and this inequality is more extreme when looking exclusively at pediatricians. Districts that have higher child physician supplies tend to have higher academic test scores in early education, independent of community socioeconomic status and racial/ethnic composition. While the national data show this positive relationship (0.012 SD, 95% CI, 0.0103-0.0127), it is most pronounced for districts in the bottom tertile of physician supply (0.163 SD, 95% CI, 0.108-0.219).

CONCLUSIONS

Our study demonstrates a highly unequal distribution of child physicians in the U.S., and that children with less access to physicians have lower academic performance in early education.

Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil

Background

Expanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality.

Methods

A cohort of 75,339 live births (January 2009-December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms.

Results

A total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth.

Interpretation

Expanding primary care to low-income populations in Rio de Janeiro was associated with improved infant health and health equity benefits.

Funding

DFID/MRC/Wellcome Trust/ESRC.

Implications of Social Determinants of Health Characteristics on Fetal Growth Restriction Among Various Racial/Ethnic Groups

OBJECTIVES

Current knowledge regarding the relationship between social determinants of health (SDOH) characteristics of hospitalized American pregnant women and fetal growth restriction (FGR) reveals a dearth in the literature. Therefore, we examined the impact of SDOH on FGR among hospitalized American women in this study.

METHODS

Using the Nationwide Inpatient Sample (NIS) dataset for the years 2016-2018, we conducted this cross-sectional study. We conducted survey logistic regression to examine the association between SDOH factors and FGR, after adjusting for various hospitalization characteristics.

RESULTS

Non-Hispanic (NH)-Black people had the highest prevalence of SDOH issues (0.7%), followed by Hispanics who had a prevalence of 0.4%. We observed that pregnant women with SDOH issues were 1.16 times as likely to experience FGR as those without SDOH (95% CI 1.0-1.34). When compared to their respective racial counterparts without SDOH, Hispanics with SDOH had increased odds, NH-White and NH-others with SDOH had the same likelihood, and NH-Black women with SDOH had lower odds of FGR.

CONCLUSIONS FOR PRACTICE

Overall, our study illustrated an association between maternal SDOH issues and FGR, and the impact of SDOH issues on the outcome of FGR across various racial/ethnic groups. While our study provides useful insight into the topic, further research is needed to explain the observed varied influence of SDOH on FGR across racial/ethnic groups.

Changes in prenatal care and birth outcomes after federally qualified health center expansion

OBJECTIVE

To evaluate whether the expansion of Federally Qualified Health Centers (FQHCs) improved late prenatal care initiation, low birth weight, and preterm birth among Medicaid-covered or uninsured individuals.

DATA SOURCES AND STUDY SETTING

We identified all FQHCs in California using the Health Resources and Services Administration's Uniform Data System from 2000 to 2019. We used data from the U.S. Census American Community Survey to describe area characteristics. We measured outcomes in California birth certificate data from 2007 to 2019.

STUDY DESIGN

We compared areas that received their first FQHC between 2011 and 2016 to areas that received it later or that had never had an FQHC. Specifically, we used a synthetic control with a staggered adoption approach to calculate non-parametric estimates of the average treatment effects on the treated areas. The key outcome variables were the rate of Medicaid or uninsured births with late prenatal care initiation (>3 months' gestation), with low birth weight (<2500 grams), or with preterm birth (<37 weeks' gestation).

DATA COLLECTION/EXTRACTION METHODS

The analysis was limited to births covered by Medicaid or that were uninsured, as indicated on the birth certificate.

PRINCIPAL FINDINGS

The 55 areas in California that received their first FQHC in 2011-2016 were more populous; their residents were more likely to be covered by Medicaid, to be low-income, or to be Hispanic than residents of the 48 areas that did not have an FQHC by the end of the study period. We found no statistically significant impact of the first FQHC on rates of late prenatal care initiation (ATT: -10.4 [95% CI -38.1, 15.0]), low birth weight (ATT: 0.2 [95% CI -7.1, 5.4]), or preterm birth (ATT: -7.0 [95% CI -15.5, 2.3]).

CONCLUSIONS

Our results from California suggest that access to primary and prenatal care may not be enough to improve these outcomes. Future work should evaluate the impact of ongoing initiatives to increase access to maternal health care at FQHCs through targeted workforce investments.

Weighting of risk factors for low birth weight: a linked routine data cohort study in Wales, UK

OBJECTIVE

Globally, 20 million children are born with a birth weight below 2500 g every year, which is considered as a low birthweight (LBW) baby. This study investigates the contribution of modifiable risk factors in a nationally representative Welsh e-cohort of children and their mothers to inform opportunities to reduce LBW prevalence.

DESIGN

A longitudinal cohort study based on anonymously linked, routinely collected multiple administrative data sets.

PARTICIPANTS

The cohort, (N=693 377) comprising of children born between 1 January 1998 and 31 December 2018 in Wales, was selected from the National Community Child Health Database.

OUTCOME MEASURES

The risk factors associated with a binary LBW (outcome) variable were investigated with multivariable logistic regression (MLR) and decision tree (DT) models.

RESULTS

The MLR model showed that non-singleton children had the highest risk of LBW (adjusted OR 21.74 (95% CI 21.09 to 22.40)), followed by pregnancy interval less than 1 year (2.92 (95% CI 2.70 to 3.15)), maternal physical and mental health conditions including diabetes (2.03 (1.81 to 2.28)), anaemia (1.26 (95% CI 1.16 to 1.36)), depression (1.58 (95% CI 1.43 to 1.75)), serious mental illness (1.46 (95% CI 1.04 to 2.05)), anxiety (1.22 (95% CI 1.08 to 1.38)) and use of antidepressant medication during pregnancy (1.92 (95% CI 1.20 to 3.07)). Additional maternal risk factors include smoking (1.80 (95% CI 1.76 to 1.84)), alcohol-related hospital admission (1.60 (95% CI 1.30 to 1.97)), substance misuse (1.35 (95% CI 1.29 to 1.41)) and evidence of domestic abuse (1.98 (95% CI 1.39 to 2.81)). Living in less deprived area has lower risk of LBW (0.70 (95% CI 0.67 to 0.72)). The most important risk factors from the DT models include maternal factors such as smoking, maternal weight, substance misuse record, maternal age along with deprivation-Welsh Index of Multiple Deprivation score, pregnancy interval and birth order of the child.

CONCLUSION

Resources to reduce the prevalence of LBW should focus on improving maternal health, reducing preterm births, increasing awareness of what is a sufficient pregnancy interval, and to provide adequate support for mothers' mental health and well-being.

Social Vulnerabilities and Spatial Access to Primary Healthcare through Car and Public Transportation System in the Albuquerque, NM, Metropolitan Area: Assessing Disparities through GIS and Multilevel Modeling

Primary healthcare (PHC) is a keystone component of population health. However, inequities in public transportation access hinder equitable usage of PHC services by minoritized populations. Using the multimodal enhanced 2-step floating catchment area method and data in 2018 and 2019 for spatial access to PHC providers (n = 1166) and social vulnerability markers through census block (n = 543) and tract data (n = 226), a generalized linear mixed-effect model (GLMEM) was constructed to test the effects of sociodemographic and community area correlates on both car and bus transit spatial access to PHC in the Albuquerque, New Mexico (NM) metropolitan area. Results for bus spatial access to PHC showed lower access for Hispanics (B =  - 0.097 ± 0.029 [- 0.154, - 0.040]) and non-Hispanic Whites (B =  - 0.106 ± 0.032 [- 0.169, - 0.043]) and a positive association between single-family households and bus spatial access (B = 1.573 ± 0.349 [0.866, 2.261]). Greater disability vulnerability (B =  - 0.569 ± 0.173 [- 0.919, - 0.259]) and language vulnerability (B =  - 0.569 ± 0.173 [- 0.919, - 0.259]) were associated with decreased bus spatial access. For car spatial access to PHC, greater SES vulnerability (B =  - 0.338 ± 0.021 [- 1.568, -0.143]), disability (B =  - 0.721 ± .092 [- 0.862, - 0.50 9]), and language vulnerability (B =  - 0.686 ± 0.172 [- 1.044, - 0.362]) were associated with less car spatial access. Results indicate a disproportionate burden of low PHC access among disadvantaged population groups who rely heavily on public transportation. These results necessitate targeted interventions to reduce these disparities in access to PHC.

Subnational variations in electricity access and infant mortality: Evidence from Ghana

Objectives

The study investigated the relationship between electricity access and infant mortality at the subnational level in Ghana, controlling for correlates such as birth interval, children living with both parents, women's education, and income distribution.

Methods

The study employed a pooled cross-section regression approach using data from the Ghana Demographic and Health Survey (GDHS) for 10 administrative regions from 1993 to 2014. The GDHS is a detailed data set that provides comprehensive information on households and their socio-economic and demographic characteristics in Ghana.

Results

The results show that in regions with low incidence of infant mortality, a 10% improvement in electricity access reduces infant death by 11.8 per 1,000 live births, whereas in high mortality regions, improvement in electricity access has no impact on infant death. Birth interval reduces the risk of infant death in low mortality regions but not in high mortality regions. Children living with both parents have a high probability of survivorship in high mortality regions. Women's median years of education lowers the likelihood of infant death in high mortality regions but increases the likelihood in low mortality regions. Wealth distribution is inconsequential for infant death in low mortality regions, but in high mortality regions, both the wealthiest and the poorest experienced significant decline in infant death.

Conclusions

The findings underscore the fruitfulness of investigating the effects of electricity access and other correlates on infant mortality at the subnational level. The study recommends that the provision of reliable access to electricity is needed to improve infant mortality rates. However, policies that seek to improve access to reliable electricity should be implemented together with health infrastructure development policies, especially in the regions with high infant mortality rates, for electricity access to have the desired effect.

Physician care access plays a significant role in extending global and regional life expectancy

BACKGROUND

Previous cross-sectional studies generally did not fully consider the potential confounding factors associated with physician impact on overall population health. This ecological study controlled for health, demographic and socioeconomic confounders while using total physician density for predicting overall population health globally and regionally.

METHODS

Ecological data were extracted from the United Nations agencies for 215 populations. Considering the competing effects of economic affluence, urban advantages and obesity, correlations between physician density and life expectancy at birth (LEB) were analysed with scatter plots, bivariate correlation, partial correlation and multiple linear regression analyses. Countries are also grouped for exploring the regional correlations between physician density and LEB.

RESULTS

Physician density correlates to LEB and this relationship remains regardless of the competition of the individual confounders, economic affluence, urbanization and obesity, or their combination. Physician density has the greatest influence on LEB, while economic affluence is second. Physician density explains 64.89% of LEB in this study. Together with constant bivariate correlations in country groupings, power correlation without a plateau or U shape in the trendline of the scatterplots, suggests that a shortage of physicians is a worldwide issue.

CONCLUSIONS

Physician density is a major independent contributor for LEB both globally and with special regard to the developing world. Telehealth may be an alternative to increase physicians' capacity while funding for increasing physician employment is desirable.

Inequality begets inequality: Income inequality and socioeconomic achievement gradients across the United States

Social scientists have found income inequality is associated with an array of health and social problems, however the implications of income inequality for education are the subject of debate. Across 100 different areas (individual counties or collections of small counties) of the United States, we investigated how income inequality was associated with 1) average mathematics and reading achievement and 2) socioeconomic gradients in mathematics and reading achievement. Using data from the Kindergarten to Fifth Grade waves of the Early Childhood Longitudinal Study, Kindergarten Class of 2011 (ECLS-K 2011), we found areas of the United States with higher income inequality had lower average achievement in mathematics and a larger socioeconomic achievement gradient in reading. In further analyses, we investigated what characteristics of school and home environments mediated the relationship between income inequality and academic achievement. We found the association between income inequality and academic achievement was partly explained by the clustering of disadvantaged students in high poverty schools/districts and more intensive parenting practices among high SES parents (structured activity participation, educational expectations).

Does the conditional maternal benefit programme reduce infant mortality in India?

India, which suffers from the largest number of infant deaths in the world, introduced the conditional maternity benefit programme, Indira Gandhi Matriya Sahayog Yojana (IGMSY), to provide cash directly to pregnant and lactating women contingent on specified maternal and infant healthcare uses. This study estimates the impact of this programme on infant mortality for the first 12 months after birth, exploiting the pilot phase of IGMSY as a natural experiment in which 52 districts were randomly chosen as pilot districts. In the matched-pair difference-in-differences framework, the treatment effect on survival rate is estimated through the fully data-driven random survival forest approach. The results show that IGMSY reduced the infant mortality rate by 8.32% in treatment districts, with 1.53 fewer deaths per 1,000 live births [95% prediction interval: 1.26-1.80]. The size of the effect substantially varies even within the first 12 months, indicating larger reductions in the neonatal period and after the first 6 months. The results also reveal greater reductions among boys and children in urban areas.

Rising childhood income inequality and declining Americans' health

Morbidity and mortality are on the rise among Baby Boomers and younger cohorts. This study investigates whether this unfavorable health trend across birth cohorts 1925-1999 is related to rising income inequality Americans face during childhood. We use two nationally representative datasets: National Health and Nutrition Examination Surveys (NHANES) 1988-2018 and Panel Studies of Income Dynamics (PSID) 1968-2013, and two health outcomes: biomarkers of physiological dysregulation, and a chronic disease index. Childhood income inequality is measured by the average of the Gini index at the national level each birth cohort is exposed to between birth and age 18, where the Gini index from 1925 to 2016 is computed based on Internal Revenue Service income data. By merging childhood income inequality to individual level data from NHANES or PSID based on birth cohort, we find childhood income inequality is positively associated with the risk of physiological dysregulation in adulthood for all gender and racial groups in the NHANES data. It is also significantly related to the risk of chronic disease in the PSID data. This association is robust to controls for individual level childhood health and family background, adulthood socioeconomic and marital status, and contemporary macro socioeconomic factors. More importantly, childhood income inequality exposure explains a substantial amount of variation in these two health outcomes across cohorts, a pattern not observed for other early life exposures that display negative temporal trends similar to those for childhood income inequality. This study provides important evidence that income inequality experienced during childhood may have a long-lasting negative consequence for adult health, which partially explains the adverse health trends experienced by Baby Boomers and younger cohorts in the United States.

Inequality of opportunity in infant mortality in South Asia: A decomposition analysis of survival data

Early-life environments into which newborn babies are born play principal roles in their development. This study explores inequalities in infant mortality that are rooted in household and parental socio-economic backgrounds in five South-Asian countries: Afghanistan, Bangladesh, India, Nepal and Pakistan. Considering multidimensional aspects of socio-demographic and socio-economic status, this study explores disparities in the trajectory of survival rates across infants with dissimilar circumstantial backgrounds over the first 12 months of their lives. This study proposes a new method to first cluster the data into advantaged and disadvantaged types and explore the differences in survival rates by a clustering approach and a random survival forest. Furthermore, this study extends a Shapley-value decomposition method to explore the determinants of inequality. The results indicate that demographic factors, parental educational background and household living standards are major factors contributing to inequality. In order to ameliorate the inequality of opportunity, priority should be given to protecting marginalised infants by compensating for their disadvantaged backgrounds.

The Impact of Health Care Reform Since 2009 on the Efficiency of Primary Health Services: A Provincial Panel Data Study in China

Background: Primary health care (PHC) is an important part of health systems in the world and in China. To improve the efficiency of PHC institutions (PHCIs), many countries have implemented reforms, including China's health care reform since 2009. This study aims to evaluate the impact of this reform on the efficiency of PHCIs from the perspective of the whole health system. Methods: Data were collected from China Health Statistical Yearbooks and China Statistical Yearbooks published from 2005 to 2019. By taking the number of beds, health technicians and PHCIs as inputs and the proportion of diagnosis, treatment and admission in PHCIs as outputs, Malmquist DEA was used to evaluate the efficiency change of PHCIs, and panel data regression was performed to analyze the impact of the reform and other factors on such efficiency. The interaction between reform and economic level was also estimated. Results: The MPI in Beijing, Tianjin, Shanghai, Hunan, and Guangdong improved after the reform. The efficiency improvement in Beijing, Tianjin and Shanghai is mainly reflected in the growth of TC, whereas the efficiency improvement in Guangdong and Hunan is mainly reflected in the growth of EC. Meanwhile, the EC and TC in Hebei, Heilongjiang, Shandong, and other provinces deteriorated. The deterioration of MPI in Shanxi, Inner Mongolia and Jilin was mainly attributed to EC. while the deterioration of MPI in Liaoning, Anhui, and Fujian provinces is mainly attributed to TC. Since 2009, the reform exerted a negative impact on MPI (β = -0.06; P < 0.01), TC (β = -0.048; P < 0.01) and EC (β = -0.03; P < 0.01). And such negative impact was weaker in economically developed areas (β = 0.076; P < 0.01). Conclusions: Attention should be paid to future reforms: China should continue investing in PHCIs, establish a structurally integrated and functionally complementary delivery system and promote the coordination of reform policies to avoid the adverse impacts of other reform policies on PHCIs.

Who is willing to participate in and provide Family Doctor Contract Service?: A cross-sectional study based on the medical staff's perspective in China

China encourages medical staff from non-primary hospitals (higher-level hospitals) to participate in and provide Family Doctor Contract Service (FDCS) due to a lack of primary medical resources in community health service centers. This study aims to explore the factors affecting the willingness of family doctor contracting from the tertiary hospital medical staff's perspective. An anonymous self-administered survey was conducted among the medical staff from tertiary hospitals in Hangzhou, Zhejiang Province. Information of the socio-demographic characteristics, the willingness of participating in FDCS and its related reasons, and factors that might affect willingness were investigated. A multivariate logistic regression was used to identify the statistically significant variables associated with willingness. A total of 346 medical staff were recruited in the survey, and 37.86% of them were willing to participate in and provide FDCS. Medical staff with the following characteristics had stronger will: (1).. with higher education level; (2).. having better knowledge with family doctor; (3).. being more attracted by the national policy of FDCS; (4).. thinking it help for income increase. The majority of willing doctors (25.95%) believed that participating in FDCS could help them achieve their personal value, and the reason chosen most for unwilling reason was “low income and unrealized personal value (32.21%).” It is necessary for the government to establish the essential matching mechanisms to guarantee the development of the family doctor, including increasing the final financial support for primary health facilities, and developing the national incentive mechanism for family doctors.

Trends of infant mortality and its determinants in Ethiopia: mixed-effect binary logistic regression and multivariate decomposition analysis

BACKGROUND

Infant mortality remains a serious global public health problem. The global infant mortality rate has decreased significantly over time, but the rate of decline in most African countries, including Ethiopia, is far below the rate expected to meet the SDG targets. Therefore, this study aimed to investigate the trends of infant mortality and its determinants in Ethiopia based on the four consecutive Ethiopian Demographic and Health Surveys (EDHSs).

METHODS

This analysis was based on the data from four EDHSs (EDHS 2000, 2005, 2011, and 2016). A total weighted sample of 46,317 live births was included for the final analysis. The logit-based multivariate decomposition analysis was used to identify significantly contributing factors for the decrease in infant mortality in Ethiopia over the last 16 years. To identify determinants, a mixed-effect logistic regression model was fitted. The Intra-class Correlation Coefficient (ICC) and Likelihood Ratio (LR) test were used to assess the presence of a significant clustering effect. Deviance, Akaike Information Criteria (AIC), and Bayesian Information Criteria (BIC) were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to identify the statistically significant determinants of infant mortality.

RESULTS

Infant mortality rate has decreased from 96.9 per 1000 births in 2000 to 48 per 1000 births in 2016, with an annual rate of reduction of 4.2%. According to the logit based multivariate decomposition analysis, about 18.1% of the overall decrease in infant mortality was due to the difference in composition of the respondents with respect to residence, maternal age, type of birth, and parity across the surveys, while the remaining 81.9% was due to the difference in the effect of residence, parity, type of birth and parity across the surveys. In the mixed-effect binary logistic regression analysis; preceding interval <  24 months (AOR = 1.79, 95% CI; 1.46, 2.19), small size at birth (AOR = 1.55, 95% CI; 1.25, 1.92), large size at birth (AOR = 1.26, 95% CI; 1.01, 1.57), BMI <  18.5 kg/m² (AOR = 1.22, 95% CI; 1.05, 1.50), and twins (AOR = 4.25, 95% CI; 3.01, 6.01), parity> 6 (1.51, 95% CI; 1.01, 2.26), maternal age and male sex (AOR = 1.50, 95% CI: 1.25, 1.79) were significantly associated with increased odds of infant mortality.

CONCLUSION

This study found that the infant mortality rate has declined over time in Ethiopia since 2000. Preceding birth interval, child-size at birth, BMI, type of birth, parity, maternal age, and sex of child were significant predictors of infant mortality. Public health programs aimed at rural communities, and multiparous mothers through enhancing health facility delivery would help maintain Ethiopia's declining infant mortality rate. Furthermore, improving the use of ANC services and maternal nutrition is crucial to reducing infant mortality and achieving the SDG targets in Ethiopia.

Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil

Objectives. To investigate the role of the Family Health Strategy (FHS) in reducing social inequalities in mortality over a 9-year follow-up period.Methods. We carried out a population-based cohort study of individuals aged 60 years and older from the city of Bagé, Brazil. Of 1593 participants at baseline (2008), 1314 (82.5%) were included in this 9-year follow-up (2017). We assessed type of primary health care (PHC) coverage and other variables at baseline. In 2017, we ascertained 579 deaths through mortality registers. Hazard ratios and their 95% confidence intervals modeled time to death estimated by Cox regression. We also tested the effect modification between PHC and wealth.Results. The FHS had a protective effect on mortality among individuals aged 60 to 64 years, a result not found among those not covered by the FHS. Interaction analysis showed that the FHS modified the effect of wealth on mortality. The FHS protected the poorest from all-cause mortality (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.36, 0.96) and avoidable mortality (HR = 0.46; 95% CI = 0.25, 0.85).Conclusions. FHS coverage reduced social inequalities in mortality among older adults. Our findings highlight the need to guarantee universal health coverage in Brazil by expanding and strengthening the FHS to promote health equity.

Urban social environment and low birth weight in 360 Latin American cities

OBJECTIVE

Using data compiled by the SALURBAL project (Urban Health in Latin America; 'Salud Urbana en América Latina') we quantified variability in low birth weight (LBW) across cities in Latin America, and evaluated the associations of socio-economic characteristics at various levels (maternal, sub-city and city) with the prevalence of LBW.

METHODS

The sample included 8 countries, 360 cities, 1321 administrative areas within cities (sub-city units) and birth registers of more than 4.5 million births for the year 2014. We linked maternal education from birth registers to data on socioeconomic characteristics of sub-cities and cities using the closest available national population census in each country. We applied linear and Poisson random-intercept multilevel models for aggregated data.

RESULTS

The median prevalence of city LBW by country ranged from a high of 13% in Guatemala to a low of 5% in Peru (median across all cities was 7.8%). Most of the LBW variability across sub-cities was between countries, but there were also significant proportions between cities within a country, and within cities. Low maternal education was associated with higher prevalence of LBW (Prevalence rate ratios (PRR) for less than primary vs. completed secondary or more 1.12 95% CI 1.10, 1.13) in the fully adjusted model. In contrast, higher sub-city education and a better city social environment index were independently associated with higher LBW prevalence after adjustment for maternal education and age, city population size and city gross domestic product (PRR 1.04 95% CI 1.03, 1.04 per SD higher sub-city education and PRR 1.02 95% CI 1.00, 1.04 per SD higher SEI). Larger city size was associated with a higher prevalence of LBW (PRR 1.06; 95% CI 1.01, 1.12).

CONCLUSION

Our findings highlight the presence of heterogeneity in the distribution of LBW and the importance of maternal education, local and broader social environments in shaping LBW in urban settings of Latin America. Implementing context-sensitive interventions guided to improve women's education is recommended to tackle LBW in the region.

Primary care and all-cause mortality in urban China: a mixed-level analysis

BACKGROUND

There is still a lack of evidence focusing on primary care supply in developing countries where the educational achievement of primary care practitioners is relatively low.

OBJECTIVES

By using a nationally representative longitudinal and prospective cohort study, this study examined whether primary care supply, measured by the availability and the number of community health centres (CHCs), was associated with 4-year mortality risk among community-dwelling participants aged 45 and above in urban China.

METHODS

Using the 2011 and 2015 waves of the China Health and Retirement Longitudinal Survey (CHARLS), we conducted a longitudinal mixed-level logistic analysis to study the impact of the availability and the number of CHC on 4-year follow-up mortality risk, after adjusting community- and individual-level covariates.

RESULTS

Individuals living in communities with CHC were 31% less likely to die during the 4-year follow-up (P < 0.05) conditional on community-level characteristics, including the basic facilities availability, population size and physical area, and individuals' socio-demographic and health characteristics and health behaviours. Also, an increased number of community-level CHC was shown to decrease residents' 4-year mortality risk significantly (odds ratio = 0.82, P < 0.05). Furthermore, the association was more pronounced among adults aged 65 and above.

CONCLUSION

This study provides additional evidence of the health-promoting effect of primary care supply among urban residents in China. Improving primary care coverage in China should be necessary to improve health care access, thus promoting population health.

Geographic Variation in Neurologist Density and Neurologic Care in the United States

OBJECTIVE

To describe geographic variation in neurologist density, neurologic conditions, and neurologist involvement in neurologic care.

METHODS

We used 20% 2015 Medicare data to summarize variation by Hospital Referral Region (HRR). Neurologic care was defined as office-based evaluation/management visits with a primary diagnosis of a neurologic condition.

RESULTS

Mean density of neurologists varied nearly 4-fold from the lowest to the highest density quintile (9.7 [95% confidence interval (CI) 9.2-10.2] vs 43.1 [95% CI 37.6-48.5] per 100,000 Medicare beneficiaries). The mean prevalence of patients with neurologic conditions did not substantially differ across neurologist density quintile regions (293 vs 311 per 1,000 beneficiaries in the lowest vs highest quintiles, respectively). Of patients with a neurologic condition, 23.5% were seen by a neurologist, ranging from 20.6% in the lowest quintile regions to 27.0% in the highest quintile regions (6.4% absolute difference). Most of the difference comprised dementia, pain, and stroke conditions seen by neurologists. In contrast, very little of the difference comprised Parkinson disease and multiple sclerosis, both of which had a very high proportion (>80%) of neurologist involvement even in the lowest quintile regions.

CONCLUSIONS

The supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not. As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson disease and multiple sclerosis). These data provide insight for policy makers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.

Disease composition and epidemiological characteristics of primary care visits in Pudong New Area, Shanghai: a longitudinal study, 2016-2018

OBJECTIVES

This study aims to analyse the disease composition of primary care visits rather than specialist visits, the former of which had scarcely been studied. We adopted specific disease classification (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), disease system and communicable/non-communicable/injury disease classification, and variations of sex and age were also analysed.

SETTING

We extracted data from all community health service centres (CHSCs) and community health service stations in Pudong, Shanghai, from 2016 to 2018 using the electronic health record systems of the Pudong health information centre.

PARTICIPANTS

Our data included all 46 720 972 primary care visits from 2016 to 2018 in CHSCs in Pudong.

RESULTS

We found that the top five diseases in primary care visits continued to be primary hypertension, problems related to medical facilities, chronic ischaemic heart disease, unspecified diabetes mellitus and acute upper respiratory infection. Lipoprotein metabolism disorder visits continued to increase over the study years. The numbers and proportions of patients with hypertension and unspecified diabetes were higher among men than women, and other cerebrovascular diseases were higher among women than men. The top five disease systems were circulatory system diseases, respiratory system diseases, endocrine/nutritional/metabolic diseases, factors influencing health status and digestive system diseases. The rankings of respiratory system and endocrine/nutritional/metabolic diseases rose over time. Non-communicable diseases (NCDs) accounted for approximately 90% of the primary care visits-a much higher percentage than other causes. The top five NCDs in primary care visits were cardiovascular and circulatory diseases, musculoskeletal disorders, diabetes, digestive diseases and urogenital diseases. Compared with women, men suffered from cardiovascular diseases at an earlier age.

CONCLUSIONS

Different from specialist visits, common diseases, especially NCDs, were the main disease composition of current primary healthcare visits while the former focused on intractable diseases such as tumours, indicating that primary healthcare had played the role of gatekeeper of the healthcare system.

Where and When: Sharpening the lens on geographic disparities in mortality

Life course theories suggest that geographic disparities in mortality may reflect a history of place-based exposures rather than (or in addition to) contemporaneous exposures; yet, few studies examined early life place exposures and later life mortality in the US due to data limitations. The aim of this study is to assess and compare the importance of state of birth and state of residence in predicting mortality for adults over age 50 in the US. Using nationally representative data of nearly 100,000 adults over age 50 from the National Longitudinal Mortality Study, we estimated individual mortality risk using multi-level logistic regression with state of birth and state of residence as second-level random effects. We assessed whether state of residence and state of birth contributed to the variation in adult mortality. We also decomposed state-of-residence random effects to compare “movers” and “stayers.” Our results indicate that state of birth is a stronger predictor of age-, race/ethnicity- and sex-adjusted mortality in the US than state of residence at the time of death. The adult mortality profiles of many states are substantially impacted by the composition of “movers.” Failing to account for residential mobility has clouded our understanding of the patterns and causes of geographic differences in adult mortality. Measures of geographic residence across the life course can improve models of adult mortality in the US and inform interventions to address geographic disparities in longevity.

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State of birth is a stronger predictor of later age mortality than state of residence.

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Geographic inequalities in mortality are results from complex groupings of “movers” and “stayers”.

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Incorporating geographic residence across the life course improves models of adult mortality.

Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates

This study evaluated persistency in county-level rates of low birthweight outcomes to identify “hotspot counties” and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

Impacts of Primary Care Physician System on Healthcare Utilization and Antibiotic Prescription: Difference-in-Differences and Causal Mediation Analyses

BACKGROUND

The overutilization of healthcare and overuse/misuse of antibiotics in Japan are responsible for the increase in healthcare expenditure and the development of antimicrobial resistance. The Japanese government started paying incentives to medical facilities for primary care physician registrations, but the impact of this new policy is still unclear.

METHODS

We conducted a retrospective cohort study for all pediatric outpatients from April 2015 to December 2016 in Japan, targeting 1.4 million children under 2 years of age. We investigated the effects of primary care physician registration on physician visits, total antibiotic use and admission rates using difference-in-differences (DID) and causal mediation analyses.

RESULTS

DID analyses showed that primary care registration policy contributed to increases in total physician visits, total and broad-spectrum antibiotic use and radiologic study utilization, but reduced out-of-hour visits and did not affect hospitalization rates. Similar results were obtained when we adjusted for and matched on potential confounders. Causal mediation analyses found that the greatest pathway was controlled by direct effects of 53.2 DOTs per 1000 person-months (95% CI: 29.1-77.2), indicating that the effect of new health policy that did not mediate increased outpatient visits mostly contributed to the excess use of antibiotics.

CONCLUSIONS

The health policy further increased antibiotic use. On April 2018, a new health policy of paying incentives for not prescribing antibiotics to children with respiratory infection or gastroenteritis was initiated. Further studies are needed whether this new health policy can mitigate the overutilization of healthcare and antibiotic use.

Associations between the supply and utilization of primary care and newborn, children and maternal health in rural counties of Guangdong Province, China

BACKGROUND

The Chinese government is ambitious regarding strengthening the primary care system for women and children. Primary care contributes to better health outcomes among neonates, infants, children and pregnant women, especially for vulnerable groups. However, few published studies have examined this issue in China.

OBJECTIVE

This study examined whether greater supply and utilization of primary care was associated with improved health outcomes among targeted populations in the total and interprovincial migrant populations in the rural counties of Guangdong Province, China.

METHODS

This ecological study analysed annual panel data from all 63 rural counties in Guangdong Province from 2014 to 2016 (n = 189). A linear random-effects panel data model was applied.

RESULTS

Higher proportions of primary care visits were significantly associated with reduced incidences of low birth weight (P < 0.05) and preterm birth rates (P < 0.05) for the total population, and were significantly associated with reduced infant (P < 0.1) and under-five (P < 0.01) mortality rates for migrants. Greater primary care physician supply was significantly associated with reduced maternal mortality (P < 0.1) rates among migrants. However, primary care indicators were insignificant for both the total and migrant populations regarding neonatal mortality rates, as well as the infant and under-five mortality rates in the total population (P > 0.1).

CONCLUSIONS

These findings support existing evidence regarding associations between primary care and improved health outcomes among newborns, children and pregnant women, especially for disadvantaged populations. However, associations were not significant for all studied health outcomes, implying the need for further study.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

Can Health Disparity Be Eliminated? The Role of Family Doctor Played in Shanghai, China

Background: Globally, the elimination of health disparity is a significant policy target. Primary health care has been implemented as a strategy to achieve this target in China for almost 10 years. This study examined whether family doctor (FD) policy in Shanghai contributed to eliminating health disparity as expected. Methods: System dynamics modeling was performed to construct and simulate a system of health disparity formation (business-as-usual (BAU) scenario, without any interventions), a system with FD intervention (FD scenario), and three other systems with supporting policies (Policy 1/Policy 2/Policy hybrid scenario) from 2013 to 2050. Health disparities were simulated in different scenarios, making it possible to compare the BAU results with those of FD intervention and with other policy interventions. Findings: System dynamics models showed that the FD policy would play a positive role in reducing health disparities in the initial stage, and medical price control—rather than health management—was the dominant mechanism. However, in this model, the health gap was projected to expand again around 2039. The model examined the introduction of two intervention policies, with findings showing that the policy focused on socioeconomic status improvement would be more effective in reducing health disparities, suggesting that socioeconomic status is the fundamental cause of these disparities. Conclusions: The results indicate that health disparities could be optimized, but not eliminated, as long as differences in socioeconomic status persists.

Association of primary care physician supply with maternal and child health in China: a national panel dataset, 2012-2017

Background

The Chinese government has been strengthening the primary care system since the launch of the New Healthcare System Reform in 2009. Among all endeavors, the most obvious and significant improvement lays in maternal and child health. This study was designed to explore the association of primary care physician supply with maternal and child health outcomes in China, and provide policy suggestions to the law makers.

Methods

Six-year panel dataset of 31 provinces in China from 2012 to 2017 was used to conduct the longitudinal ecological study. Linear fixed effects regression model was applied to explore the association of primary care physician supply with the metrics of maternal and child health outcomes while controlling for specialty care physician supply and socio-economic covariates. Stratified analysis was used to test whether this association varies across different regions in China.

Results

The number of primary care physicians per 10,000 population increased from 15.56 (95% CI: 13.66 to 17.47) to 16.08 (95% CI: 13.86 to 18.29) from 2012 to 2017. The increase of one primary care physician per 10,000 population was associated with 5.26 reduction in maternal mortality per 100,000 live births (95% CI: − 6.745 to − 3.774), 0.106% (95% CI: − 0.189 to − 0.023) decrease in low birth weight, and 0.419 decline (95% CI: − 0.564 to − 0.273) in perinatal mortality per 1000 live births while other variables were held constant. The association was particularly prominent in the less-developed western China compared to the developed eastern and central China.

Conclusion

The sufficient supply of primary care physician was associated with improved maternal and child health outcomes in China, especially in the less-developed western region. Policies on effective and proportional allocation of resources should be made and conducted to strengthen primary care system and eliminate geographical disparities.

Structural Racial Inequities in Socioeconomic Status, Urban-Rural Classification, and Infant Mortality in US Counties

Objectives

Despite improvements in infant mortality rates (IMR) in the United States, racial gaps in IMR remain and may be driven by both structural racism and place. This study assesses the relationship between structural racism and race-specific IMR and the role of urban-rural classification on race-specific IMR and Black/White racial gaps in IMR.

Methods

We conducted an analysis of variance tests using 2019 County Health Rankings Data to determine differences in structural racism indicators, IMR and other co-variates by urban-rural classification. We used linear regressions to determine the associations between measures of structural racism and county-level health outcomes.

Results

Study results suggest that racial inequities in education, work, and homeownership negatively impact Black IMR, especially in large fringe, medium, and small metro counties, and positively impact White IMR. Structural racism is also associated with Black-White gaps in IMR.

Conclusions

Factors related to structural racism may not be homogenous or have the same impacts on overall IMR, race-specific IMR, and racial differences in IMR across places. Understanding these differential impacts can help public health professionals and policymakers improve Black infant health and eliminate racial inequities in IMR.

Impact of the social context on the prognosis of Chagas disease patients: Multilevel analysis of a Brazilian cohort

The present study aims to investigate how the social context contributes to the prognosis of Chagas disease (CD). This is a multilevel study that considered individual and contextual data. Individual data came from a Brazilian cohort study that followed 1,637 patients who lived in 21 municipalities to which CD is endemic, over two years. Contextual data were collected from official Brazilian government databases. The dependent variable was the occurrence of cardiovascular events in CD during the two-year follow-up, defined from the grouping of three possible combined events: death, development of atrial fibrillation, or pacemaker implantation. Analysis was performed using multilevel binary logistic regression. Among the individuals evaluated, 205 (12.5%) manifested cardiovascular events in CD during two years of follow-up. Individuals living in municipalities with a larger rural population had protection for these events (OR = 0.5; 95% CI = 0.4-0.7), while those residing in municipalities with fewer physicians per thousand inhabitants (OR = 1.6; 95% CI = 1.2-2.5) and those living in municipalities with lower Primary Health Care (PHC) coverage (OR = 1.4; 95% CI = 1.1-2.1) had higher chances of experiencing cardiovascular events. Among the individual variables, the probability of experiencing cardiovascular events was higher for individuals aged over 60 years (OR = 1.4; 95% CI = 1.01-2.2), with no stable relationship (OR = 1.4; 95% CI = 0.98-2.1), without previous treatment with Benznidazole (OR = 1.5; 95% CI = 0.98-2.9), with functional class limitation (OR = 2.0; 95% CI = 1.4-2.9), with a QRS complex duration longer than 120 ms (OR = 1.5; 95% CI = 1.1-2.3), and in individuals with high NT-proBNP levels (OR = 6.4; 95% CI = 4.3-9.6). CONCLUSION: The present study showed that the occurrence of cardiovascular events in individuals with CD is determined by individual conditions that express the severity of cardiovascular involvement. However, these individual characteristics are not isolated protagonists of this outcome, and the context in which individuals live, are also determining factors for a worse clinical prognosis.

Inequalities in birth weight and maternal education: a time-series study from 1996 to 2013 in Brazil

Maternal education represents one of the most important social determinants of inequality in birth weight (BW) in developing countries. The present study sought to investigate secular trends in health inequality considering the difference in mean BW between extremes of maternal educational attainment in Brazil. Using a time-series design, data from 6,452,551 live births which occurred in all Brazilian state capitals from 1996 to 2013 were obtained from the Information System on Live Births. Secular trends of the difference in mean birth weight between low (<8 years of schooling) and high (≥12 years of schooling) educational attainment were analyzed. The main finding was that differences in mean birth weight between the two extremes of maternal educational attainment decreased over time. There was a significant decrease in mean BW in neonates born to mothers with higher educational attainment, and a slight increase in those born to mothers with lower educational attainment. One of the key factors involved in decreasing inequality was an increase in the number of antenatal visits. In view of these results, we conclude, that despite a slight increase of mean birth weight among mothers with low education, the reduction of inequality in pregnancy outcomes over time in Brazil is attributable to a worsening scenario for mothers who are better off rather than to improvements for the most vulnerable group of mothers.

State- and county-level income inequality and infant mortality in the USA in 2010: a cohort study

OBJECTIVES

We examined the relationship between income inequality and the risk for infant/neonatal mortality at the state and county level and tested possible mediators of this relationship.

METHODS

We first linked state and county Gini coefficients to US Vital Statistics 2010 Cohort Linked Birth and Infant Death records (n = 3,954,325). We then fit multilevel models to test whether income inequality was associated with infant/neonatal mortality. County-level factors were tested as potential mediators.

RESULTS

Adjusted analyses indicated that income inequality at the county level-but not at the state level-was associated with increased odds of infant mortality (OR 1.14, 95% CI 1.10, 1.18) and neonatal death (OR 1.17, 95% CI 1.12, 1.23). Our mediators explained most of this variation. Bivariate analyses revealed associations between 3 county-level measures-patient-to-physician ratio, the violent crime rate, and sexually transmitted infection rate-and infant and neonatal mortality. Proportion of college-educated adults was associated with decreased odds for neonatal mortality.

CONCLUSIONS

Local variations in access to care, the rate of sexually transmitted disease, and crime are associated with infant mortality, while variations in college education in addition to these mediators explain neonatal mortality. To reduce infant and neonatal mortality, experiments are needed to examine the effectiveness of policies targeted at reducing income inequality and improving healthcare access, policing, and educational opportunities.

Assessing the impact of a doctor in remote areas of Brazil

OBJECTIVES

The More Doctors Program (MDP) is an ongoing Brazilian policy that aims to improve healthcare by providing physicians to the most vulnerable municipalities. We aimed to measure the impact of MDP in mortality and infant mortality rate, the proportion of live births with low weight, prenatal appointments, childbirths at first and fifth min Apgar, public health investment and immunization in Brazil.

METHODS

Municipal health indicators were collected before and after the intervention (2012 and 2015). Effects were measured by applying propensity score matching with difference-in-differences.

RESULTS

Our findings show that infant mortality presented the highest improvement during the period (a decrease in 11 infant deaths per 1000 live births, p < 0.01). A significant effect, albeit smaller, was also found for the age-standardized total mortality (a decrease in five deaths per 10,000 residents), proportion of children with Apgar score lower than 8 in the fifth min and children with low birth weight.

CONCLUSIONS

MDP contributed to improve important health indicators, highlighting the importance of a doctor in remote areas of Brazil.

The association between the supply and utilization of community-based primary care and child health in a context of hospital-oriented healthcare system in urban districts of Guangdong, China: a panel dataset, 2014-2016

Background

Since 2009, the Chinese government has been reforming the healthcare system and has committed to reinforcing increased use of primary care. To date, however, the Chinese healthcare system is still heavily reliant on hospital-based specialty care. Studies consistently show an association between primary care and improved health outcomes, and the same association is also found among the disadvantaged population. Due to the “hukou” system, interprovincial migrants in the urban districts are put in a weak position and become the disadvantaged. Therefore, the aim of this study is to investigate whether greater supply and utilization of primary care was associated with reduced child mortality among the entire population and the interprovincial migrants in urban districts of Guangdong province, China.

Methods

An ecological study was conducted using a 3-year panel data with repeated measurements within urban districts in Guangdong province from 2014 to 2016, with 178 observations in total. Multilevel linear mixed effects models were applied to explore the associations.

Results

Higher visit proportion to primary care was associated with reductions in the infant mortality rate and the under-five mortality rate in both the entire population and the interprovincial migrants (p < 0.05) in the full models. The association between visit proportion to primary care and reduced neonatal mortality rate was significant among the entire population (p < 0.05) while it was insignificant among the interprovincial migrants (p > 0.05).

Conclusions

Our ecological study based in urban districts of Guangdong province found consistent associations between higher visit proportion to primary care and improvements in child health among the entire population and the interprovincial migrants, suggesting that China should continue to strengthen and develop the primary care system. The findings from China adds to the previously reported evidence on the association between primary care and improved health, especially that of the disadvantaged.

Communicable disease mortality trends and characteristics of infants in rural China, 1996-2015

BACKGROUND

More attention should be paid to communicable disease-specific infant mortality rate (CD-IMR) in rural China. However, few studies have examined specific geographic patterns and trends in CD-IMR in these areas. Our aims were to assess the epidemiological distribution and trends in CD-IMR in rural China for the period 1996-2015.

METHODS

We used data from China's Under-5 Child Mortality Surveillance System (U5CMSS). The time trends in communicable disease-specific IMR (CD-IMR) were assessed by Poisson regression model, and the proportion of total infant deaths due to communicable disease was assessed by the Cochran Armitage trend test. Differences in CD-IMR among and within geographic regions were assessed for significance using the Cochran-Mantel-Haenszel test.

RESULTS

The overall CD-IMR fell by 86.0% from 1444.3 to 201.5 per 100,000 live births in rural mainland China from 1996 to 2015. The proportion of total infant deaths related to communicable disease fell from 33.4 to 19.7%. Using eastern rural areas as the reference, rate ratios (RRs) of IMR due to all communicable diseases ranged between 1.7 and 3.1 in central rural areas and between 4.4 and 9.8 in western areas during the four study intervals. Acute respiratory infection (ARI) accounted for 71% of deaths, followed by diarrhea and septicemia.

CONCLUSIONS

IMR due to communicable disease remains a major public health issue. ARI is the leading cause of mortality, followed by diarrhea. A regional gap remains in the risk of infant exposure to communicable disease in rural China. More attention should be paid to western rural areas.

War is not healthy. Political violence and infant health outcomes in Colombia

OBJECTIVES

To establish and quantify the effect of the internal armed conflict in Colombia on infant health, particularly birth weight.

METHODS

This document explores time differences in relation to the impact of the internal armed conflict in Colombia, measured by municipal homicide rates, on infant health, quantified as infant mortality and birth weight. Based on individual data from the 1995 and 2000 Colombian National Demographic and Health Surveys, along with annual municipal data on violence and economic performance, results obtained from two biological siblings are compared using a maternal fixed logistic regression, as one was born in a violent era and the other during a peaceful moment.

RESULTS

Political violence negatively affected infant health outcomes during the peak of violence experienced by Colombia in the 1990s, with worse outcomes for male infants than for females. Controlling fixed maternal effects shows a three times greater probability of being born with low birth in infants born during increased violence, compared to their siblings born in more peaceful times.

CONCLUSIONS

These results make visible all the effects of intense and long-lasting armed conflicts, as is the case of Colombia, since not only direct actors involved in conflict are affected, but also infants who show worse health outcomes. These results allows targeting policies for reducing the effects on populations in conflict or during the reconstruction period; in this case, the provision of maternal care during the gestational period and special care for newborns in areas under high violence levels should be a priority.

Promoting access to family medicine in Québec, Canada: Analysis of bill 20, enacted in November 2015

Primary care can potentially make an important contribution to improving health system performance. However, Canada does not fare as well as other developed countries in terms of timely access to primary health care services. In November 2015, Bill 20 was introduced in the province of Québec. The goal of Bill 20 was to optimize the utilisation of medical and financial resources to improve access to primary care. Bill 20 states the obligations of general practitioners to register a minimum number of patients, ensure the continuity of care of that population, and practice a minimum number of hours in hospitals. Many actors agreed that access to primary care had to be improved in Québec, but disagreed with Bill 20. In particular, family physicians strongly opposed the financial penalties that were introduced for physicians failing to meet the specified targets. In January 2018, 3 years after Bill 20, indicators for patient registration and continuity of care have considerably improved. However, the attractiveness of general practice seems to have decreased among medical graduates, which creates uncertainty regarding the sustainability of the achievements brought on by Bill 20.

Primary care physicians and infant mortality: Evidence from Brazil

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates.

Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015

IMPORTANCE

Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population health, independent of other health care and socioeconomic factors.

OBJECTIVES

To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality.

DESIGN, SETTING, AND PARTICIPANTS

This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018.

MAIN OUTCOMES AND MEASURES

Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time.

RESULTS

Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply.

CONCLUSIONS AND RELEVANCE

Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.

Operational efficiency, patient composition and regional context of U.S. health centers: Associations with access to early prenatal care and low birth weight

Community health centers (CHCs) provide comprehensive medical services to medically under-served Americans, helping to reduce health disparities. This study aimed to identify the unique compositions and contexts of CHCs to better understand variation in access to early prenatal care and rates of low birth weights (LBW). Data include CHC-level data from the Uniform Data System, and regional-level data from the US Census American Community Survey and Behavioral Risk Factor Surveillance System. First, latent class analysis was conducted to identify unobserved subgroups of CHCs. Second, data envelopment analysis was performed to evaluate the operational efficiency of CHCs. Third, we used generalized linear models to examine the associations between the CHC subgroups, efficiency, and perinatal outcomes. Seven classes of CHCs were identified, including two rural classes, one suburban, one with large centers serving poor minorities in low poverty areas, and three urban classes. Many of these classes were characterized by the racial compositions of their patients. Findings indicate that CHCs serving white patients in rural areas have greater access to early prenatal care. Health centers with greater efficiency have lower rates of LBW, as do those who serve largely white patient populations in rural areas. CHCs serving poor racial minorities living in low-poverty areas had particularly low levels of access to early prenatal care and high rates of LBW. Findings highlight that significant diversity exists in the sociodemographic composition and regional context of US health centers, in ways that are associated with their operations, delivery of care, and health outcomes. Results from this study highlight that while the provision of early prenatal care and the efficiency with which a health center operates may improve the health of the women served by CHCs and their babies, the underlying social and economic conditions facing patients ultimately have a larger association with their health.

The impact of the health care workforce on under-five mortality in rural China

BACKGROUND

Previous studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.

METHODS

We estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.

RESULTS

The U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.

CONCLUSIONS

This study demonstrates that increased health professionals were associated with reductions in U5MR. The largest association was seen in poor counties and those with low and slowly increasing GDP per capita, which justifies further expansion of the health care workforce in these areas. This study could be instructive for other developing countries to achieve Sustainable Development Goal 3 by helping them identify where additional health professionals would make the greatest contribution.

Can the primary health care model affect the determinants of neonatal, post-neonatal and maternal mortality? A study from Brazil

BACKGROUND

The state of São Paulo recorded a significant reduction in infant mortality from 1990 to 2013, but the desired reduction in maternal mortality was not achieved. Knowledge of the factors with impact on these indicators would be of help in formulating public policies. The aims of this study were to evaluate the relations between socioeconomic and demographic factors, health care model and both infant mortality (considering the neonatal and post-neonatal dimensions) and maternal mortality in the state of São Paulo, Brazil.

METHODS

In this ecological study, data from national official open sources were used to conduct a population-based study. The units analyzed were 645 municipalities in the state of São Paulo, Brazil. For each municipality, the infant mortality (in both neonatal and post-neonatal dimensions) and maternal mortality rates were calculated for every 1000 live births, referring to 2013. Subsequently, the association between these rates, socioeconomic variables, demographic models and the primary care organization model in the municipality were verified. For statistical analysis, we used the zero-inflated negative binomial model. Gross analysis was performed and then multiple regression models were estimated. For associations, we adopted "p" at 5%.

RESULTS

The increase in the HDI of the city and proportion of Family Health Care Strategy implemented were significantly associated with the reduction in both infant mortality (neonatal + post-neonatal) and maternal mortality rates. In turn, the increase in birth and caesarean delivery rates were associated with the increase in infant and maternal mortality rates.

CONCLUSIONS

It was concluded that the Family Health Care Strategy was a Primary Care organization model that contributed to the reduction in infant (neonatal + post-neonatal) and maternal mortality rates, and so did actors such as HDI and cesarean section. Thus, public health managers should prefer this model when planning the organization of Primary Care services for the population.

Income Inequality and Population Health: A Global Gradient?

Cross-national empirical research about the link between income inequality and population health produces conflicting conclusions. We address these mixed findings by examining the degree to which the income inequality and health relationship varies with economic development. We estimate fixed-effects models with different measures of income inequality and population health. Results suggest that development moderates the association between inequality and two measures of population health. Our findings produce two generalizations. First, we observe a global gradient in the relationship between income inequality and population health. Second, our results are consistent with income inequality as a proximate or conditional cause of lower population health. Income inequality has a 139.7% to 374.3% more harmful effect on health in poorer than richer countries and a significantly harmful effect in 2.1% to 53.3% of countries in our sample and 6.6% to 67.6% of the world's population but no significantly harmful effect in richer countries.

Factors associated with residents' contract behavior with family doctors in community health service centers: A longitudinal survey from China

BACKGROUND

China adopted family doctor (FD) to help achieve "Healthy China 2030" through providing continuous, comprehensive, and life-cycle contract services. However, there is a disparity between actual and targeted FD use, as residents continue to visit specialists in large hospitals. The government implemented initiatives to improve residents' willingness to sign up with and visit their FDs. Factors that influence contract behavior are therefore significant for frontier policy research.

METHODS

Two survey waves were conducted in Shanghai (2013 and 2016). The first wave included 2754 people and the second 1995 people. Exploratory factor analysis was used to synthesize "satisfaction" as a predictor of contract behavior. Pearson's chi-square, pooled and logistic regression models were used to estimate associations between influencing factors and contract behavior, and clarify variations in factors across the two waves.

RESULTS

Four factors were extracted from 15 satisfaction items: "Treatment Environment," "Medical Technology," "Service Specification" and "Service Attitude". Consistent with descriptive analysis, longitudinal analysis showed sociodemographic characteristics (age, education, marital status, and hukou) were significant predictors of contract behavior. The odds ratio of non-communicable diseases (NCD) patients for contract behavior was 2.218 times that of residents without NCD. Contract behavior was positively correlated with awareness of FD services (OR = 21.674, 95%CI = 15.043-31.229), satisfaction with Service Attitude (OR = 1.210, 95%CI = 1.009-1.451), and visit compliance (OR = 1.959, 95%CI = 1.564-2.452). Over time, the odds ratios of the married, Shanghai hukou, NCD, and awareness of FD services declined from 0.456, 1.795, 2.492, 28.690 to 0.443, 1.678, 1.910 and 14.031 respectively, while those of age, and visit compliance increased from 1.027, 1.521 to 1.041 and 2.305 respectively. In 2016, an education-contract gradient had formed (the higher the education level, the higher probability of signing with a FD), whereas high school education had the highest odds ratio (OR = 1.163,95%CI = 0.740-1.827) in 2013. Service Attitude was the only significant satisfaction-related predictor (OR = 1.358, 95%CI = 1.001-1.842) in 2016, compared with "Treatment Environment" (OR = 1.224, 95%CI = 1.001-1.496) and "Service Specification" in 2013(OR = 1.270, 95%CI = 1.040-1.552).

CONCLUSIONS

Except for the socio-demographic variables, NCD, awareness of FD services, satisfaction and visit compliance were significant predictors of contract behavior with FDs. The effect of visit compliance had increased over time while NCD and awareness of FD services were losing impact over time. Significant satisfaction factors had also changed from "Treatment Environment" and "Service Specification" to "Service Attitude".

Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey

BACKGROUND

Despite the substantial attention to primary care (PC), few studies have addressed the relationship between patients' experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries.

METHODS AND FINDINGS

We conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37-1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34-7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01-1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02-1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03-2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56-0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04-1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19-1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11-1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables.

CONCLUSIONS

Overall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.

Impact of federal transfers upon US infant mortality rates: a secondary analysis using a fixed effects regression approach

OBJECTIVES

In order to improve health outcomes, the federal government allocates hundreds of billions of annual dollars to individual states in order to further the well-being of its citizens. This study examines the impact of such federal intergovernmental transfers on reducing state-level infant mortality rates.

SETTING

Annual data are collected from all 50 US states between 2004 and 2013.

PARTICIPANTS

Entire US population under the age of 1 year between 2004 and 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

State-level infant mortality rate, neonatal mortality rate and postneonatal mortality rate.

RESULTS

Using a fixed effects regression model to control for unmeasurable differences between states, the impact of federal transfers on state-level infant mortality rates is estimated. After controlling for differences across states, increases in per capita federal transfers are significantly associated with lower infant, neonatal and postneonatal mortality rates. Holding all other variables constant, a $200 increase in the amount of federal transfers per capita would save one child's life for every 10 000 live births.

CONCLUSIONS

Considerable debate exists regarding the role of federal transfers in improving the well-being of children and families. These findings indicate that increases in federal transfers are strongly associated with reductions in infant mortality rates. Such benefits should be carefully considered when state officials are deciding whether to accept or reject federal funds.