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Background: Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting. Methods: A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes. Conclusions: Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic inequalities in cardiovascular (CVD) health outcomes are well documented. While Russia has one of the highest levels of CVD mortality in the world, the literature on contemporary socio-economic inequalities in biomarker CVD risk factors is sparse. This paper aims to assess the extent and the direction of SEP inequalities in established physiological CVD risk biomarkers, and to explore the role of lifestyle factors in explaining SEP inequalities in physiological CVD risk biomarkers. Methods: We used cross-sectional data from a general population-based survey of Russians aged 35-69 years living in two cities (n = 4540, Know Your Heart study 2015-18). Logistic models were used to assess the associations between raised physiological risk biomarkers levels (blood pressure levels, cholesterol levels, triglycerides, HbA1C, and C-reactive protein) and socioeconomic position (SEP) (education and household financial constraints) adjusting for age, obesity, smoking, alcohol and health-care seeking behavior. Results: High education was negatively associated with a raised risk of blood pressure (systolic and diastolic) and C-reactive protein for both men and women. High education was positively associated with total cholesterol, with higher HDL levels among women, and with low triglycerides and HbA1c levels among men. For the remaining risk biomarkers, we found little statistical support for SEP inequalities. Adjustment for lifestyle factors, and particularly BMI and waist-hip ratio, led to a reduction in the observed SEP inequalities in raised biomarkers risk levels, especially among women. High financial constraints were weakly associated with high risk biomarkers levels, except for strong evidence for an association with C-reactive protein (men). Conclusions: Notable differences in risk biomarkers inequalities were observed according to the SEP measure employed. Clear educational inequalities in raised physiological risk biomarkers levels, particularly in blood pressure and C-reactive protein were seen in Russia and are partly explained by lifestyle factors, particularly obesity among women. These findings provide evidence-based information on the need for tackling health inequalities in the Russian population, which may help to further contribute to CVD mortality decline. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels. Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015–16, India. The sample size of this study was 148,145 women aged 15–49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization. Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only. Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels. [ABSTRACT FROM AUTHOR]

Background: Prenatal care coverage is still not universal or adequately provided in many low and middle income countries. One of the main barriers regards the presence of socioeconomic inequalities in prenatal care utilization. In Brazil, prenatal care is supplied for the entire population at the community level as part of the Family Health Strategy (FHS), which is the main source of primary care provided by the public health system. Brazil has some of the greatest income inequalities in the world, and little research has been conducted to investigate prenatal care utilization of FHS across socioeconomic groups. This paper addresses this gap investigating the socioeconomic and regional differences in the utilization of prenatal care supplied by the FHS in the state of Minas Gerais, Brazil. Methods: Data comes from a probabilistic household survey carried out in 2012 representative of the population living in urban areas in the state of Minas Gerais. The sample size comprises 1,420 women aged between 13 and 45 years old who had completed a pregnancy with a live born in the last five years prior to the survey. The outcome variables are received prenatal care, number of antenatal visits, late prenatal care, antenatal tests, tetanus immunization and low birthweight. A descriptive analysis and logistic models were estimated for the outcome variables. Results: The coverage of prenatal care is almost universal in catchment urban areas of FHT of Minas Gerais state including both antenatal visits and diagnostic procedures. Due to this high level of coverage, socioeconomic inequalities were not observed. FHS supplied care for around 80% of the women without private insurance and 90% for women belonging to lower socioeconomic classes. Women belonging to lower socioeconomic classes were at least five times more likely to receive antenatal visits and any of the antenatal tests by the FHS compared to those belonging to the highest classes. Moreover, FHS was effective in reducing low birthweight. Women who had prenatal care through FHS were 40% less likely to have a child with low birthweight. Conclusion: This paper presents strong evidence that FHS promotes equity in antenatal care in Minas Gerais, Brazil. [ABSTRACT FROM AUTHOR]

Background: Lesbian, gay and bisexual (LGB) people often face individual- and system-level barriers in health care. However, LGB people's experiences of health care in non-European and non-American settings have been scarcely studied. In China, while it has been estimated that there are at least 70 million gender and sexual minorities, there has been no larger-scale study on LGB people's experiences of health care beyond a focus on gay men and HIV. This study is the first larger-scale quantitative study to investigate LGB people's experiences of health care in China, where non-heterosexuality is officially silenced and the needs of non-heterosexual people are largely ignored by service providers. Methods: An online survey was designed in joint partnership by academic, community groups and the United Nations Development Programme. Targeted and snowball sampling was adopted for participant recruitment. Such unique cross-sectoral partnership made this research possible in the authoritarian state of China where data collection on LGB people is extremely rare. For the analysis in this paper, a sample of 15,611 Chinese LGB people were included. Frequency and descriptive statistics were conducted to describe the LGB respondents' demographic characteristics and their experiences in health care settings. Chi-square tests were conducted to test how experiences vary across LGB people with different demographic characteristics. Results: More than three quarters of the respondents said they would be willing to disclose to their medical care providers their sexual orientation if asked. However, only 5.7% of the respondents said that medical care providers ever asked them about their sexual orientation. About 8.0% of the LGB people surveyed reported having experienced negative treatment in medical care settings. Six percent (5.7%) of the Chinese LGB people said in accessing mental health care services, they were recommended, coaxed into, or provided conversion therapy for sexual orientation, gender identity or gender expression. Conclusions: There is a strong need to enhance LGB cultural competence among health care providers. Policymakers in China should also formulate laws, policies, regulations, clearly articulated codes of conduct, and transparent procedures and practices to ensure non-discrimination of LGB people in the health care system, with a particular focus on banning conversion therapy. [ABSTRACT FROM AUTHOR]

Background: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. Methods: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. Results: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. Conclusions: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment. [ABSTRACT FROM AUTHOR]

Background: To describe the relationship between longevity and local access to preventive healthcare at the county level. Methods: We used Medicare outpatient reimbursement data from the 2010 Dartmouth Health Atlas and longevity data from Chetty et al. (2016) to identify the cross-sectional associations between county longevity, access to outpatient care, and the quality of primary care. Results: We find that the cost of outpatient care is inversely correlated with area life expectancy for individuals in the bottom income quartile. Much of this correlation is driven by men in the bottom income quartile. We also find that disaggregating a preventive care index produces significant relationships between components of the index and longevity where none were previously found. Conclusions: These results counter prior assertions that local health costs are not associated with life expectancy. Additionally, the results also suggest that the local cost of outpatient care and the quality of that care may influence the longevity of low-income populations, especially for low-income men. [ABSTRACT FROM AUTHOR]

In this study, we evaluated and forecasted the cumulative opportunities for residents to access radiotherapy services in Cali, Colombia, while accounting for traffic congestion, using a new people-centred methodology with an equity focus. Furthermore, we identified 1–2 optimal locations where new services would maximise accessibility. We utilised open data and publicly available big data. Cali is one of South America's cities most impacted by traffic congestion. Methodology: Using a people-centred approach, we tested a web-based digital platform developed through an iterative participatory design. The platform integrates open data, including the location of radiotherapy services, the disaggregated sociodemographic microdata for the population and places of residence, and big data for travel times from Google Distance Matrix API. We used genetic algorithms to identify optimal locations for new services. We predicted accessibility cumulative opportunities (ACO) for traffic ranging from peak congestion to free-flow conditions with hourly assessments for 6–12 July 2020 and 23–29 November 2020. The interactive digital platform is openly available. Primary and secondary outcomes: We present descriptive statistics and population distribution heatmaps based on 20-min accessibility cumulative opportunities (ACO) isochrones for car journeys. There is no set national or international standard for these travel time thresholds. Most key informants found the 20-min threshold reasonable. These isochrones connect the population-weighted centroid of the traffic analysis zone at the place of residence to the corresponding zone of the radiotherapy service with the shortest travel time under varying traffic conditions ranging from free-flow to peak-traffic congestion levels. Additionally, we conducted a time-series bivariate analysis to assess geographical accessibility based on economic stratum. We identify 1–2 optimal locations where new services would maximize the 20-min ACO during peak-traffic congestion. Results: Traffic congestion significantly diminished accessibility to radiotherapy services, particularly affecting vulnerable populations. For instance, urban 20-min ACO by car dropped from 91% of Cali's urban population within a 20-min journey to the service during free-flow traffic to 31% during peak traffic for the week of 6–12 July 2020. Percentages represent the population within a 20-min journey by car from their residence to a radiotherapy service. Specific ethnic groups, individuals with lower educational attainment, and residents on the outskirts of Cali experienced disproportionate effects, with accessibility decreasing to 11% during peak traffic compared to 81% during free-flow traffic for low-income households. We predict that strategically adding sufficient services in 1–2 locations in eastern Cali would notably enhance accessibility and reduce inequities. The recommended locations for new services remained consistent in both of our measurements. These findings underscore the significance of prioritising equity and comprehensive care in healthcare accessibility. They also offer a practical approach to optimising service locations to mitigate disparities. Expanding this approach to encompass other transportation modes, services, and cities, or updating measurements, is feasible and affordable. The new approach and data are particularly relevant for planning authorities and urban development actors. [ABSTRACT FROM AUTHOR]

Background: The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children. Methods: We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities. Results: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity. Conclusions: Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children. [ABSTRACT FROM AUTHOR]

Background: To appreciate dental care utilization in ‌the context of socio-economic inequalities, it is imperative to identify sources of inequalities and evaluate the extent to which dental care utilization is still related to socio-economic status. This study aimed to quantify the influence of contributed determinants on dental care utilization in the context of socio-economic inequalities amongst adults residing in Tehran metropolis. Methods: In this cross-sectional community-based study, a stratified random sample of 1,510 subjects aged over 18 years was investigated by the zero-inflated Poisson analysis to measure the effect of determinants on utilization of dental care, and concentration index as well as the decomposition approach to identify the contributions of deterministic variables to the socio-economic inequality. Data was obtained by employing a phone interview survey. Individuals who were not willing or able to answer the questions in the telephone interview due to hearing or neurological problems did not participate in the interview. Dental care utilization was measured using the number of dental appointments. Results: Gender (male), oral health-related behaviors (such as brushing and dental flossing), experience of toothache, and concern about dental appearance were associated with an increased likelihood of utilizing dental care. Individuals who belonged to advanced age groups and lived alone significantly underutilized dental care. The concentration index equaling 0.05 (SE = 0.05) corroborates a pro-rich inequality. Decomposition analysis demonstrated the impact of oral health-related behaviors (i.e. dental brushing and use of dental flossing), concern about dental appearance, toothache, gender (male), insurance coverage of dental care, and smoking habit on the poor-rich gap in the dental care utilization. Conclusions: The influence of socio-economic inequalities on dental care utilization is discernable along the entire spectrum of socio-economic status. Individuals with lower socio-economic status experience more underutilization of dental care. Community subgroups, particularly the more deprived bracket, require consideration from key stakeholders, including policymakers and health professionals for the enhancement of dental care utilization as revealed by underlying determinants. [ABSTRACT FROM AUTHOR]

Background: Although it is widely acknowledged that access to civil justice (ATJ) is a key social determinant of health (SDOH), the existing literature lacks empirical evidence supporting ATJ as a SDOH for specific dimensions of health. Methods: A legal epidemiological, cross-sectional, postal survey was conducted on n = 908 randomly sampled participants in Hong Kong in March 2023. Data collected were perceptions of the civil justice system, health, and sociodemographics. Perceived ATJ was assessed using a modified version of the Inaccessibility of Justice scale (IOJ) and Perceived Inequality of Justice scale (PIJ), i.e. the "modified IOJ-PIJ", consisting of 12 of the original 13 items from both scales divided into two subdomains: "procedural fairness", and "outcome neutrality". For health data, quality of life was assessed using the Hong Kong version of the Abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-BREF(HK)), psychological distress (including symptoms of anxiety and depression) was assessed using the four-Item Patient Health Questionnaire (PHQ-4), and having comorbidities was assessed using Sangha's Self-Administered Comorbidity Questionnaire (SCQ). Structural equation modelling (SEM) was used to investigate the relationships between perceived ATJ and the measured health outcomes. Results: SEM demonstrated that both subdomains for ATJ had significantly negative associations (B < 0; p < 0.05) with all quality-of-life subdomains, except for between outcome neutrality with social relationships; both subdomains for ATJ had significantly positive association (B > 0; p < 0.05) with both anxiety and depression; and, after adjusting for age, only "procedural fairness" had significantly positive association (B > 0; p < 0.05) with having comorbidities. Conclusion: This study provided empirical evidence that ATJ is a SDOH for specific dimensions of health. The results of this study encourage laws, policies, and initiatives aimed at improving ATJ, as well as collaborative efforts from the legal and health sectors through health-justice partnerships, and from the broader community, to safeguard and promote public health by strengthening ATJ. [ABSTRACT FROM AUTHOR]

Background: Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons' healthcare disparities in Uganda. Therefore, this paper aimed at investigating factors associated with older persons' healthcare access in Uganda, using a nationally representative sample. Methods: We conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. We used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations. We fit generalized linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. Results: More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households (RR = 0.91, 95% CI: 0.83-0.99); with some walking difficulty (RR = 0.90, 95% CI: 0.83-0.97); or with a lot of walking difficulty (RR = 0.84, 95% CI: 0.75-0.95). Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages (RR = 1.08, 95% CI: 1.00-1.15) and missed work due to illness for 1-7 days (RR =1.19, 95% CI: 1.10-1.30); and 8-14 days (RR = 1.19, 95% CI: 1.07-1.31). In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes (RR= 1.09, 95% CI: 1.01-1.16); were more likely to access healthcare during the last 30 days. Conclusion: In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility imitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons. [ABSTRACT FROM AUTHOR]

Background Many countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania. Methods Using household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider. Results Generally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members. Conclusions Reducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity. [ABSTRACT FROM AUTHOR]

Background: Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. Methods: Using a cross-sectional survey across four of South Africa's nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. Results: A quarter of respondents remained uninsured, even higher among 20-29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. Conclusions: By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country's financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole. [ABSTRACT FROM AUTHOR]

Background: In a context of population ageing, it is a priority for planning and prevention to understand the socioeconomic (SE) patterning of functional limitations and its consequences on healthcare needs. This paper aims at measuring the gender and SE inequalities in functional limitations and their age of onset among the Southern European elderly; then, we evaluate how functional status is linked to formal and informal care use. Methods: We used Portuguese, Italian and Spanish data from the Survey of Health, Ageing and Retirement in Europe (SHARE) of 2011 (n = 9233). We constructed a summary functional limitation score as the sum of two variables: i) Activities of Daily Living (ADL) and ii) Instrumental Activities of Daily Living (IADL). We modelled the functional limitation as a function of age, gender, education, subjective poverty, employment and marital status using multinomial logit models. We then estimated how functional limitation affected informal and formal care demand using negative binomial and logistic models. Results: Women were 2.3 percentage points (pp) more likely to experience severe functional limitation than men, and overcame a 10% probability threshold of suffering from severe limitation around 5 years earlier. Subjective poverty was associated with a 3.1 pp. higher probability of severe functional limitation. Having a university degree reduced the probability of severe functional limitation by 3.5 pp. as compared to none educational level. Discrepancies were wider for the oldest old: women aged 65-79 years old were 3.3 pp. more likely to suffer severe limitations, the excess risk increasing to 15.5 pp. among those older than 80. Similarly, educational inequalities in functional limitation were wider at older ages. Being severely limited was related with a 32.1 pp. higher probability of receiving any informal care, as compared to those moderately limited. Finally, those severely limited had on average 3.2 hospitalization days and 4.6 doctor consultations more, per year, than those without limitations. Conclusion: Functional limitations are unequally distributed, hitting women and the worse-off earlier and more severely, with consequences on care needs. Considering the burden on healthcare systems and families, public health policies should seek to reduce current inequalities in functional limitations. [ABSTRACT FROM AUTHOR]

Background: Supplemental private health insurance (PHI) plays a crucial role in complementing China's social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system. Methods: Data from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences. Results: Among UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities. Conclusion: The findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases (NCDs) are high on the priority list of the Kerala government, and exploring the extent to which transgender and gender diverse (TGD) community members benefit from the services of national programmes for NCDs can provide valuable insights on improving the inclusivity of the health system as it moves towards Universal Health Coverage. This study was conducted to explore the prevalence of NCD risk factors as well as facilitators and barriers to NCD management among the TGD population in Kerala. Methods: A multiple methods study, including a cross-sectional survey of 120 self-identifying TGD people that included an adaptation of the WHO STEPS questionnaire, as well as in-depth interviews with thirteen individuals, was conducted in three districts of Kerala to explore the barriers and facilitators to NCD prevention and management. Results: The results are presented using the key dimensions emerging out of the Diederichsen framework. A range of discrimination faced by TGD people in Kerala traps them in situations of low educational outcomes with consequent disadvantages in the job market when they search for livelihoods. This results in a large proportion of our sample living away from families (69 percent), and finding themselves in precarious jobs including sex work (only 33 percent had a regular job), with all these aforementioned factors converging to marginalise their social position. This social position leads to differential risk exposures such as increased exposure to modifiable risk factors like alcohol (40 percent were current alcohol users) and tobacco use (40.8 percent currently used tobacco) and ultimately metabolic risk factors too (30 and 18 percent were hypertensive and diabetic respectively). Due to their differential vulnerabilities such as the discrimination that TGD people are subjected to (41.7 percent had faced discrimination at a healthcare centre in the past one year), those with higher exposure to risk factors often find it hard to bring about behavioural modifications and are often not able to access the services they require. Conclusions: The disadvantaged social position of TGD people and associated structural issues result in exacerbated biological risks, including those for NCDs. Ignoring these social determinants while designing health programmes is likely to lead to sub-optimal outcomes. [ABSTRACT FROM AUTHOR]

Background: Young people (aged 10 to 24 years) in sub-Saharan Africa bear a huge and disproportionate burden of poor sexual and reproductive health (SRH) outcomes due to inequalities and discrimination in accessing sexual and reproductive health services (SRHS). This study assessed the experiences and perceptions of discrimination among young people seeking SRH services in Primary Health Centers (PHCs) using an intersectionality lens. Methods: A cross-sectional mixed-methods study was undertaken in six local government areas (LGAs) in Ebonyi State, southeast Nigeria. The LGAs comprise both urban and rural locations. The study population for the quantitative survey consisted of 1025 randomly selected young boys and girls aged 15–24 years. Eleven focus group discussions (FGDs) were conducted with the young people. Descriptive and inferential analyses were performed for quantitative data, while thematic analysis was performed for the qualitative data, using NVivo. Results: A total of 16.68% participants in the survey reported that young girls/women were treated badly/unfairly compared to young boys/men when seeking SRH services in PHCs; 15.22% reported that young clients get treated badly/unfairly from adults; and 12.49% reported that young clients with poor economic status were treated unfairly. Respondents also reported that young clients with disability (12.12%), and those who are poorly educated or uneducated (10.63%) are treated badly by healthcare providers when they access SRH services. Young people in urban areas were about 7 times more likely to believe that girls/young women are treated badly than boys/young men when seeking SRH services in PHCs compared to those who live in rural areas (p < 0.001). Among the young girls/women, residing in urban areas, being poor and in school increased the likelihood of getting treated badly/unfairly when receiving SRH services by 4 times (p < 0.001). The qualitative results revealed that health workers were generally harsh to young people seeking SRH services and the level of harshness or unfriendliness of the health workers varied depending on the young person's social identity. Conclusion: There are varieties of intersecting factors that contribute to the discrimination of young clients in PHCs. This underscores the urgent need to prioritize intersectional perspectives in the design and implementation of interventions that will improve access and use of SRH services by young people. [ABSTRACT FROM AUTHOR]

Background: Family caregivers are vital for long-term care for persons with serious health-related suffering in Kerala. Long-term caregiving and ageing may become burdensome and detrimental to patients and caregivers. We compared the caregiver burden and quality-of-life of ageing caregivers with younger caregivers. We also explored the palliative care nurses' perceptions of the family caregivers' issues. Methods: We did a mixed method study focusing on two groups: (i) three in-depth interviews and a cross-sectional survey among 221 caregivers of palliative care patients in five randomly selected panchayats (most peripheral tier of three-tier local self-government system in India concerned with governance of a village or small town) of Kollam district, Kerala, as part of development and validation of the Achutha Menon Centre Caregiver Burden Inventory; (ii) five in-depth interviews with purposively selected primary palliative care nurses as part of a study on local governments and palliative care. We used a structured interview schedule to collect cross-sectional data on sociodemographic and caregiving-related characteristics, caregiver burden, and health-related quality of life using the EuroQol EQ5D5L and interview guidelines on caregiver issues tailored based on participant type for qualitative interviews. Results: Older caregivers comprised 28.1% of the sample and had significantly poorer health and quality-of-life attributes. More senior caregivers experiencing caregiver burden had the lowest mean scores of 0.877 (Standard deviation (SD 0.066, 95% confidence intervals (CI) 0.854–0.899) followed by younger caregivers with high burden (0.926, SD 0.090, 95% CI 0.907–0.945), older caregivers with low burden (0.935, SD 0.058, 95% CI 0.912–0.958) and younger caregivers with low burden (0.980, SD 0.041, 95% CI 0.970–0.990). Caregivers faced physical, psychological, social, and financial issues, leading to a caregiver burden. The relationships between the palliative care nurses and family caregivers were complex, and nurses perceived caregiver burden, but there were no specific interventions to address this. Conclusion: In our study from Kollam, Kerala, three out of ten caregivers of palliative care patients were 60 years of age or older. They had significantly lower health-related quality of life, particularly if they perceived caregiver burden. Despite being recognized by palliative care nurses, caregiver issues were not systematically addressed. Further research and suitable interventions must be developed to target such problems in the palliative care programme in Kerala. [ABSTRACT FROM AUTHOR]

Background: In South Korea, Korean Chinese workers experience ethnic discrimination although they share physical similarities and ethnic heritage with native-born Koreans. This study aimed to examine whether perceived ethnic discrimination is associated with poor self-rated health and whether the association differs by gender among Korean Chinese waged workers in South Korea. Methods: We conducted a pooled cross-sectional analysis using data of 13,443 Korean Chinese waged workers from the Survey on Immigrants' Living Conditions and Labor Force conducted in 2018, 2020, and 2022. Based on perceived ethnic discrimination, asking for fair treatment, and subsequent situational improvement, respondents were classified into the following four groups: "Not experienced," "Experienced, not asked for fair treatment," "Experienced, asked for fair treatment, not improved," and "Experienced, asked for fair treatment, improved." Poor self-rated health was assessed using a single question "How is your current overall health?" We applied logistic regression to examine the association between perceived ethnic discrimination and poor self-rated health, with gender-stratified analyses. Results: We found an association between ethnic discrimination and poor self-rated health among Korean Chinese waged workers. In the gender-stratified analysis, the "Experienced, not asked for fair treatment" group was more likely to report poor self-rated health compared to the "Not experienced" group, regardless of gender. However, gender differences were observed in the group stratified by situational improvements. For male workers, no statistically significant association was found in the "Experienced, asked for fair treatment, improved" group with poor self-rated health (odd ratios: 0.87, 95% confidence intervals: 0.30–2.53). Conversely, among female workers, a statistically significant association was observed (odd ratios: 2.63, 95% confidence intervals: 1.29–5.38). Conclusions: This study is the first to find an association between perceived ethnic discrimination and poor self-rated health, along with gender differences in the association between situational improvements after asking for fair treatment and poor self-rated health among Korean Chinese waged workers in South Korea. [ABSTRACT FROM AUTHOR]

Background: Water, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area. Methods: In this cross-sectional binational study, we interviewed PWID (age 18+) in 2020–2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates. Results: Of 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02–2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28–1.64), and bathing (aRR: 1.21, 95%CI: 1.06–1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07–3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52–2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55–6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36–4.89) than participants living in permanent housing. Conclusion: WASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID—especially those who are unsheltered. [ABSTRACT FROM AUTHOR]

Introduction: Equitable access to health care is a key health systems goal, and is a particular concern in low-income countries. In Kenya, public facilities are an important resource for the poor, but little is known on the equity of service provision. This paper assesses whether poorer areas have poorer health services by investigating associations between public facility characteristics and the poverty level of the area in which the facility is located. Methods: Data on facility characteristics were collected from a nationally representative sample of public health centers and dispensaries across all 8 provinces in Kenya. A two-stage cluster randomized sampling process was used to select facilities. Univariate associations between facility characteristics and socioeconomic status (SES) of the area in which the facility was located were assessed using chi-squared tests, equity ratios and concentration indices. Indirectly standardized concentration indices were used to assess the influence of SES on facility inputs and service availability while controlling for facility type, province, and remoteness. Results: For most indicators, we found no indication of variation by SES. The clear exceptions were electricity and laboratory services which showed evidence of pro-rich inequalities, with equity ratios of 3.16 and 3.43, concentration indices of 0.09 (p<0.01) and 0.05 (p=0.01), and indirectly standardized concentration ratios of 0.07 (p<0.01) and 0.05 (p=0.01). There were also some indications of pro-rich inequalities for availability of drugs and qualified staff. The lack of evidence of inequality for other indicators does not imply that availability of inputs and services was invariably high; for example, while availability was close to 90% for water supply and family planning services, under half of facilities offered delivery services or outreach. Conclusions: The paper shows how local area poverty data can be combined with national health facility surveys, providing a tool for policy makers to assess the equity of input and service availability. There was little evidence of inequalities for most inputs and services, with the clear exceptions of electricity and laboratory services. However, efforts are required to improve the availability of key inputs and services across public facilities in all areas, regardless of SES. [ABSTRACT FROM AUTHOR]

Background: Adverse Childhood Experiences (ACEs) have been linked to an increased risk of health and social problems throughout life. Studies on gender differences from developing countries are scarce. In this paper, we will examine gender variations in the types of reported ACEs and gender-specific relationships between cumulative ACEs and physical and mental health, and Risky Health Behaviors (RHB) in adulthood in the Kingdom of Saudi Arabia (KSA). Methods: A cross sectional national study was conducted in all of the 13 regions in KSA in 2013 using the ACE-International Questionnaire (ACE-IQ). We used multivariate logistic regression to examine the relationship between 4 +ACEs and physical, mental health and RHBs for both men and women separately after adjusting for age, education, marital status and current employment. Results: The total number of participants was 10,156 and women comprised 48% of the sample. The majority of respondents (80%) reported at least one ACE. Women had higher percentages of < =2 ACEs (65% vs 55%; p <0.05) while men were more likely to have 4+ ACEs (33% vs 25%; p < 0.05). When compared to participants with 0 ACE, men who reported 4+ ACEs were associated with the highest likelihood of using drugs (OR = 9.7; 95% CI: 6.4-14.5) and drinking alcohol (OR = 9.2; 95% CI: 6.3-13.6). On the other hand, women who experienced 4+ ACEs were associated with the highest likelihood of depression (OR = 7.0; 95% CI: 5.2-9.4), anxiety (OR = 6.4; 95% CI: 5.0-8.2) and other mental illnesses (OR = 7.4; 95% CI: 5.2-10.6). As for chronic diseases, abused men and women in childhood showed similarly a twofold increased risk of developing diabetes, hypertension, coronary heart disease and obesity when compared to non-abused participants. Conclusion: Findings highlight the need to consider gender specific differences in the development of preventive strategies to address ACEs in KSA. [ABSTRACT FROM AUTHOR]

Background: Several studies suggest that socioeconomic status affects (SES) affects self-rated health (SRH), both in Greece and internationally. However, prior research mainly uses objective measures of SES, instead of subjective evaluations of individuals' social status. Based on this, this paper aims to examine (a) the impact of the economic downturn on SRH in Greece and (b) the relationship between subjective social status (SSS), social network and SRH. Methods: The descriptive analysis is based on four cross-sectional surveys conducted by the National School of Public Health, Athens, Greece (2002, 2006, 2011, 2015), while the data for the empirical investigation were derived from the 2015 survey (Health + Welfare Survey GR). The empirical strategy is based on an ordinal logistic regression model, aiming to examine how several variables affect SRH. Size of social network and SSS are among the independent variables employed for the empirical analysis Results: According to our findings, average SRH has deteriorated, and the percentage of the population that reports very good/good SRH has also decreased. Moreover, our empirical analysis suggests that age, existence of a chronic disease, size of social network and SSS affect SRH in Greece. Conclusion: Our findings are consistent with the existing literature and confirm a social gradient in health. According to our analysis, health disparities can be largely attributed to socioeconomic inequalities. The adverse economic climate has impact on socioeconomic differences which in turn affect health disparities. Based on these, policy initiatives are necessary in order to mitigate the negative impact on health and the disparities caused by economic downturn and the occuring socioeconomic inequalities. [ABSTRACT FROM AUTHOR]

Background: Inequalities in demographic, socio-economic and health status for China labor force place them at greater health risks, and marginalized them in the utilization of healthcare services. This paper identifies the inequalities which limit the utilization of health services among China labor force, and provides a reference point for health policy. Methods: Data were collected from 23,505 participants aged 15 to 65, from the 2014 China Labor Force Dynamic Survey (a nationwide cross-sectional survey covering 29 provinces with a multi-stage cluster, and stratified, probability sampling strategy) conducted by Sun Yat-sen University. Logistic regression models were used to study the effects of demographic (age, gender, marital status, type of hukou and migration status), socio-economic (education, social class and insurance) and health status (self-perceived general health and several chronic illnesses) variables on the utilization of health services (two-week visiting and hospitalization during the past 12 months). Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating curve (AUC). Results: Migrants with more than 1 (OR 2.80, 95% CI 1.01 ~ 7.82) or none chronic illnesses (OR 1.26, 95% CI 1.01 ~ 7.82) are more likely to be two week visiting to the clinic than non-migrants; migrants with none chronic illnesses (OR 0.61, 95% CI 0.45 ~ 0.82) are less likely to be in hospitalization during the past 12 months than non-migrants. Female, elder, hukou of non-agriculture, higher education level, higher social class, purchasing more insurance and poorer selfperceived health were predictors for more utilization of health service. More insurance benefited more two-week visiting (OR 1.12, 95% CI 1.06 ~ 1.17) and hospitalization during the past 12 months (OR 1.12, 95% CI 1.07 ~ 1.18) for individuals with none chronic illness but not ≥1 chronic illnesses. All models achieved good calibration (Hosmer-Lemeshow test's P range of 0.258-0.987) and discrimination (AUC range of 0.626-0.725). Conclusions: This study has shown that there are inequalities of demographic, socio-economic and health status in the utilization of health services for China labor force. Prudent health policy with equitable utilization of health services eliminating mentioned inequalities should be a priority in shaping China's healthcare system reform. [ABSTRACT FROM AUTHOR]

Introduction: Diet is a major risk factor for non-communicable diseases (NCDs) and is also strongly patterned by socioeconomic factors. Whether interventions promoting healthy eating reduce social inequalities in diet in low- and middle-income countries (LMICs) remains uncertain. This paper aims to summarize current evidence on interventions promoting healthy eating in LMICs, and to establish whether they reduce social inequalities in diet. Methods: Systematic review of cross-sectional or quasi-experimental studies (pre- and post-assessment of interventions) in Pubmed, Scielo and Google Scholar databases, including adults in LMICs, assessing at least one outcome of healthy eating and showing results stratified by socioeconomic status. Results: Seven intervention studies including healthy eating promotion, conducted in seven LMICs (Brazil, Chile, Colombia, Iran, Panama, Trinidad and Tobago, and Tunisia), met our inclusion criteria. To promote healthy eating, all interventions used nutrition education and three of them combined nutrition education with improved acces to foods or social support. Interventions targeted mostly women and varied widely regarding communication tools and duration of the nutrition education sessions. Most interventions used printed material, media use or face-to-face training and lasted from 6 weeks to 5 years. Four interventions targeted disadvantaged populations, and three targeted the entire population. In three out of four interventions targeting disadvantaged populations, healthy eating outcomes were improved suggesting they were likely to reduce social inequalities in diet. All interventions directed to the entire population showed improved healthy eating outcomes in all social strata, and were considered as having no impact on social inequalities in diet. Conclusion: In LMICs, agentic interventions promoting healthy eating reduced social inequalities in diet when specifically targeting disadvantaged populations. Further research should assess the impact on social inequalities in diet of a combination of agentic and structural approaches in interventions promoting healthy eating. [ABSTRACT FROM AUTHOR]

Background: Self-rated health (SRH) and socioeconomic position (SEP) as important determinants of health differences are associated with health and economic changes in society. The objectives of this paper were (1) to describe trends in SRH and (2) to analyze associations between SRH and SEP among adults in Estonia in 1996-2014. Methods: The study was based on a 25-64-year-old subsample (n = 18757) of postal cross-sectional surveys conducted every second year in Estonia during 1990-2014. SRH was measured using five-point scale and was dichotomized to good and less-than-good. Standardized prevalence of SRH was calculated for each study year. Poisson regression with likelihood ratio test was performed for testing trends of SRH over study years. Age, nationality, marital status, education, work status and income were used to determine SEP. Logistic regression analysis was used to assess association between SRH and SEP. Results: The prevalence of dichotomized good self-rated health increased significantly over the whole study period with slight decrease in 2008-2010. Until 2002, good SRH was slightly more prevalent among men, but after that, among women. Good SRH was significantly associated with younger age, higher education and income and also with employment status among both, men and women. Good SRH was more prevalent among Estonian women and less prevalent among single men. Conclusions: There was a definite increase of good SRH over two decades in Estonia following economic downturn between 2008 and 2010. Good SRH was associated with higher SEP over the study period. Further research is required to study the possible reasons behind increase of good SRH, and it's association with SEP among adults in Estonia. [ABSTRACT FROM AUTHOR]

Background: Female migrant domestic workers (MDW), approximately 8.5 million globally, often live in their employer's home under vulnerable conditions. In Hong Kong, MDWs currently comprise 5% of the population. This study was conducted to assess the association between employment conditions and mental health, and the mediating roles stress and job satisfaction have, among female MDWs in Hong Kong. Methods: Participants completed an online cross-sectional survey. A total of 1,965 survey were collected between August 2020 and August 2021. Questions in the survey were related to MDWs background information, employment conditions, stress, job satisfaction, and two mental health outcomes: anxiety and depression. An employment conditions score was created to assess the cumulative effect poor employment conditions had on mental health. A multicategorical parallel mediation analysis was used to assess the direct effect employment conditions have on mental health and the indirect effects through stress and job satisfaction. Results: Overall, 17.7% of MDWs were reported to be suffering from anxiety and 30.8% from depression. An increase in poor employment conditions was statistically associated with an increase in both outcomes, while stress levels and job satisfaction mediated this association. Conclusions: The findings call for increased scrutiny of employment conditions and mental well-being of MDWs. [ABSTRACT FROM AUTHOR]

Background: Social health inequalities are still of great public health importance in modern societies. The COVID-19 pandemic may have affected social inequalities in people's health due to containment measures. As these measures particularly affected children, they might have been particularly vulnerable to increased social inequalities. The aim of the study was to describe health inequalities during the pandemic based on language delay (LD) in children in order to inform public health interventions for a population at risk of long-term health and education inequalities. Methods: Data of 5–7 year old children from three consecutive school entry surveys in the German federal state of Brandenburg were used, including data compulsorily collected before the pandemic (2018/2019: n = 19,299), at the beginning of the pandemic (2019/2020: n = 19,916) and during the pandemic (2020/2021: n = 19,698). Bivariate and multivariate binary regression analyses [OR, 95% CI] cross-sectionally examined the relationship between the prevalence of LD [yes/no] and social inequalities, operationalized by family socioeconomic position [SEP low/middle/high], migration background [native-German language/non-native German language] and length of kindergarten attendance [< 4 years/ ≥ 4 years]. Factors contributing to inequality in LD were examined by socioeconomic stratification. Results: Cross-sectionally, LD prevalence has decreased overall (2018/2019: 21.1%, 2019/2020: 19.2%, 2020/2021: 18.8%), and among children from both high SEP and native German-speaking families. As LD prevalence increased among children from families with low SEP and remained stable among non-native German speakers, social inequalities in LD prevalence increased slightly during the pandemic i) by low SEP (2018/2019: OR = 4.41, 3.93–4.94; 2020/2021: OR = 5.12, 4.54–5.77) and ii) by non-German native language (2018/2019: OR = 2.22, 1.86–2.66; 2020/2021: OR = 2.54, 2.19–2.95). During the pandemic, both migration background and kindergarten attendance determined LD prevalence in the high and middle SEP strata. However, the measured factors did not contribute to LD prevalence in children from families with low SEP. Conclusion: Social inequalities in LD increased due to opposing trends in prevalence comparing low and high SEP families. To promote health equity across the life course, early childhood should be of interest for tailored public health actions (e.g. through targeted interventions for kindergarten groups). Further analytical studies should investigate determinants (e.g., parental investment). [ABSTRACT FROM AUTHOR]

Background: Physical inactivity is associated with an increased risk of all-cause mortality and entails a substantial economic burden for health systems. Also, the analysis of inequality in lifestyles for young populations may contribute to reduce health inequalities during adulthood. This paper examines the income-related inequality regarding leisure-time physical inactivity in Spanish children. Methods: In this cross-sectional study based on the Spanish National Health Survey for 2011-12, concentration indices are estimated to measure socioeconomic inequalities in leisure-time physical inactivity. A decomposition analysis is performed to determine the factors that explain income-related inequalities. Results: There is a significant socioeconomic gradient favouring the better-off associated with leisure-time physical inactivity amongst Spanish children, which is more pronounced in the case of girls. Income shows the highest contribution to total inequality, followed by education of the head of the household. The contribution of several factors (education, place of residence, age) significantly differs by gender. Conclusions: There is an important inequity in the distribution of leisure-time physical inactivity. Public policies aimed at promoting physical activity for children should prioritize the action into the most disadvantaged subgroups of the population. As the influence of determinants of health styles significantly differ by gender, this study points out the need of addressing the research on income-related inequalities in health habits from a gender perspective. [ABSTRACT FROM AUTHOR]

Background: Poor mental health contributes to poor HIV prevention, treatment and care outcomes. This paper documents factors associated with psychological distress among men who have sex with men (MSM) in Cambodia and discusses potential ways in which routine mental health management could be integrated into HIV services. Methods: A cross-sectional study was conducted in 2014 among 394 MSM randomly selected from two provinces using a two-stage cluster sampling method. A structured questionnaire was used to assess psychological distress, sexual behaviors, substance use, adverse childhood experiences and family dysfunction. Multivariate logistic regression analysis was performed to explore factors associated with levels of psychological distress. Results: In total, 10.7 % of the respondents reported having suicidal thoughts and 6.6 % reported having attempted to commit suicide in the past three months, while 38.8 % had a higher level of psychological distress (GHQ-12 > 3), which indicates poor mental health. Higher levels of psychological distress were independently associated with older age (AOR = 1.09, 95 % CI 1.03-1.14), alcohol use (AOR = 3.3, 95 % CI 1.36-7.83), illicit drug use (AOR = 3.53, 95 % CI 1.12-11.18), poor self-reported quality of life (AOR = 7.45, 95 % CI 1.79-3.04), and reduced condom use at last sex (AOR = 0.40, 95 % G 0.21-0.73). MSM with higher levels of psychological distress were significantly more likely to report that a family member said hurtful things to them (AOR = 1.80, 95 % O 1.10-2.97), a parent or guardian had been physically abused (AOR = 3.51, 95 % CI 1.86-6.62), and a family member had been mentally ill (AOR = 4.01, 95 % CI 2.06-7.81) when they were growing up. Conclusions: In order to mitigate psychological distress among MSM in Cambodia, integration of mental health interventions within HIV programmes should be strengthened. To achieve optimal impact, these interventions should also address alcohol and other substance use, and low condom use among distressed MSM. In addition, training of clinical and non-clinical HIV service providers to screen for mental health symptoms, and subsequent provision of peer-based outreach and social support for MSM identified with psychological distress is required. [ABSTRACT FROM AUTHOR]

Background: Access to medicines is one of the major challenges in health policy. The high out-of-pocket expenditures on medicines in the Latin American and Caribbean (LAC) region represents important barrier to affordable access to care for NCDs. This paper aim to identify key barriers in access to medicines for household members with a diagnosed chronic condition in three Central America countries. Methods: This was a cross-sectional analytic study, based on data from three household surveys using a common methodology. We examined associated factors to: (1) seeking care for chronic illness from a trained clinician in the formal health system, and (2) obtaining all medicines sought for the chronic conditions reported. Results: A chronic condition was reported in 29.8 % (827) of 2761 households - 47.0, 30.7 and 11.8 % in Nicaragua, Honduras and Guatemala, respectively. The three main chronic conditions reported were hypertension, arthritis, and diabetes. Seeking care in the formal health system ranged from 73.4 % in Nicaragua to 83.1 % in Honduras, while full access to medicines varied from 71.6 % in Guatemala to 88.0 % in Honduras. The main associated factors of seeking care in the formal health system were geographic location, household head gender, Spanish literacy, patient age, perceived health status, perceived quality of public sector care, household economic level, and having health insurance. Seeking care in the formal health system was the main bivariate associated factor of obtaining full access to medicines (OR: 4.3 95 % CI 2.6 - 7.0). The odds of full access to medicines were significantly higher when the household head was older than 65 years, medicines were obtained for free, households had higher socioeconomic status, and health care was sought in the private sector. Conclusions: The nature of the health system plays an important role in access to medicines. Access is better when public facilities are available and function effectively, or when private sector care is affordable. Thus, understanding how people seek care in a given setting and strengthening key health system components will be important strategies to improve access to medicines, especially for populations at high risk of poor access. [ABSTRACT FROM AUTHOR]

Introduction Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. Methods We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness- standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. Results Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). Conclusions The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations. [ABSTRACT FROM AUTHOR]

Background The provision of insecticide-treated nets (ITNs) is widely accepted in Burkina Faso thanks to large-scale national distribution campaigns. However, household also use other methods of prevention. Thus far, there is little knowledge about the expenditures of these malaria prevention methods, particularly in combination with the national interventions. This paper presents the utilization levels and expenditures of malaria prevention tools in Burkina Faso and explores the potential inequality in ownership. Methods The analysis is based on a cross-sectional survey, conducted during the 2010 high transmission season from July to September in the Nanoro Health and Demographic Surveillance Site. Following a systematic sampling technique, the survey covers 500 households with children under 5 years of age from 24 villages. In the survey, households were asked about expenditures on malaria prevention methods in the month preceding the survey. This includes expenditure on coils, indoor spraying, aerosols, repellents, herbs, cleaning of the environment and clearing of the vegetation. The data analysis was conducted with SPSS taking into account the socio-economic status (SES) of the household to examine any differences in the utilization of the prevention method and expenditure quintiles. An asset-based index, created through principal components analysis (PCA), was used to categorize the households into quintiles. Findings Of the households surveyed, 45% used one preventive measure in the past month; 29% used two measures; and 25% used three or more measures. A significant association was found between the number of prevention measures and the SES of the household (p < 0.05). The majority of households owned at least one insecticide treated net (ITN) (98%). Among households that used ITN, 53.8% used methods other than bed nets. The majority of households paid nothing for malaria prevention. Conclusion Most of the households received bed nets and other preventive method for free. There is equity in expenditures across SES groups. Free distribution of ITNs ensured that there was equity in ITN ownership among households. More research on the possibility of increasing access to other locally relevant methods of malaria control that proved to be effective is need. [ABSTRACT FROM AUTHOR]

Introduction Measurement of health inequities is fundamental to all health equity initiatives. It is complex because it requires considerations of ethics, methods, and policy. Drawing upon the recent developments in related specialized fields, in this paper we incorporate alternative definitions of health inequity explicitly and transparently in its measurement. We propose a three-stage approach to measuring health inequities that assembles univariate health inequality, univariate health inequity, and bivariate health inequities in a systematic and comparative manner. Methods We illustrate the application of the three-stage approach using the Joint Canada/United States Survey of Health, measuring health by the Health Utilities Index (HUI). Univariate health inequality is the distribution of the observed HUI across individuals. Univariate health inequity is the distribution of unfair HUI -- components of HUI associated with ethically unacceptable factors -- across individuals. To estimate the unfair HUI, we apply two popular definitions of inequity: "equal opportunity for health" (health outcomes due to factors beyond individual control are unfair), and "policy amenability" (health outcomes due to factors amenable to policy interventions are unfair). We quantify univariate health inequality and inequity using the Gini coefficient. We assess bivariate inequities using a regression-based decomposition method. Results Our analysis reveals that, empirically, different definitions of health inequity do not yield statistically significant differences in the estimated amount of univariate inequity. This derives from the relatively small explanatory power common in regression models describing variations in health. As is typical, our model explains about 20% of the variation in the observed HUI. With regard to bivariate inequities, income and health care show strong associations with the unfair HUI. Conclusions The measurement of health inequities is an excitingly multidisciplinary endeavour. Its development requires interdisciplinary integration of advances from relevant disciplines. The proposed three- stage approach is one such effort and stimulates cross-disciplinary dialogues, specifically, about conceptual and empirical significance of definitions of health inequities. [ABSTRACT FROM AUTHOR]

Background: This study aimed to analyze coronavirus disease 2019 (COVID-19)vaccine policies and effectiveness in Korea, Japan, and Singapore, thereby providing empirical experience for vaccination and response to similar public health emergencies. Methods: The study systematically summarized the COVID-19 vaccine policies in Korea, Japan, and Singapore through public information from the Our World in Data website and the official websites of the Ministries of Health in these three countries.Total vaccinations, COVID-19 vaccination rates, rates of fully vaccinated, rates of boostervaccinated, and total confifirmed cases were selected for cross-sectional comparison of COVID-19 vaccination in these three countries. Combining the basic characteristics of these three countries, daily cases per million, daily deaths per million, and the effective reproduction rate were calculated to measure the effectiveness of COVID-19 vaccine policies implementation in each of these three countries Results: The countermeasures against the COVID-19 in Korea, Japan, and Singapore, although seemingly different on the surface, have all taken an aggressive approach. There are large similarities in the timing of the start of COVID-19 vaccination, the type of vaccine, how vaccine appointments are made, and whether vaccination are free, and all had high vaccination rates. A systematic comparison of the anti-epidemic practices in the three East Asian countries revealed that all three countries experienced more than one outbreak spike due to the spread of new mutant strains after the start of mass vaccination with COVID-19 vaccination, but that vaccination played a positive role in reducing the number of deaths and stabilizing the effective reproduction rate. Conclusions: This study comparatively analyzed the COVID-19 vaccine policies and their effects in South Korea, Japan, and Singapore, and found that there is a common set of logical combinations behind the seemingly different strategies of these three countries. Therefore, in the process of combating COVID-19, countries can learn from the successful experience of combating the epidemic and continue to strengthen the implementation of vaccination programs, as well as adjusting public perceptions to reduce the level of vaccine hesitancy, enhance the motivation for vaccination, and improve the coverage of COVID-19 vaccine based on different cultural factors, which remains the direction for future development. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has had major ramifications for health and the economy at both the individual and collective levels. This study examined exogenous negative changes in household income and their implications on psychological well-being (PWB) among the Chinese population during the COVID-19 pandemic. Methods: Data were drawn from the early China COVID-19 Survey, a cross-sectional anonymous online survey administered to the general population in China. Self-reported PWB was measured using a 5-point Likert scale with five questions related to the participants' recent psychological state. Hierarchical multiple linear regression was employed to examine whether income loss during the COVID-19 pandemic was associated with poor psychological health. Results: This study included 8,428 adults, of which 90% had suffered from a moderate or severe loss of household income due to the early COVID-19 pandemic. Those who had experienced moderate or severe loss of income scored significantly lower on psychological well-being than those who did not experience income loss (19.96 or 18.07 vs. 21.46; P < 0.001); after controlling for confounders, income loss was negatively associated with PWB scores (moderate income loss: B = − 0.603, P < 0.001; severe income loss: B = − 1.261, P < 0.001). An interaction effect existed between the degree of income loss and pre-pandemic income groups. Specifically, participants in the middle-income group who had suffered severe income loss scored the lowest on PWB (B = − 1.529, P < 0.001). There was also a main effect on income loss, such that participants with varying degrees of income loss differed across five dimensions, including anhedonia, sleep problems, irritability or anger, difficulty with concentration, and repeated disturbing dreams related to COVID-19. Conclusions: Income loss during the pandemic has had detrimental consequences on psychological well-being, and the magnitude of the impact of income loss on psychological well-being varied according to previous income levels. Future policy efforts should be directed toward improving the psychological well-being of the economically vulnerable and helping them recover from lost income in the shortest time possible. [ABSTRACT FROM AUTHOR]

Background: Access to essential medicines is a critical component of universal health coverage. However, the availability of essential medicines in Sudan isn't well studied. As well, most Sudanese people lack health insurance, making out-of-pocket spending the primary source of drug financing. Therefore, the affordability of medicines in Sudan is questionable, with only 30% of the total population being covered by a public health service or public health insurance. We undertook this study to assess the availability and prices of essential medicines in public-sector health facilities in Khartoum state. Moreover, this study aims at assessing patients' perceived affordability of essential medicines, and accommodation and acceptability of the public facility. Methods: A cross-sectional study was carried out at 30 primary healthcare facilities' drug dispensaries across three districts in Khartoum state. Within each Centre's dispensary unit, a standardized checklist evaluated the availability and affordability of 21 essential medicines selected from Sudan's national essential medicines list and assessed their storage conditions. Furthermore, 630 patients were selected from all dispensary units for an exit interview that assessed their perceived accessibility, acceptability, accommodation, and affordability of essential medicines. Data were collected through the Kobo toolbox and analyzed using SPSS version 26. Results: Participants' ratings of accessibility, affordability, accommodation, and acceptability were 3.7/5, 1.5/4, 5/6, and 5.4/6, respectively, with a 26.7% full access and weak correlation between some of the indices. The overall availability of adults and pediatric medicines was 36.8% 6.7%, respectively. Cost of a single course of treatment for 10 and 16 drugs out of the 19 drugs consumed exceeds the daily wage of insured and uninsured patients, with a median price ratio of 16.4 and 62.8, respectively. Moreover, the dispensary area conditions were found to be of good quality, yet the storerooms were not functioning in 40% of the outlets. Conclusion: Patients had limited access to their needed drugs due to high prices and physical unavailability, and primary healthcare capacities are not meeting the demands of citizens. The outcomes for the patients' access variables (accessibility, accommodation, acceptance, and affordability) are comparable to those in countries with low incomes. Ensuring access to free medicines is likely to improve patients' satisfaction with healthcare services and reduce private expenditure on medicines, which is a long-term, sustainable way towards universal health coverage in Sudan. [ABSTRACT FROM AUTHOR]

Objective: We describe awareness about the modified "public charge" rule among Oregon's Mexican-origin Latino/a population and whether concerns about the rule influenced disenrollment from state-funded programs, which do not fall under the public charge. Methods: We conducted a cross-sectional survey of adults (ages 18–59) recruited at the Mexican consulate and living in the state of Oregon. Our outcomes were awareness (of the public charge, source of knowledge, and confidence in knowledge of the public charge) and disenrolling self or family members from state-funded public healthcare programs due to concerns about the rule. We described outcomes and used logistic regression and calculated adjusted probabilities to identify factors associated with awareness of the public charge. Results: Of 498 Latino/a respondents, 48% reported awareness of the public charge. Among those who knew about the public charge, 14.6% had disenrolled themselves or family members from public healthcare programs and 12.1% were hesitant to seek care due to concerns about the public charge. Younger respondents had a lower adjusted probability of awareness of the public charge (18–24 years: 15.6% (95% CI 3.1–28.2); 30–39 years 54.9% (95% CI 47.7–62.0). Higher education was associated with a higher adjusted probability of awareness of the public charge; ability to speak English was not associated with awareness of the public charge. Conclusion: Our study reveals limited awareness about the public charge among Mexican-origin Oregon Latino/as. Outreach and advocacy are essential to ensure Latino/as know their rights to access available state-funded healthcare programs. [ABSTRACT FROM AUTHOR]

Background: Migrants is a large population in China. To improve the health and wellbeing of migrants is a critical policy and social issue in China, and to enhance the utilization of primary health care by migrants is one of the most important approaches in promoting equity in health. However, there exists little research about the association between social integration and the utilization of primary health care. To address the research gap, this research aims at exploring the relation between social integration and the utilization of primary health care among migrants in China. Methods: Using the national data from China Migrants Dynamic Survey (CMDS) in 2017, 169,989 migrants were included in this study. Social integration was measured by social communication, acculturation and self-identity, with 8 indicators. The utilization of primary health care was measured by the receiving of health education on infectious diseases (ID) and noncommunicable diseases (NCD) as well as the first visit institution when migrants were sick. After the descriptive statistical analysis, binary logistic regression was employed to evaluate the association between social integration and the utilization of primary health care. Results: 65.99% of the migrants received health education on infectious diseases (ID), 40.11% of the migrants received health education on noncommunicable diseases (NCD) and 8.48% of the migrants chose to go to Community Health Center (CHC) seeking for health services. There was a positive effect of social organization participation, the influence of hometown customs, differences of hygiene habits between migrants and local people, integration willingness and evaluation of identity on the receiving of health education on ID and NCD, as well as a positive effect of civil activities engagement and differences of hygiene habits between migrants and local people on the utilization of CHC after getting sick. Conclusions: Social integration was associated with the utilization of primary health care among migrants in China. Generally speaking, greater social integration was associated with higher possibility of receiving health education on ID and NCD. However, the effect of social integration on the utilization of CHC was more complex among different indicators. There should be more policy interventions to improve the social integration of migrant which help them to get familiar with the health resource available, as well as improve the capacity of CHC. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

Background: The use of hygienic products, such as sanitary napkins, tampons, and menstrual cups, to absorb menstrual blood is vital for the health and well-being of adolescent girls in India. However, the degree of inequity in the use of such products among this subpopulation remains inadequately explored. To fill this critical knowledge gap, this study aims to investigate the spatiotemporal dynamics of hygienic product use among adolescent girls in India from 2015 to 2020. Methods: In this cross-sectional study, we analyzed data from 117,749 to 114,839 adolescent girls aged 15–19, obtained from two consecutive rounds of the National Family Health Survey (NFHS) conducted in India during 2015-16 and 2019-21. Our approach involved utilizing Erreygers' Concentration Index (ECI) and Concentration Curve to quantitatively assess and visually represent socioeconomic inequality in hygienic product usage. Additionally, we investigated the spatiotemporal variation in this inequality over the study period and decomposed the ECI to identify the key contributing factors. Results: The findings reveal that hygienic product usage among adolescent girls in India has increased by 13 percentage points (PP), from 37% in 2015-16 to 50% in 2019-21. This increase is also visible across all household wealth quintiles. However, the bottom quintiles experienced a greater rise (+ 15 to 16 PP) than the top quintile (+ 8 PP). During the study period, the ECI reduced marginally, from 0.48 in 2015-16 to 0.43 in 2019-21. However, the extent of this reduction varied across different states. The greatest reduction in ECI was recorded in Punjab (-0.23 points), Telangana (-0.16 points), and West Bengal (-0.14 points). In contrast, there were a number of states with high socioeconomic inequality (ECI > 0.30) in 2015-16, where inequality reduction was minimal (< 0.05 points) over the study period. This included more developed states of Kerala, Karnataka, Maharashtra and Gujarat and relatively less developed states of Odisha, Jharkhand, Chhattisgarh, Uttar Pradesh, and Assam. Some states, such as Bihar and Madhya Pradesh, recorded an increase in socioeconomic inequality over the study period, with ECI rising to 0.31 and 0.46 (highest in the country) in 2019-21. The decomposition analysis revealed that the inequality in using hygienic products was primarily explained by place of residence, exposure to mass-media, education, and region of residence. Conclusions: The findings suggest the need for targeted policies to reduce existing socioeconomic inequality in the usage of hygienic products among adolescent girls in India. Specifically, interventions should target regions with low use of hygienic products, economically disadvantaged groups, and poor and vulnerable populations. State-specific policies and programs are also necessary to address the disparities in socioeconomic inequality. Additionally, efforts to reduce inequality should address the underlying factors contributing to inequality. [ABSTRACT FROM AUTHOR]

Background: Over the past decade, the United States (US) has seen a spike in migration across the US-Mexico border with an increase in hospital admissions of migrants and asylum-seekers under the custody of immigration law enforcement (ILE). This study aimed to determine how the presence of ILE officials affects patient care and provider experience in a teaching hospital setting. Methods: This cross-sectional online survey solicited quantitative and qualitative feedback from medical students, residents, and attending physicians (n = 1364) at a teaching hospital system with two campuses in Arizona. The survey included participant demographics and addressed participants' experience caring for patients in ILE custody, including the perception of respect, violations of patients' privacy and autonomy, and the comfort level with understanding hospital policies and patient rights. Thematic analyses were also performed based on respondent comments. Results: 332 individuals (24%) responded to the survey. Quantitative analyses revealed that 14% of participants described disrespectful behaviors of ILE officials, mainly toward detained patients. Qualitative thematic analyses of respondent comments revealed details on such disrespectful encounters including ILE officers violating the Health Insurance Portability and Accountability Act (HIPAA) and using intimidation tactics with patients. Nearly half of the respondents did not have knowledge of policies about ILE detainees' medical care, detainees' privacy rights, or ILE's authority in patient care. Conclusions: This study points out the complexities, challenges, and ethical considerations of caring for patients in ILE custody in the hospital setting and the need to educate healthcare professionals on both patient and provider rights. It describes the lived experiences and difficulties that providers on the border face in trying to achieve equity in the care they provide to detained migrant patients. [ABSTRACT FROM AUTHOR]

Background: Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. Methods: A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July–October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality—the Slope Index of Inequality (SII) and a relative measure—the Relative Concentration Index (RCI). Results: A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. Conclusion: While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state. [ABSTRACT FROM AUTHOR]

Introduction The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation. The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to: 1. identify the criteria used to set priorities in Indigenous-specific health care services; 2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decisionmakers. Methods We used a paper survey instrument, adapted from Mitton and colleagues' work, and a faceto- face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. Results The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. Conclusions An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians. [ABSTRACT FROM AUTHOR]

Introduction Access to quality maternal health services mainly depends on existing policies, regulations, skilled and knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. Objectives This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. Methods 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. Findings Among a total of 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. Conclusion TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services. [ABSTRACT FROM AUTHOR]

Introduction: The socio-economic circumstances and health of people with disabilities has been relatively ignored in public health research, policy and practice in Australia and internationally. This is despite emerging evidence that the socio-economic circumstances that people with disabilities live in contributes to their poorer health. Compared to other developed countries, Australians with disabilities are more likely to live in disadvantaged circumstances, despite being an economically prosperous country; it is therefore likely that the socio-economic disadvantage experienced by Australians with disabilities makes a significant contribution to their health. Despite the importance of this issue Australia does not routinely monitor the socio-economic inequalities for people with disabilities. This paper addresses this gap by describing time trends in socio-economic conditions for Australians with and without disabilities according to the severity of the disability and sex. Methods: Cross-sectional analyses of the Australian Bureau of Statistics Survey of Disability, Ageing and Carers were carried out at three time points (1998, 2003 and 2009) to estimate the proportions of women and men (aged between 25 and 64 years) who were living on low incomes, had not completed year 12, were not in paid work, living in private rental and experiencing multiple disadvantage (three or more of the indicators). Results: People with disabilities are less likely to have completed year 12, be in paid work and are more likely to be living on low incomes and experiencing multiple disadvantage. These conditions worsened with increasing severity of disability and increased or persisted over time, with most of the increase between 1998 and 2003. While women with milder disabilities tended to fare worse than men, the proportions were similar for those with moderate and severe/profound disabilities. Conclusion: People with disabilities experience high levels of socio-economic disadvantage which has increased or persisted over time and these are likely to translate into poorer health outcomes. A large proportion experience multiple forms of disadvantage, reinforcing the need to tackle disadvantage in a coordinated way across sectors. People with disabilities should be a priority population group for public health. Monitoring socio-economic conditions of people with disabilities is critical for informing policy and assessing the impact of disability reforms. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil. Methods: A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers. Results: Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months. Conclusions: The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples. [ABSTRACT FROM AUTHOR]