Psychological distress and the increased risk of falling into poverty: a longitudinal study of Australian adults

Postnatal Major Depressive Disorder in Australia: Inequalities and Costs of Healthcare to Individuals, Governments and Insurers

BACKGROUND

Perinatal mental health has pervasive impacts on the wellbeing of both the mother and child, affecting quality of life, bonding and attachment and cognitive development.

OBJECTIVES

The aim of this study was to (i) quantify the costs to government healthcare funders, private health insurers and individuals through out-of-pocket fees, of women with postnatal major depressive disorder (MDD); and (ii) identify any socioeconomic inequalities in health service use and costs amongst these women.

METHODS

A whole-of-population linked administrative dataset containing the clinical records and health service use for all births in the state of Queensland, Australia between 01 July 2012 and 30 June 2015 was used (n = 189,081). Postnatal MDD was classified according to ICD-10 code, with women hospitalised for MDD in the 12 months after birth classified as having 'postnatal MDD' (n = 728). Health service use and costs from birth to 12 months post-birth were included. Total costs included cost to government funders and private health insurers and out-of-pocket fees. Total costs and costs to different funders were compared for women with postnatal MDD and for women without an inpatient event for postnatal MDD, with unadjusted means presented. A generalised linear model was used to compare the difference in total costs, adjusting for key confounders. Costs to different funders and number of different services accessed were then compared for women with postnatal MDD by socioeconomic status, with unadjusted means presented.

RESULTS

The total costs from birth to 12 months post-birth were 636% higher for women with postnatal MDD than women without an inpatient event for postnatal MDD, after accounting for differences in private hospital use, mode of birth, clinical characteristics and socioeconomic status. Amongst women with postnatal MDD, the cost of all services accessed was higher for women of highest socioeconomic status than for women of lowest socioeconomic status (A$15,787.66 vs A$11,916.94). The cost of services for women of highest socioeconomic status was higher for private health insurers (A$8941.25 vs A$2555.26), but lower for public hospital funders (A$2423.39 vs A$6582.09) relative to women of lowest socioeconomic status. Outside of public hospitals, costs to government funders was higher for women of highest socioeconomic status (A$2766.80 vs A$1952.00). Women of highest socioeconomic status accessed more inpatient (8.2 vs 3.1) and specialist services (13.4 vs 5.5) and a higher proportion had access to psychiatric specialist care (39.7% vs 13.6%) and antidepressants (97.6% vs 93.8%).

CONCLUSION

MDD is costly to all funders of healthcare. Amongst women with MDD, there are large differences in the types of services accessed and costs to different funders based on socioeconomic status. There may be significant financial and structural barriers preventing equal access to care for women with postnatal MDD.

Accumulation of economic hardship and health during the COVID-19 pandemic: Social causation or selection?

This study examines whether economic hardship during the COVID-19 pandemic is deleteriously associated with psychological distress and self-rated health. A social causation perspective suggests that exposure to economic hardship will harm well-being, but a social selection perspective suggests that the appearance of health effects of hardship during the pandemic are attributable to the increased risk of exposure to hardship associated with poor well-being at the start of the pandemic. We also propose a third perspective, economic selection, which suggests that economic hardship prior to the pandemic negatively affects health and increases risk of exposure to hardship during the pandemic; consequently, an association between health and economic hardship during the pandemic may be spurious, and entirely due to pre-existing levels of hardship. To test these competing perspectives, we use a longitudinal study based in Canada that began in late March of 2020 and followed respondents monthly in April, May, and June. Baseline psychological distress and self-rated health, as well as economic hardship prior to the pandemic, independently predict the accumulation of monthly periods of hardship from April to June. The accumulation of periods of hardship from April to June is deleteriously associated with psychological distress and self-rated health in June. Controls for prior economic hardship and baseline health weaken the association between accumulation of periods of hardship and psychological distress, while also eliminating the association between accumulation of hardship and self-rated health. These findings favor a social causation perspective for psychological distress and a social selection perspective for self-rated health, with less evidence found in support of economic selection. This study took place during the first months of the COVID-19 pandemic, though, and associations with self-rated health may have become more evident as hardship further wore on individual well-being over a longer period of time.

Out-of-pocket healthcare expenditure in Australia: trends, inequalities and the impact on household living standards in a high-income country with a universal health care system

BACKGROUND

Poor health increases the likelihood of experiencing poverty by reducing a person's ability to work and imparting costs associated with receiving medical treatment. Universal health care is a means of protecting against the impoverishing impact of high healthcare costs. This study aims to document the recent trends in the amount paid by Australian households out-of-pocket for healthcare, identify any inequalities in the distribution of this expenditure, and to describe the impact that healthcare costs have on household living standards in a high-income country with a long established universal health care system. We undertook this analysis using a longitudinal, nationally representative dataset - the Household Income and Labour Dynamics in Australia Survey, using data collected annually from 2006 to 2014. Out of pocket payments covered those paid to health practitioners, for medication and in private health insurance premiums; catastrophic expenditure was defined as spending 10% or more of household income on healthcare.

RESULTS

Average total household expenditure on healthcare items remained relatively stable between 2006 and 2014 after adjusting for inflation, changing from $3133 to $3199. However, after adjusting for age, self-reported health status, and year, those in the lowest income group (decile one) had 15 times the odds (95% CI, 11.7-20.8) of having catastrophic health expenditure compared to those in the highest income group (decile ten). The percentage of people in income decile 2 and 3 who had catastrophic health expenditure also increased from 13% to 19% and 7% to 13% respectively.

CONCLUSIONS

Ongoing monitoring of out of pocket healthcare expenditure is an essential part of assessing health system performance, even in countries with universal health care.

The impact of social assistance programs on population health: a systematic review of research in high-income countries

Background

Socioeconomic disadvantage is a fundamental cause of morbidity and mortality. One of the most important ways that governments buffer the adverse consequences of socioeconomic disadvantage is through the provision of social assistance. We conducted a systematic review of research examining the health impact of social assistance programs in high-income countries.

Methods

We systematically searched Embase, Medline, ProQuest, Scopus, and Web of Science from inception to December 2017 for peer-reviewed studies published in English-language journals. We identified empirical patterns through a qualitative synthesis of the evidence. We also evaluated the empirical rigour of the selected literature.

Results

Seventeen studies met our inclusion criteria. Thirteen descriptive studies rated as weak (n = 7), moderate (n = 4), and strong (n = 2) found that social assistance is associated with adverse health outcomes and that social assistance recipients exhibit worse health outcomes relative to non-recipients. Four experimental and quasi-experimental studies, all rated as strong (n = 4), found that efforts to limit the receipt of social assistance or reduce its generosity (also known as welfare reform) were associated with adverse health trends.

Conclusions

Evidence from the existing literature suggests that social assistance programs in high-income countries are failing to maintain the health of socioeconomically disadvantaged populations. These findings may in part reflect the influence of residual confounding due to unobserved characteristics that distinguish recipients from non-recipients. They may also indicate that the scope and generosity of existing programs are insufficient to offset the negative health consequences of severe socioeconomic disadvantage.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6337-1) contains supplementary material, which is available to authorized users.

Psychological distress increases the risk of falling into poverty amongst older Australians: the overlooked costs-of-illness

Background

This paper aimed to identify whether high psychological distress is associated with an increased risk of income and multidimensional poverty amongst older adults in Australia.

Methods

We undertook longitudinal analysis of the nationally representative Household Income and Labour Dynamics in Australian (HILDA) survey using modified Poisson regression models to estimate the relative risk of falling into income poverty and multidimensional poverty between 2010 and 2012 for males and females, adjusting for age, employment status, place of residence, marital status and housing tenure; and Population Attributable Risk methodology to estimate the proportion of poverty directly attributable to psychological distress, measured by the Kessler 10 scale.

Results

For males, having high psychological distress increased the risk of falling into income poverty by 1.68 (95% CI: 1.02 to 2.75) and the risk of falling into multidimensional poverty by 3.40 (95% CI: 1.91 to 6.04). For females, there was no significant difference in the risk of falling into income poverty between those with high and low psychological distress (p = 0.1008), however having high psychological distress increased the risk of falling into multidimensional poverty by 2.15 (95% CI: 1.30 to 3.55). Between 2009 and 2012, 8.0% of income poverty cases for people aged 65 and over (95% CI: 7.8% to 8.4%), and 19.5% of multidimensional poverty cases for people aged 65 and over (95% CI: 19.2% to 19.9%) can be attributed to high psychological distress.

Conclusions

The elevated risk of falling into income and multidimensional poverty has been an overlooked cost of poor mental health.

Lifetime impact of injury on education, employment and income for Australians of labour force participation age

BACKGROUND

Research shows that employment rates are low post injury.

AIMS

To quantify the economic impact of a long-term injury and identify whether having a tertiary level of education attainment would offset this impact.

METHODS

Cross-sectional analysis of the 2012 Survey of Disability, Aging and Carers, which is nationally representative of the Australian population.

RESULTS

Males with any long-term injury had incomes 41% less than males with no chronic health condition (95% confidence interval [CI] -49.3%, -31.6%). For males with a long-term injury, there was no significant difference in the likelihood of being not in the labour force between those with and without a tertiary qualification (odds ratio [OR] 0.83, 95% CI 0.45-1.52). There was no significant difference in the incomes of females with any long-term injury compared with those with no chronic health conditions. For females with a long-term injury, there was a significant difference in the likelihood of being not in the labour force between those with and without a tertiary qualification (OR 0.37, 95% CI 0.17-0.80). If men with a long-term injury had the same probability of participating in the workforce as women, the percentage of men not in the labour force would reduce from 37 to 18%.

CONCLUSIONS

Having a long-term injury was a significant personal cost in terms of labour force absence and lower income for males regardless of higher education attainment. For females, sustaining a long-term injury did not appear to significantly affect income.

Pathways between health, education and income in adolescence and adulthood

OBJECTIVE

To quantify the impact of household income, and physical and mental health in adolescence on education attainment, household income and health status in adulthood.

DESIGN

Path analysis and regression models using waves 1-12 of the Household, Income and Labour Dynamics in Australia survey.

PARTICIPANTS

Individuals aged 17 or 18 in 2001, 52% were males (n=655) and 48% were female (52%). Of those participating in wave 1, five did not respond in wave 12.

MAIN OUTCOME MEASURES

Education attainment, household income, physical and mental health at age 29/30.

RESULTS

For females, physical health at age 17/18 was significantly related to level of education attainment at age 29/30 (standardised total effect 0.290, p<0.001), with this influence being greater in magnitude than that of household income at age 17/18 on level of education attainment at age 29/30 (standardised total effect 0.159, p=0.022). Females' physical health at age 17/18 was also significantly related to household income at age 29/30 (standardised total effect 0.09, p=0.018). Both adjusted for initial household income at age 17/18. For males, the total standardised total effect of physical health at age 17/18 had a greater impact than household income at age 17/18 on education attainment at age 29/30 (0.347, p<0.001 for physical health and 0.276, p<0.001 for household income). The OR of achieving a year 12 or higher level of education attainment was 4.72 (95% CI 1.43 to 15.58, p=0.0110) for females with good physical health at age 17/18 and 5.05 (95% CI 1.78 to 14.36, p=0.0024) for males, compared with those with poor physical health at age 17/18.

CONCLUSIONS

As physical health in adolescence appears to have a stronger influence on education attainment in adulthood than household income, equity strategies for education attainment should also target those with poor health.