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In the global context, health and the quality of life of people are adversely affected by either one or more types of chronic diseases. This paper investigates the differences in the level of income and expenditure between chronically-ill people and non-chronic population. Data were gathered from a national level survey conducted namely, the Household Income and Expenditure Survey (HIES) by the Department of Census and Statistics (DCS) of Sri Lanka. These data were statistically analysed with one-way and two-way ANOVA, to identify the factors that cause the differences among different groups. For the first time, this study makes an attempt using survey data, to examine the differences in the level of income and expenditure among chronically-ill people in Sri Lanka. Accordingly, the study discovered that married females who do not engage in any type of economic activity (being unemployed due to the disability associated with the respective chronic illness), in the age category of 40–65, having an educational level of tertiary education or below and living in the urban sector have a higher likelihood of suffering from chronic diseases. If workforce population is compelled to lose jobs, it can lead to income insecurity and impair their quality of lives. Under above findings, it is reasonable to assume that most health care expenses are out of pocket. Furthermore, the study infers that chronic illnesses have a statistically proven significant differences towards the income and expenditure level. This has caused due to the interaction of demographic and socio-economic characteristics associated with chronic illnesses. Considering private-public sector partnerships that enable affordable access to health care services for all as well as implementation of commercial insurance and community-based mutual services that help ease burden to the public, are vital when formulating effective policies and strategies related to the healthcare sector. Sri Lanka is making strong efforts to support its healthcare sector and public, which was affected by the coronavirus (COVID-19) in early 2020. Therefore, findings of this paper will be useful to gain insights on the differences of chronic illnesses towards the income and expenditure of chronically-ill patients in Sri Lanka.

Objective To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. Methods Institutional review board approval for this study was granted from Public Health Service—Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0–11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. Results CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). Conclusion This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women’s age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization.

BackgroundIn Southeast Asia, the prevalence of multimorbidity is gradually increasing. This paper aimed to investigate the association between educational level and multimorbidity among over 15-years old adults in Southeast Asia.MethodsWe conducted a systematic review of published observational studies. Studies were selected according to eligibility criteria of addressing definition and prevalence of multimorbidity and associations between level of education and multimorbidity in Southeast Asia. The Newcastle-Ottawa Scale (NOS) was used to measure the quality and risk of bias. The methodology has been published in PROSPERO with registered number ID: CRD42021259311.ResultsEighteen studies were included in the data synthesis. The results are presented using narrative synthesis due to the heterogeneity of differences in exposures, outcomes, and methodology. The prevalence of multimorbidity ranged from 1.7% to 72.6% among over 18 years-old adults and from 1.5% to 51.5% among older people (≥ 60 years). There were three association patterns linking between multimorbidity and education in these studies: (1) higher education reducing odds of multimorbidity, (2) higher education increasing odds of multimorbidity and (3) education having no association with multimorbidity. The association between educational attainment and multimorbidity also varies widely across countries. In Singapore, three cross-sectional studies showed that education had no association with multimorbidity among adults. However, in Indonesia, four cross-sectional studies found higher educated persons to have higher odds of multimorbidity among over 40-years-old persons.ConclusionsPublished studies have shown inconsistent associations between education and multimorbidity because of different national contexts and the lack of relevant research in the region concerned. Enhancing objective data collection such as physical examinations would be necessary for studies of the connection between multimorbidity and education. It can be hypothesised that more empirical research would reveal that a sound educational system can help people prevent multimorbidity.

The community and home-based elderly care service system has been proved an effective pattern to mitigate the elderly care dilemma under the background of accelerating aging in China. In particular, the participation of social organizations in community and home-based elderly care service has powerfully fueled the multi-supply of elderly care. As the industry of the elderly care service is in the ascendant, the management lags behind, resulting in the waste of significant social resources. Therefore, performance evaluation is proposed to resolve this problem. However, a systematic framework for evaluating performance of community and home-based elderly care service centers (CECSCs) is absent. To overcome this limitation, the SBM-DEA model is introduced in this paper to evaluate the performance of CECSCs. 186 social organizations in Nanjing were employed as an empirical study to develop the systematic framework for performance evaluation. Through holistic analysis of previous studies and interviews with experts, a systematic framework with 33 indicators of six dimensions (i.e., financial management, hardware facilities, team building, service management, service object and organization construction) was developed. Then, Sensitivity Analysis is used to screen the direction of performance optimization and specific suggestions were put forward for government, industrial associations and CECSCs to implement. The empirical study shows the proposed framework using SBM-DEA and sensitivity analysis is viable for conducting performance evaluation and improvement of CECSCs, which is conducive to the sustainable development of CECSCs.

This paper aims to demonstrate the importance of studying interactions among various sociodemographic risk factors of childhood stunting in Bangladesh with the help of an interpretable machine learning method. Data used for the analyses are extracted from the Bangladesh Demographic and Health Survey (BDHS) 2014 and pertain to a sample of 6,170 under-5 children. Social and economic determinants such as wealth, mother’s decision making on healthcare, parental education are considered in addition to geographic divisions and common demographic characteristics of children including age, sex and birth order. A classification tree was first constructed to identify important interaction-based rules that characterize children with different profiles of risk for stunting. Then binary logistic regression models were fitted to measure the importance of these interactions along with the individual risk factors. Results revealed that, as individual factors, living in Sylhet division (OR: 1.57; CI: 1.26–1.96), being an urban resident (OR: 1.28; CI: 1.03–1.96) and having working mothers (OR: 1.21; CI: 1.02–1.44) were associated with higher likelihoods of childhood stunting, whereas belonging to the richest households (OR: 0.56; CI: 0.35–0.90), higher BMI of mothers (OR: 0.68 CI: 0.56–0.84) and mothers’ involvement in decision making about children’s healthcare with father (OR: 0.83, CI: 0.71–0.97) were linked to lower likelihoods of stunting. Importantly however, risk classifications defined by the interplay of multiple sociodemographic factors showed more extreme odds ratios (OR) of stunting than single factor ORs. For example, children aged 14 months or above who belong to poor wealth class, have lowly educated fathers and reside in either Dhaka, Barisal, Chittagong or Sylhet division are the most vulnerable to stunting (OR: 2.52, CI: 1.85–3.44). The findings endorse the need for tailored-intervention programs for children based on their distinct risk profiles and sociodemographic characteristics.

The Future Health Index (FHI) is developed by the Royal Philips to help determine the readiness of countries to address global health challenges and build sustainable, fit-for-purpose national health systems. The FHI 2018 presents the Value Measure to measure the value of 16 health systems, which is formulated by taking the arithmetic average of Access, Satisfaction and Efficiency. However, this scheme is not the Pareto optimal and loses association with weights. For these reasons, this paper proposes to apply the social choice theory and Stochastic Multicriteria Acceptability Analysis for group decision making (SMAA-2) to measure the value of health systems, by means of re-constructing the Value Measure. Specifically, we begin with considering all possible individual preferences among Access, Satisfaction and Efficiency, which is mathematically represented by ranked weights of them; the pessimistic and optimistic outcomes under certain individual preference are derived in a closed-form manner, according to which an interval decision matrix is then formulated; the SMAA-2 is then lastly applied to compute the holistic acceptability index, which is considered as a revised Value Measure. An empirical study using the data of 16 health systems is conducted to show the effectiveness and superiority of our method. It is demonstrated that our method always outperforms the Value Measure, by means of comparing the Spearman’s rank correlation coefficients.

BackgroundCultural competency describes interventions that aim to improve accessibility and effectiveness of health services for people from ethnic minority backgrounds. Interventions include interpreter services, migrant peer educators and health worker training to provide culturally competent care. Very few studies have focussed on cultural competency for migrant service use in Low- and Middle-Income Countries (LMIC). Migrants and refugees in Thailand and Malaysia report difficulties in accessing health systems and discrimination by service providers. In this paper we describe stakeholder perceptions of migrants' and health workers' language and cultural competency, and how this affects migrant workers' health, especially in Malaysia where an interpreter system has not yet been formalised.MethodWe conducted in-depth interviews with stakeholders in Malaysia (N = 44) and Thailand (N = 50), alongside policy document review in both countries. Data were analysed thematically. Results informed development of Systems Thinking diagrams hypothesizing potential intervention points to improve cultural competency, namely via addressing language barriers.ResultsLanguage ability was a core tenet of cultural competency as described by participants in both countries. Malay was perceived to be an easy language that migrants could learn quickly, with perceived proficiency differing by source country and length of stay in Malaysia. Language barriers were a source of frustration for both migrants and health workers, which compounded communication of complex conditions including mental health as well as obtaining informed consent from migrant patients. Health workers in Malaysia used strategies including google translate and hand gestures to communicate, while migrant patients were encouraged to bring friends to act as informal interpreters during consultations. Current health services are not migrant friendly, which deters use. Concerns around overuse of services by non-citizens among the domestic population may partly explain the lack of policy support for cultural competency in Malaysia. Service provision for migrants in Thailand was more culturally sensitive as formal interpreters, known as Migrant Health Workers (MHW), could be hired in public facilities, as well as Migrant Health Volunteers (MHV) who provide basic health education in communities.ConclusionPerceptions of overuse by migrants in a health system acts as a barrier against system or institutional level improvements for cultural competency, in an already stretched health system. At the micro-level, language interventions with migrant workers appear to be the most feasible leverage point but raises the question of who should bear responsibility for cost and provision-employers, the government, or migrants themselves.

Background Needlestick injury (NSI) is one of the most burdensome professional hazards in any medical setting; it can lead to transmission of fatal infectious diseases, such as hepatitis B, hepatitis C and human immunodeficiency virus. In the United States, the annual cost burden was estimated as somewhere between $118 million to $591 million; in the United Kingdom it is approximated to be £500,000 (US$919,117.65) per the National Health Service. Method This is the first published paper on the national cost burden of NSIs in Japan. A systematic literature review was conducted to review previous study design in global studies and to extract parameter values from Japanese studies. We conducted abstract searches through PubMed and the Japan Medical Abstracts Society (Ichushi), together with grey literature and snowball searches. A simple economic model was developed to calculate cost burden of NSIs from a societal perspective over a one-year time horizon. We assumed all NSIs are reported and perfect adherence in post NSI management that presented in the labour compensation scheme. Local guidelines were also referenced to extract resource utilization. Lastly, a deterministic sensitivity analysis was conducted and a scenario analysis which considered a payer perspective was also included. Result and conclusion The national cost burden of in-hospital NSIs is estimated as ¥33.4 billion (US$302 million) annually, based on an average cost per NSI of ¥63,711 (US$577) and number of NSIs at 525,000/year. 70% of the cost is due to initial laboratory tests, followed by productivity loss, estimated at 20% of the total cost. Cost of contaminated NSIs remains at 5% of the total cost. Change in number of NSIs significantly influences outcomes. Variation in post-exposure management practices suggests a need for NSI specific National guidelines and holistic labour compensation scheme development in Japan.

Introduction The living arrangements among the older population form a basic pointer to the care and support of older adults in India, and living with extended kin is clearly differentiated from living separately. This paper attempts to understand the associations between socio-economic and health-related variables with preference for the separate living among older adults in India. Materials and methods Using data from Building Knowledge Base on Population Ageing in India (BKPAI), we employed bivariate and probit regressions on a sample of 9540 older adults to fulfil the study objective. Results Nearly 21% of older adults were living alone/with a spouse. Additionally, those older adults who lived alone/with spouse had specific reasons, i.e. about 14.6% reported that they had no children, 47.3% of older adults had their children away and 15.9% of older adults reported a family conflict. Availability of children is consistently found to be negatively associated with the preference of separate living. Besides, better self-rated health, independence in daily activities, and facing any type of violence were the strongest predictors of preference for separate living. In addition, the background characteristics, including age, sex, education, religion, and ethnicity, were found as significant predictors of living arrangement preference. Preference for co-residential arrangements emerges among older persons who have a feeling of importance within their family. Conclusion Physical proximity to kin and health conditions, in addition to economic conditions, substantially determine the swing towards separate living among older adults in India. This suggests that attention has to be paid to the demand for specialized care and health services among older adults living separately.

Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015–16 and District Level Household and Facility Survey (DLHS) 2012–13. The study is limited to only districts whose data are available in both DLHS 2012–13 and NFHS 2015–16. The methods of analysis include bivariate statistics, Pearson’s chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client’s confidence in the services, which is the key to success for any voluntary family planning program like in India.

A growing body of literature has documented that community-based early childhood development (ECD) interventions can improve child developmental outcomes in vulnerable communities. One critical element of effective community-based programs is consistent program participation. However, little is known about participation in community-based ECD interventions or factors that may affect participation. This paper examines factors linked to program participation within a community-based ECD program serving 819 infants and their caregivers in 50 rural villages in northwestern China. The results find that more than half of families did not regularly attend the ECD program. Both village-level social ties within the program and proximity to the program significantly predict program participation. Increased distance from the program site is linked with decreased individual program participation, while the number of social ties is positively correlated with participation. The average program participation rates among a family's social ties is also positively correlated with individual participation, indicating strong peer effects. Taken together, our findings suggest that attention should be given to promoting social interactions and reducing geographic barriers among households in order to raise participation in community-based ECD programs.

Public pension insurance has become a major form of social protection around the world. However, little is known about the association between public pension expansion and individuals' fertility in developing economies. In this paper, we examine the effects of the New Rural Pension Scheme (NRPS) on the fertility of married women in rural China. Using data from the China Family Panel Studies (CFPS), the difference-in-differences approach is employed to estimate the impact of NRPS expansion on fertility outcomes. The robustness of results is checked through additional estimations, including difference-in-differences with propensity score matching, fixed-effects model, and instrumental variable approach. Results show that the NRPS expansion has a significantly negative effect on the number of children, and it reduces the likelihood of having a second child. The fertility-reducing effect of the NRPS is larger for the younger, well-educated women and those in high-income families. Considerations of the fertility effects and their population differences are needed in the impact evaluations of relevant public pension reform.

Objectives In this paper, we aim to estimate the effect cancer diagnosis has on labour-force participation among middle-aged and older populations in Japan. We investigate the impact of cancer diagnosis on job cessation and the gap between gender or job types. Methods We sourced data from a nationwide, annual survey targeted population aged 51-70 featuring the same cohort throughout, and examined respondents' cancer diagnoses and whether they continued to work, while also considering differences between gender (observations: 53 373 for men and 44 027 for women) and occupation type (observations: 64 501 for cognitive worker and 20 921 for manual worker) in this regard. We also examined one-year lag effects, using propensity score matching to control for confounding characteristics. We also implement Logistic regression and derive the odds ratio to evaluate the relative risk of cancer diagnosis, which supplements the main result by propensity score matching. Results Overall, the diagnosis of cancer has a huge effect on labour-force participation among the population, but this effect varies across subpopulations. Male workers are more likely to quit their job in the year they are diagnosed with cancer (10.1 percentage points), and also in the following year (5.0 percentage points). Contrastingly, female workers are more likely to quit their job immediately after being diagnosed with cancer (18.6 percentage points); however, this effect totally disappears when considering likelihoods for the following year. Cognitive workers are more prone to quit their job in the year of diagnosis by 11.6 percentage points, and this effect remains significant, 3.8 percentage points, in the following year. On the other hand, for manual workers the effect during the year of diagnosis is huge. It amounts to 18.7 percentage points; however, the effect almost disappears in the following year. Conclusion Our results indicate the huge effect of cancer on job cessation, and that there might be a degree of discrimination in workplaces between gender and job types.

Background No study of obesity risk for people in developed countries has conducted a multi-dimensional analysis of the association of socioeconomic status with obesity. In this paper, we investigated if education functions as either a confounder or an effect modifier in the association of another socioeconomic status indicator with obesity. Methods This cross-sectional study analyzed data of an adult population sample (10,905 men and 14,580 women) from the Korea National Health and Nutrition Examination Survey (2010–2014). The study performed multivariate logistic regression analyses for three education levels and four indicators of socioeconomic status (i.e., marital status, residential area, occupation, and income). Results The overall prevalence of obesity was 38.1% in men and 29.1% in women (p < 0.001). In men, while education functioned as an effect modifier in the association between marital status and obesity (p for interaction = 0.006), it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction < 0.001) in the association between residential area and obesity. In contrast, in women, education functioned as a confounder in the association of residential area with obesity (p = 0.010). However, it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction = 0.012) in the association between income and obesity. A prediction showed that unlike in women, education was positively associated with obesity risk for some socioeconomic indicator groups in men; for example, in a rural resident group, a higher level of education increased the probability of being obese by 19.7%. Conclusions The present study suggests the need to examine sex-specific studies regarding the role of education on the association between other socioeconomic status indicators and obesity. This should be considered in planning education policies to reduce the risk of obesity.

Purpose Diabetes mellitus (DM) is a global pandemic metabolic disorder. In recent years, the amount of medical resources required for the treatment of diabetes has increased as diabetes rates have gradually risen. The combined effects of individual and neighbourhood socio-economic status (SES) on DM survival rates are still not clear, especially in patients of working age. In this paper, we aim to analyze the combined effects of neighbourhood and individual SES on DM survival rates in patients of working age in Taiwan. Methods The study of 23,781 people who were diagnosed with DM by using population—based study between 2002 and 2006. Each sample was followed up for 4 years or as a sensor case. We defined Individual SES and neighbourhood SES by each patient’s job category and household income which characterized as advantaged or disadvantaged. Then we compared the survival rates by SES group used Cox proportional hazards model for adjust risk factors. Results The 4-year overall survival rates of diabetic patients were worst for those with low individual SES who living in advantaged neighbourhoods. After adjustment for patient characteristics, DM patients with high individual SES living in disadvantaged neighbourhoods had the same risk of mortality as those patients with high individual SES living in advantaged neighbourhoods (hazard ratio: 1.11; 95% confidence interval [CI]: 0.81–1.51). The study found that DM patients with low individual SES who live in disadvantaged areas had a greater risk of mortality than those with high SES (odds ratio: 2.57; 95% CI: 2.04–3.24). There were significant differences in survival rates between patients with high individual SES and patients with low individual SES. In contrast, the results did not statistically significant differences in survival rates between advantaged and disadvantaged neighbourhood SES groups. Conclusion DM patients with low individual SES had the worst survival rate, regardless of whether they were living in a high or low SES neighbourhood area. The competitive cause of death, i.e., the fact that complications, rather than DM itself, are often the cause of death, may be the reason for the inverse relationship found between the effects of individual SES and neighbourhood SES on DM survival. We conclude that the socio-economic gradient in survival among DM patients may be the result of differences in access to medical treatment and attributes related to individual SES.

Background Around the world, regulatory bodies have taken the lead in determining the competencies required to become a physician. As a first step in addressing this project, it was decided to develop a set of core competencies that were unique to China and that might serve as a basis for medical education. The purpose of this paper was to construct a competency model for clinical physicians in China. Methods Data was collected using a cross-sectional survey of 6247 clinicians from seven administrative regions (31 provinces, autonomous regions and municipalities directly under the central government) in China. The total sample was randomly divided into two sub-samples, an initial sample (Sample 1) and a replication sample (Sample 2). Independent exploratory factor analysis was conducted in each sample and the results were compared to determine the stability. After that the confirmatory factor analysis was used to ascertain the competency model for physicians. The reliability, convergent and discriminant validity of competency-based instrument were also examined. Results 76 items with 8 dimensions were identified, accounting for 68.41% of the construct’s total variance in the initial sample and 67.47% in the replication sample. For the two samples, the overall scale reliability (Cronbach’s alpha) was both 0.985 with dimensions from 0.905 to 0.954 for the initial sample and from 0.902 to 0.955 for the replication sample after deleting the items. In confirmatory factor analysis, the result showed that all items had acceptable goodness of fit index. RMSEA and SRMR were less than 0.08 (RMSEA = 0.046, SRMR = 0.040), while GFI, NFI, IFI, and CFI were higher than 0.9 (GFI = 0.905, NFI = 0.903, IFI = 0.909, CFI = 0.909), leading to acceptable construct validity. All construct reliability values of the factors were higher than 0.70, and all average variance extracted values exceeded 0.50. Thus, we considered the reliability and validity of the 8 dimensions were acceptable. Conclusions The instrument was shown to be both valid and reliable for measuring clinical physicians’ competency in China. The results of the competency-based instrument can be used by ministry of health and administrators of hospitals to assess physicians’ competencies, encourage and guide them to modify their behaviors according to the evaluation criteria, and also cultivate physicians with strong clinical practice, innovation and independent scientific research ability. Through these measurements and understandings, the overall level of clinical physicians will be increased in China.

Background In this paper, we report findings regarding the prevalence of expressed distress and depressive conditions among women living in a rural region of Sichuan Province. As well, we know of no data among women in rural China that examine whether “depression,” as categorically defined in classifications such as the DSM, adequately captures the expressed distress and symptomatic complaints of women in rural China. Methods A multistage sampling method was employed to recruit the target population. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure distress symptoms, and MINI International Neuropsychiatric Interview (MINI) was employed to determine the prevalence of diagnosable depression and other disorders. Results Among 1898 rural women, 12.4% (236) scored ≥16 on the CES-D, indicative of distress, and a subset of 7.7% (146) had scores ≥21, highly suggestive of a clinically significant disorder. We found that 49.8% women with ≥16 CES-D score were identified as showing features consistent with a current major depressive episode (MDE) vs. 1.9% in a sample of randomly selected women with