Socio-economic inequalities in health and health service use among older adults in India: results from the WHO Study on Global AGEing and adult health survey

Socioeconomic gradient of lean diabetes in India: Evidence from National Family Health Survey, 2019-21

Diabetes is a global public health challenge, particularly in India, affecting millions. Among diabetic patients, lean type 2 diabetes is a severe subtype with higher microvascular complication risks. While studies on the prevalence, variations and risk factors of diabetes are increasingly available, there has been limited research on the prevalence, variations, and socioeconomic disparities of lean diabetes in India. This study used NFHS-5 microdata, and lean diabetes is defined as those with a BMI level of under 25 and random blood glucose levels of over 200 or under diabetic medication. Descriptive and multivariate analyses were conducted to understand lean diabetes variations and related factors. Socioeconomic disparities were measured using concentration curves and the concentration index. The study unveiled important insights into lean diabetes in India. 8.2% of men and 6.0% of women had elevated blood glucose levels, indicating a significant diabetes burden. Notably, 2.9% of men and 2.4% of women were diagnosed with lean diabetes. Among type 2 diabetics, 52.56% of males and 43.57% of females had lean type 2 diabetes. Lean diabetes prevalence varied from 11.6% in the poorest quintile to 1.1% in the richest. The odds of lean type 2 diabetes among those in the poorest quintile was 6.7 compared to the richest quintile. The concentration index of lean type 2 diabetes was -0.42 for men and -0.39 for women, suggesting a disproportionate impact on lower socioeconomic groups. This study advances our understanding of the complex interplay between socioeconomic factors and lean type 2 diabetes in India. To address the rising burden of lean diabetes among lower socioeconomic strata, policymakers and healthcare professionals must prioritise initiatives enhancing healthcare access, promoting healthy lifestyles, and ensuring effective diabetes management. By addressing socioeconomic disparities and implementing interventions for vulnerable populations, India can reduce diabetes-related mortality and enhance its citizens' overall health.

Factors associated with public and private healthcare utilization for outpatient care among older adults in India: A Wagstaff's decomposition of Anderson's behavioural model

In India, an expanding ageing population will become a public health alarm, putting additional pressure on the healthcare system. Therefore, the current study aimed to examine the factors associated with outpatient healthcare choices among older Indian adults. We used data from the first wave of the Longitudinal Ageing Study in India (LASI, 2017-2018). A total of 34,588 individuals (age 45 years and over) who accessed outpatient healthcare services in the last 12 months during the survey were included in this research. A bivariate chi-square test was used to present the percentage distribution of types of outpatient healthcare utilisation by background characteristics. Multinomial logistic regression and Wagstaff's decomposition analyses were employed to explore the interplay of outpatient healthcare utilisation and allied predisposing, enabling, and need factors and examine these factors' contributions to the wealth-based inequalities in public, private, and other healthcare utilisation. Outpatient healthcare utilisation varied significantly according to socioeconomic and demographic factors. The findings suggest that consumption quintiles, place of residence, education, and health insurance were significant determinants of private and public healthcare utilisation and contributed to wealth-based inequalities in healthcare choices. The current study emphasises the need to strengthen and promote public healthcare services.

Self-Reported Health Inequalities among Older Adults in Saudi Arabia

Considering the rising life expectancy, the growing population of older adults poses challenges in providing adequate healthcare services. Self-reported health is an important indicator of overall health, predicting morbidity and mortality. This study investigated self-reported health inequalities among older adults in Saudi Arabia and the underlying factors contributing to establishing such inequalities. The study utilized data from the 2018 Saudi Family Health Survey, focusing on 2023 respondents aged ≥60 years with complete data. Univariate, bivariate, and multivariate logistic regression analyses were employed to explore socio-economic factors linked to health inequalities. Additionally, concentration curves and indices were used to assess the magnitude of health inequalities among older adults. The findings indicate a higher prevalence of self-reported poor health among respondents aged ≥70 years and those with chronic diseases. Age, education, income level, marital status, and insurance coverage were other factors significantly linked to reporting poor health. Inequality analysis revealed a concentration of poor health among less educated individuals (concentration index = -0.261, p < 0.01). Both income- and education-based indices highlighted a concentration of poor health among men with lower income and education levels. Addressing healthcare inequalities among older adults requires targeted policy efforts, focusing on those aged ≥70, unmarried individuals, those without insurance coverage, those with chronic illnesses, and those with lower education levels. Targeted interventions for these groups can address their unique healthcare needs and promote equitable health outcomes.

Socioeconomic deprivation, medical services accessibility, and income-related health inequality among older Chinese adults: evidence from a national longitudinal survey from 2011 to 2018

BACKGROUND

Health inequality poses a challenge to improving the quality of life of older adults as well as the service system. The literature rarely explores the moderating role of medical services accessibility in the association between socioeconomic deprivation and health inequality.

OBJECTIVE

This study examines the socioeconomic deprivation and medical services accessibility associated with health inequality among older Chinese adults, which will contribute to the medical policy reform.

METHODS

Using data from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we analyse 14,232 older adults. This paper uses a concentration index (CI) to measure the income-related health inequality among the target population and employs a recentered influence function-concentration index-ordinary least squares (RIF-CI-OLS) model to empirically analyse the correlation between socioeconomic deprivation and health inequality among older Chinese adults. Based on the correlation analysis, we discuss the moderating effect of medical services accessibility.

RESULTS

We find that health inequality exists among older Chinese adults and that the relative deprivation in socioeconomic status (SES) is significantly associated with health inequality (β∈  [0.1109,  0.1909], P < 0.01). The correlation between socioeconomic deprivation and health inequality is moderated by medical services accessibility, which means that an increase in medical services accessibility can weaken the correlation between socioeconomic deprivation and health inequality.

CONCLUSION

China needs an in-depth reform of its medical services accessibility system to promote the equitable distribution of medical services resources, strengthen medical costs and quality management, and ultimately mitigate the SES reason for health inequality among older Chinese adults.

The Impact of the Medical Insurance System on the Health of Older Adults in Urban China: Analysis Based on Three-Period Panel Data

The impact of the medical insurance system (MIS) on the health of older adults is a key element of research in the field of social security. Because China's MIS consists of different types of insurance, and the benefits and levels of coverage received by participating in different medical insurance vary, different medical insurance may have a differential impact on the health of older adults. This has rarely been studied before. In this paper, the panel data of the third phase of the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2013, 2015 and 2018 were used to investigate the impact of participation in social medical insurance (SMI) and commercial medical insurance (CMI) on the health of urban older adults and its mechanism relationship. The study found that SMI had a positive impact on the mental health of older adults, but only in the eastern region. Participation in CMI was positively correlated with the health of older adults, but this association was relatively small and was only observed in the sample of older adults aged 75 years and above. In addition, future life security plays an important role in the process of improving the health of older adults through medical insurance. Both research hypothesis 1 and research hypothesis 2 were verified. The results of this paper show that the evidence of the positive effect of medical insurance on the health of older adults in urban areas proposed by scholars is not convincing enough. Therefore, the medical insurance scheme should be reformed, focusing not only on coverage, but on enhancing the benefits and level of insurance, so as to enhance its positive impact on the health of older adults.

Inequality of opportunity in health service utilization among middle-aged and elderly community-dwelling adults in China

BACKGROUND

The inequality caused by circumstances is known as "inequality of opportunity" (IOp). Many scholars have studied IOp in the health field, but few studies have quantified contributors to the IOp of health service utilization among middle-aged and elderly people. This study measured the IOp of health service utilization and decomposed the contributors to IOp present among Chinese middle-aged and elderly people.

METHODS

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015 and 2018. A mean-based regression method was adopted to measure the IOp of health service utilization. Shapley-Shorrocks decomposition was used to analyze the main contributors to IOp seen among the middle-aged and elderly.

RESULTS

Although the absolute IOp of health service utilization decreased over time, IOp still explains the total inequality to a large extent. The absolute IOp and relative IOp were greatest in the areas of self-treatment and inpatient care utilization, respectively. Shapley decomposition results showed that the out-of-pocket (OOP) ratio contributed most to the IOp of outpatient care utilization; and the residence area highly explains the IOp of inpatient service utilization. Meanwhile, social and economic factors such as work status and income contribute more to the IOp of inpatient care utilization than outpatient and self-treatment.

CONCLUSIONS

Strategies aimed at achieving equal opportunities remain necessary to ensure the fairness of health service utilization. Policies and measures should further adjust the medical insurance compensation policies, and pay more attention to the middle-aged and elderly residents in rural areas, optimize health resource allocation, improve the social security systems, and narrow the socioeconomic gap between urban and rural areas in China.

Indigenous population and major depressive disorder in later life: a study based on the data from Longitudinal Ageing Study in India

BACKGROUND

Existing evidence suggests that the indigenous older population who live with their families and friends might experience lesser depressive symptoms due to better emotional support and well-being. The present study aimed to investigate the differentials in the prevalence of the major depressive disorder among tribal and non-tribal older populations in India and to explore the contribution of socio-demographic, health-related, and household factors in such disparities.

METHODS

A cross-sectional study was conducted using data from the Longitudinal Aging Study in India (2017-18). The analytical sample included 30,637 older adults, among whom 5,025 and 25,612 belonged to the Scheduled Tribe (ST) and non-Scheduled Tribe (non-ST) social groups, respectively. Major depressive disorder assessed by the Composite International Diagnostic Interview short-form (CIDI-SF) scale was the outcome variable. Descriptive statistics, bivariate and multivariable regression and, decomposition analyses were conducted.

RESULTS

About 4.8% and 8.9% of older adults from the ST and non-ST social groups had major depression. For both tribal and non-tribal groups, older adults who were unmarried, dissatisfied with living arrangements, and those who faced lifetime discrimination were at increased risk of major depression. Findings from differences due to characteristics (E) revealed that if the regional differences were minimized, it would decrease the ST-non-ST gap in major depression by about 19.6%. Similarly, equal self-rated health status and chronic conditions among ST and non-ST groups would decrease the gap in major depression by almost 9.6% and 7.9%, respectively. Additionally, an equal status of Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) among older adults would decrease the gap in major depression by about 3.8% and 3% respectively. Also, findings from differences due to coefficients (C) revealed that if older adults from the ST group had the same status of ADL as of older adults from the non-ST group, it would decrease the gap in major depression by about 11.8%.

CONCLUSION

The findings revealed a greater prevalence of major depression in older adults belonging to the non-ST group than the ST group. For both tribal and non-tribal groups, older adults who were unmarried, dissatisfied with living arrangements, and those who faced lifetime discrimination were at increased risk of major depression and these factors along with health-related variables contributed to significant ST-non-ST gap in depression, advantageous to tribal population; suggesting further research on the coping mechanisms of mental illnesses among indigenous population in India.

Does social pension buy improved mental health and mortality outcomes for senior citizens? Evidence from South Africa's 2008 pension reform

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The 2008 pension reform in South Africa improved access to healthcare.

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The 2008 pension reform improved mental health and 60-year-old deaths.

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The impact of the 2008 pension reform in averting 60-year-old deaths is higher in urban regions than rural regions.

In South Africa, men were traditionally eligible to receive government pensions at 65 years. However, that eligibility criterion was changed in 2008 to allow men to receive a pension payout at 60 years. This study is designed to quantify the impact of the 2008 pension reform on mental health outcomes (depression and traumatic stress) and deaths among 60-year-old men from disadvantaged households without advanced education. This analysis used secondary data issued by Statistic South Africa- General Household Survey. Men who reported earning a pension at 60 years from 2008 to 2014 were exposed to the 2008 pension reform and thus were classified as the treatment group. The 60-year-old men during 2002–2007 were ineligible to earn the pension, therefore considered the control group. We then used a Two-stage Least Squared Model (2SLS) to quantify the impact of the 2008 pension reform on healthcare utilization, depression cases, traumatic stress cases, and deaths among 60-year-old men. The model shows that the 2008 pension reform improved healthcare utilization by 3 % in the cohorts of men who benefitted from the 2008 reform. The 2008 pension reform averted depression cases, traumatic stress cases, and deaths among 60-year-old men by 3 %, 4 %, and 5 %, respectively. The impact of the 2008 pension reform in averting deaths among 60-year-old men was higher in urban regions than rural regions. We concluded that the 2008 pension reform successfully bought improved mental health outcomes and prevented depression, traumatic stress, and deaths among 60-year-old men.

Obesity-related measures and successful ageing among community-dwelling older adults in India: a cross-sectional study

Obesity is a chief lifestyle disease globally and causes a significant increase in morbidities. Overweight/ obesity prevalence has been rising faster in India compared to the world average. Therefore, the study examined the association between overweight/ obesity and successful ageing among older population in India. We also explored the gender difference in risks posed by obesity on successful ageing and the different socio-economic correlates associated with successful ageing. This study utilized data from India's first nationally representative longitudinal ageing survey (LASI-2017-18). The effective sample size for the present study was 31,464 older adults with a mean age of 69.2 years (SD: 7.53). Overweight/ obesity was defined as having a body mass index of 25 or above. The study carried out a bivariate analysis to observe the association between dependent and independent variables. Further, multivariable analysis was conducted to examine the associations after controlling for individual socio-demographic, lifestyle and household/community-related factors. The study included 47.5% men and 52.5% women. It was found that the prevalence of obesity/overweight was higher among older women compared to older men (23.2% vs 15.5%). Similarly, high-risk waist circumference (32.7% vs 7.9%) and high-risk waist-hip ratio (69.2% vs 66.5%) were more prevalent among older women than older men. The study found significant gender differences (men-women: 8.7%) in the prevalence rate of successful ageing (p < 0.001). The chances of successful ageing were significantly higher among older adults who were not obese/overweight [AOR: 1.31; CI 1.31-1.55], had no high-risk waist circumference [AOR: 1.41; CI 1.29-1.54], and those who had no high-risk waist-hip ratio [AOR: 1.16; CI 1.09-1.24] compared to their respective counterparts. Interaction results revealed that older women who were not obese/overweight had a lower likelihood of successful ageing compared to the older men who was not obese/overweight [AOR: 0.86; CI 0.80-0.93]. Similarly, older womens who had no high-risk waist circumference [AOR: 0.86; CI 0.80-0.96] and no high risk-hip ratio [AOR: 0.81; CI 0.73-0.89] were less likely to have successful ageing compared to their counterparts, respectively. Being overweight/ obese and having high-risk waist circumference and waist-hip ratio were found to be significant factors associated with less successful ageing among older adults, especially women in this study. The current findings highlight the importance of understanding the modifiable factors, including nutritional awareness and developing targeted strategies for promoting successful ageing.

Improving Access and Health Outcomes in Palliative Care through Cultural Competence: An exploration of opportunities and challenges in India

People who belong to ethnic, racial and cultural minorities often have less access to healthcare and have poorer health outcomes when compared to the majority population. In the COVID pandemic, too, health disparities have been observed. Similar disparities have been noted in patients with advanced disease and suffering from pain, with minority patients having less access to or making less use of palliative care. In the US, a range of solutions has been proposed to address the issue of inequality in access to healthcare, with cultural competence figuring prominently among them. This study explores whether and how cultural competence may be applied to palliative care in India to improve access and health outcomes. In the literature, it is argued that, in diverse societies, cultural competence is an essential part of the solution towards equitable healthcare systems. Solutions to problems of healthcare disparities must go beyond an increase in financial resources as more financial resources will not necessarily make the healthcare system more equitable. A culturally competent system recognises and integrates at all levels the culture as a significant component of care, which is particularly relevant at the end of life. If efficiently implemented, cultural competence will lead to higher patient satisfaction, better follow-up and patient compliance and an improved reputation of palliative care among minorities. This may help to reduce inequalities in access and health outcomes in palliative care.

Region of birth differences in healthcare navigation and optimisation: the interplay of racial discrimination and socioeconomic position

Background

While a large body of research has documented socioeconomic and migrant inequities in the effective use of healthcare services, the reasons underlying such inequities are yet to be fully understood. This study assesses the interplay between racial discrimination and socioeconomic position, as conceptualised by Bourdieu, and their contributions to healthcare navigation and optimisation.

Methods

Using a cross-sectional survey in Luxembourg we collected data from individuals with wide-ranging migration and socioeconomic profiles. We fitted sequential multiple linear and logistic regressions to investigate the relationships between healthcare service navigation and optimisation with perceived racial discrimination and socioeconomic position measured by economic, cultural and social capital. We also investigated whether the ownership of these capitals moderates the experience of racial discrimination in healthcare settings.

Results

We observed important disparities in healthcare navigation among different migrant communities. These differences were explained by accounting for the experience of racial discrimination. Racial discrimination was also negatively related with the extent of healthcare services optimisation. However, the impact of discrimination on both health service navigation and optimisation was reduced after accounting for social capital. Higher volumes of economic and social capital were associated with better healthcare experience, and with a lower probability of perceived racial discrimination.

Conclusions

Racial discrimination plays a substantial role in accounting for inequality in healthcare service navigation by different migrant groups. This study highlights the need to consider the complex interplay between different forms of economic, cultural and social capital and racial discrimination when examining migrant, and racial/ethnic differences in healthcare. Healthcare inequalities arising from socioeconomic position and racism need to be addressed via multilevel policies and interventions that simultaneously tackle structural, interpersonal, and institutional dimensions of racism.

Assessing equity and quality indicators for older people – Adaptation and validation of the Assessing Care of Vulnerable Elders (ACOVE) checklist for the Portuguese care context

Background

Development has promoted longer and healthier lives, but the rise in the proportion of older adults poses new challenges to health systems. Susceptibilities of older persons resulting from lower knowledge about services availability, health illiteracy, lower income, higher mental decline, or physical limitations need to be identified and monitored to assure the equity and quality of health care. The aim of this study was to develop equity indicators for the Assessing Care of Vulnerable Elders (ACOVE)-3 checklist and perform the first cross-cultural adaptation and validation of this checklist into Portuguese.

Methods

A scoping literature review of determinants or indicators of health (in)equity in the care of older people was performed. A total of 5 language experts and 18 health professionals were involved in the development and validation of the equity and quality indicators through expert opinion and focus groups. Data collected from focus groups was analyzed through directed or conventional content analysis. The usefulness of the indicators was assessed by analyzing the clinical records of 30 patients.

Results

The literature review revealed that there was a worldwide gap concerning equity indicators for older people primary health care. A structured and complete checklist composed of equity and quality indicators was obtained, validated and assessed. A significant number of non-screened quality or equity related potential occurrences that could have been avoided if the proposed indicators were implemented were detected. The percentage of non-registered indicators was 76.6% for quality and 96.7% for equity.

Conclusions

Applying the proposed checklist will contribute to improve the monitoring of the clinical situation of vulnerable older people and the planning of medical and social actions directed at this group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03104-5.

Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

BACKGROUND

In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.

DATA

Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.

RESULTS

A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).

CONCLUSION

The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India.

Effect of education and multimorbidity on mortality among older adults: findings from the health, well-being and ageing cohort study (SABE)

OBJECTIVES

This study assessed the moderating role of education on the relationship between multimorbidity and mortality among older adults in Brazil.

STUDY DESIGN

This was a cohort study.

METHODS

This study used data from 1768 participants of the Health, Well-Being and Ageing Cohort Study (SABE) who were assessed between 2006 and 2015. The Cox Proportional Risks Model was used to evaluate the association between multimorbidity (two or more chronic diseases) and mortality. An interaction term between education and multimorbidity was included to test the moderating role of education in this association.

RESULTS

The average follow-up time was 4.5 years, with a total of 589 deaths in the period. Multimorbidity increased the risk of mortality (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.27-1.91), and this association was not moderated by education (HR 1.06, 95% CI 1.00-1.13; P value = 0.07).

CONCLUSIONS

The impact of education and multimorbidity on mortality emphasises the need for an integrated approach directed towards the social determinants of health to prevent multimorbidity and its burden among older adults.

Horizontal inequity in self-reported morbidity and untreated morbidity in India: Evidence from National Sample Survey Data

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.

Understanding equity of institutional delivery in public health centre by level of care in India: an assessment using benefit incidence analysis

BACKGROUND

The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India.

METHODS

Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015-16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis.

RESULTS

Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015-16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was - 0.161 [95% CI, - 0.158, - 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres.

CONCLUSION

Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India.

Effect of weight loss on the retinochoroidal structural alterations among patients with exogenous obesity

PURPOSE

To evaluate the changes in the retinochoroidal vasculature in patients with exogenous obesity using swept-source optical coherence tomography (SS-OCT) and OCT angiography (OCTA).

METHODS

In this prospective study, 60 patients diagnosed with obesity (47 males) (mean age: 46.47±10.9 years) were included, of which 30 patients underwent bariatric surgery (Group A), and 30 patients underwent conservative management (exercise/diet) (Group B). Parameters including choroidal thickness (CT), choroidal vascularity index (CVI) and retinal capillary density index (CDI) and arteriovenous ratio (AVR) were measured at the baseline and three months follow up. 30 eyes (30 age and gender-matched) of normal participants were included for comparison.

RESULTS

Baseline CT was lower in 60 participants with obesity compared to controls. Compared with normal subjects, subjects with obesity had higher mean CVI (0.66±0.02 versus 0.63±0.04; p<0.01), smaller FAZ area (0.26±0.07 versus 0.45±0.32; p<0.01), higher CDI (superficial plexus: 0.7±0.04 versus 0.68±0.06; p = 0.04, deep plexus: 0.38±0.02 versus 0.35±0.06; p = 0.01), and lower AVR (0.68±0.05 versus 0.70±0.03 versus; p<0.01). At 3-month after intervention, CT showed a significant increase in participants from Group A (329.27±79μm; p<0.01) but not in Group B from baseline. No significant change was noted in CVI or CDI at 3-month in either group compared to baseline. AVR significantly increased in Group B (p = 0.03).

CONCLUSION

Subclinical changes in retinochoroidal vasculature occurs in participants with exogenous obesity compared to healthy subjects. Surgical intervention (bariatric surgery) may have a favorable outcome on the choroidal thickness in these patients.

Reduction in inequalities in health insurance coverage and healthcare utilization among older adults in the Philippines after mandatory national health insurance coverage: trend analysis for 2003-2017

BACKGROUND

Health policies in the Philippines have evolved in response to increasing health demands of older adults. However, there is a lack of research on equity among the ageing population in low-middle income countries. The objective of this study was to identify the trends in National Health Insurance Program (NHIP) coverage and healthcare utilization among older adults in the Philippines for the period from 2003 to 2017, during which NHIP expansion policies were implemented, focusing on reductions in socio-economic inequalities.

METHODS

A literature search of policies for older adults and an analysis of four Philippine National Demographic and Health Surveys (2003, 2008, 2013, and 2017) with data from 25,217 older adults who were 60 years or older were performed. The major outcome variables were NHIP coverage, self-reported illness, outpatient healthcare utilization, and inpatient healthcare utilization. Inequalities in NHIP coverage and healthcare utilization according to wealth were evaluated by calculating the concentration index for individual years, followed by a regression-based decomposition analysis.

RESULTS

NHIP coverage among older adults increased from 9.4 (2003) to 87.6% (2017). Although inequalities according to wealth quintile were observed in all four surveys (all P < 0.001), the concentration index declined from 0.3000 (2003) to 0.0247 (2017), showing reduced inequalities in NHIP coverage over time as observed for self-reported illness and healthcare utilization. NHIP coverage expansion for older adults in 2014 enabled equal opportunity for access to healthcare.

CONCLUSION

The passage of mandatory NHIP coverage for older Filipino adults in 2014 was followed by a reduction in inequality in NHIP coverage and healthcare utilization according to wealth.

Ethnic disparities in the uptake of anti-dementia medication in young and late-onset dementia

OBJECTIVES

People with dementia can face barriers when trying to access care after a diagnosis, particularly in young-onset dementia (YOD). Little is known about the effects of ethnicity on the use of anti-dementia medication and variations between age groups. The aim of this study was to analyze national data on variations in the uptake of anti-dementia medication between people with YOD and late-onset dementia (LOD).

DESIGN

Cross-sectional longitudinal cohort study.

SETTING

Data from the U.S. National Alzheimer's Coordinating Centre were obtained from September 2005 to March 2019.

PARTICIPANTS

First visits of people with a diagnosis of Alzheimer's disease (AD) dementia, Lewy body dementia (LBD), and Parkinson's disease dementia (PDD) were included.

MEASUREMENTS

Logistic regression was used to analyze the effects of education and ethnicity on use of cholinesterase inhibitors and memantine, accounting for YOD/LOD, gender, living situation, severity stage, and comorbidities.

RESULTS

In total, 15,742 people with AD dementia and LBD/PDD were included, with 11,019 PwD having completed a first follow-up visit. Significantly more people with YOD used memantine than those with LOD, while fewer used cholinesterase inhibitors. PwD from minority ethnic backgrounds used memantine and cholinesterase inhibitors less often than those from a White ethnic background. Logistic regression analysis showed that ethnicity was a significant determinant of both memantine and cholinesterase inhibitors usage, while education was only a significant determinant for memantine usage.

CONCLUSIONS

Findings highlight the impact of social factors on current usage of anti-dementia medication and the need for more resources to enable equitable use of anti-dementia medication.

Predictors of healthcare utilisation among poor older people under the livelihood empowerment against poverty programme in the Atwima Nwabiagya District of Ghana

BACKGROUND

Like many other low- and middle-income countries (LMICs), the Ghanaian healthcare system remains poor which is likely to affect the utilisation of healthcare services, especially among poor older people who are faced with multiple health problems. Yet, factors that explain healthcare use among poor older people in LMICs, particularly Ghana remain largely unexplored. Understanding the predictors of healthcare use among poor older people could have a huge impact on health policies in LMICs including Ghana. This study, therefore, examined factors associated with healthcare use among poor older people under the Livelihood Empowerment Against Poverty (LEAP) programme in the Atwima Nwabiagya District of Ghana.

METHODS

Cross-sectional data were obtained from an Ageing, Health, Lifestyle and Health Services (AHLHS) study conducted between 1 and 20 June 2018 (N = 200) in Atwima Nwabiagya District, Ghana. Sequential logistic regression models were performed to estimate the variables that predict healthcare use among poor older people. All test results were considered significant at 0.05 or less.

RESULTS

The fully adjusted model showed that respondents aged 85-89 years (AOR = 0.094, CI: 0.007-1.170), acquired basic education (AOR =0.251, CI: 0.085-0.987), received no family support (AOR = 0.771, CI: 0.120-0.620), with no past illness records (AOR = 0.236, CI: 0.057-0.197) and who were not diagnosed of chronic non-communicable diseases (AOR = 0.418, CI: 0.101-0.723) were significantly less likely to utilise health facility compared with their respective counterparts. Moreover, those with no disability (AOR = 19.245, CI: 2.415-29.921) and who consumed low fruits (AOR = 1.435 = CI: 0.552-8.740) and vegetables (AOR = 1.202 = CI: 0.362-10.20) had a higher likelihood to use healthcare.

CONCLUSION

The study has outlined multiple factors influencing utilisation of healthcare among poor older people under the LEAP programme in Ghana. The results, therefore, validate the importance of social and behavioural determinants of healthcare use in the Ghanaian poor older population. We highlight the need for health planners and stakeholders to consider demographic, socio-economic, health-related and lifestyle factors when formulating health policy for poor older people in Ghana.

Equity in distribution of public subsidy for noncommunicable diseases among the elderly in India: an application of benefit incidence analysis

Background

Rapid ageing of the population and increasing non-communicable diseases (NCDs) among the elderly is one of the major public health challenges in India. To achieve the Universal Health Coverage, ever-growing elderly population should have access to needed healthcare, and they should not face any affordability related challenge. As most of the elderly suffers from NCDs and achieving health-equity is a priority, this paper aims to - study the utilization pattern of healthcare services for treatment of NCDs among the elderly; estimate the burden of out-of-pocket expenditure for the treatment of NCDs among the elderly and analyze the extent of equity in distribution of public subsidy for the NCDs among the elderly.

Methods

National Sample Survey data (71st round) has been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, out-of-pocket expenditure and distribution of public subsidy among economic classes. Concentration curves and indices are also estimated.

Results

Results show that public-sector hospitalization for NCDs among the elderly has a pro-rich trend in rural India. However, in urban sector, for both inpatient and outpatient care the poorest class has substantial share in utilization of public facilities. Same result is also observed for rural outpatient care. Analysis shows that out-of-pocket expenditure is very high for both medicine and medical care even in public facilities for all economic groups. It is also observed that medicine has the highest share in total medical expenses during treatment of NCDs among the elderly in both the region. Benefit incidence analysis shows that the public subsidy has a pro-rich distribution for inpatient care treatment in both the sectors. In case of outpatient care, subsidy share is the maximum among the richest in the urban sector and in the rural region the poorest class gets the maximum subsidy benefit.

Conclusions

It is evident that a substantial share of the public subsidies is still going to the richer sections for the treatment of NCDs among the elderly. Evidences also suggest that procuring medicines and targeted policies for the elderly are needed to improve utilization and equity in the public healthcare system.

Barriers to formal healthcare utilisation among poor older people under the livelihood empowerment against poverty programme in the Atwima Nwabiagya District of Ghana

BACKGROUND

Even though there is a growing literature on barriers to formal healthcare use among older people, little is known from the perspective of vulnerable older people in Ghana. Involving poor older people under the Livelihood Empowerment Against Poverty (LEAP) programme, this study explores barriers to formal healthcare use in the Atwima Nwabiagya District of Ghana.

METHODS

Interviews and focus group discussions were conducted with 30 poor older people, 15 caregivers and 15 formal healthcare providers in the Atwima Nwabiagya District of Ghana. Data were analysed using the thematic analytical framework, and presented based on an a posteriori inductive reduction approach.

RESULTS

Four main barriers to formal healthcare use were identified: physical accessibility barriers (poor transport system and poor architecture of facilities), economic barriers (low income coupled with high charges, and non-comprehensive nature of the National Health Insurance Scheme [NHIS]), social barriers (communication/language difficulties and poor family support) and unfriendly nature of healthcare environment barriers (poor attitude of healthcare providers).

CONCLUSIONS

Considering these barriers, removing them would require concerted efforts and substantial financial investment by stakeholders. We argue that improvement in rural transport services, implementation of free healthcare for poor older people, strengthening of family support systems, recruitment of language translators at the health facilities and establishment of attitudinal change programmes would lessen barriers to formal healthcare use among poor older people. This study has implications for health equity and health policy framework in Ghana.

Socioeconomic inequalities in healthcare utilisation in Indonesia: a comprehensive survey-based overview

OBJECTIVE

Monitoring inequality in healthcare utilisation is essential to reduce persistent inequalities in health in lower-middle income countries. This study aimed to assess socioeconomic inequalities in the utilisation of primary care, secondary care and preventive care in Indonesia.

METHODS

A cross-sectional study was conducted using data from the 2014 Indonesia Family Life Survey with a total of 42 083 adult participants. Socioeconomic status (SES) was measured by educational level and income. Healthcare utilisation was measured in: (1) primary care, (2) outpatient in secondary care, (3) inpatient care and (4) cardiovascular-related preventive care. The magnitude of inequalities was measured using the relative index of inequality (RII).

RESULTS

Small educational inequalities were found for primary care utilisation (RII 1.13, 95% CI 1.01 to 1.26). Larger educational inequalities were found for outpatient secondary care (RII 10.35, 95% CI 8.11 to 13.22) and inpatient care (RII 2.78, 95% CI 2.32 to 3.32). The largest educational inequalities were found for preventive care, particularly regarding blood glucose tests (RII 30.31, 95% CI 26.13 to 35.15) and electrocardiography tests (RII 30.90, 95% CI 24.97 to 38.23). Compared with educational inequalities, income inequalities were larger for primary care (RII 1.68, 95% CI 1.52 to 1.85) and inpatient care (RII 3.11, 95% CI 2.63 to 3.66), but not for outpatient secondary care and preventive care.

CONCLUSIONS

Socioeconomic inequalities in healthcare utilisation in Indonesia are particularly large in secondary and preventive care. Therefore, it is recommended to prioritise policies focused on improving timely, geographical and financial access to secondary and preventive care for lower SES groups.

Correlates of Health-Related Quality of Life for Māori Elders Involved in a Peer Education Intervention

The purpose of this study was to identify social determinant and communication correlates of health-related quality of life for kaumātua (Māori elders) in New Zealand. A total of 209 kaumātua completed a self-report survey of self-rated health, physical/mental quality of life, spirituality, and a series of questions about social determinants (e.g., factors related to income) and communication variables (e.g., loneliness, social support, cultural identity, and perceived burden/benefit). The survey was baseline data for a peer education intervention to help kaumātua work through life transitions in older age. The main findings of this study were that social determinants, particularly difficulty paying bills, accounted for a small amount of variance in physical/mental quality of life and self-rated health. Further, the communication correlates of loneliness, perceived burden, and desired support accounted for about three times as much variance in these two outcomes all with negative associations. Strength of tribal identity, importance of whānau (extended family), and knowledge of tikanga (customs and protocols) accounted for a moderate amount variance in spirituality with positive associations. These findings have important theoretical and practical implications for positive aging.

Prevalence and Patterns of Health Care Use Among Poor Older People Under the Livelihood Empowerment Against Poverty Program in the Atwima Nwabiagya District of Ghana

In spite of the growing literature on prevalence and patterns of health care use in later life globally, studies have generally overlooked subjective standpoints of vulnerable Ghanaian older people obstructing the achievement of the United Nations’ health-related Sustainable Development Goals. We examined the prevalence and patterns of health care use among poor older people in the Atwima Nwabiagya District of Ghana. Cross-sectional data were obtained from an Aging, Health, Lifestyle and Health Services Survey conducted between June 1 and 20, 2018 (N = 200). Chi-square and Fisher’s exact tests were carried out to estimate the differences between gender and health care utilization with significant level of less than or equal to 0.05. Whereas, 85% of the respondents utilized health care, females were higher utilizers (88% vs. 75%) but males significantly incurred higher health care expenditure. The majority utilized health services on monthly basis (38%) and consulted public health care providers (77%). While 68% utilized services from hospitals, most sourced health information from family members (54%) and financed their health care through personal income (45%). The study found that the Livelihood Empowerment Against Poverty grant played a little role in reducing health poverty. Stakeholders should review social programs that target poor older people in order to improve their well-being and utilization of health care.

Socioeconomic inequality in functional deficiencies and chronic diseases among older Indian adults: a sex-stratified cross-sectional decomposition analysis

OBJECTIVES

Older adults with adverse socioeconomic conditions suffer disproportionately from a poor quality of life. Stratified by sex, income-related inequalities have been decomposed for functional deficiencies and chronic diseases among older adults, and the degree to which social and demographic factors contribute to these inequalities was identified in this study.

DESIGN

Cross-sectional study.

PARTICIPANTS

Data used for this study were retrieved from the WHO Study on Global AGEing and Adult Health Wave 1. A total of 3753 individuals (men: 1979, and women: 1774) aged ≥60 years were found eligible for the analysis.

MEASURES

Instrumental Activity of Daily Living (IADL) deficiency and presence of chronic diseases.

METHOD

The decomposition method proposed by Adam Wagstaff and his colleagues was used. The method allows estimating how determinants of health contribute proportionally to inequality in a health variable.

RESULTS

Compared with men, women were disproportionately affected by both functional deficiencies and chronic diseases. The relative contribution of sociodemographic factors to IADL deficiency was highest among those with poor economic status (38.5%), followed by those who were illiterate (22.5%), which collated to 61% of the total explained inequalities. Similarly, for chronic diseases, about 93% of the relative contribution was shared by those with poor economic status (42.3%), rural residence (30.5%) and illiteracy (20.3%). Significant difference in predictors was evident between men and women in IADL deficiency and chronic illness.

CONCLUSION

Pro-poor intervention strategies could be designed to address functional deficiencies and chronic diseases, with special attention to women.

Gendered "Long Arm" of Parental Education? Life Course Influences on Later Life Functional Limitations in India

Objective: We adopt a novel approach to mediation analysis to account for interrelated life course social processes that constitute later life health disparities. We examine gender-specific direct effect of parental education on functional limitations in later life. Method: Based on the first wave (2007-2010; n = 7,150) of the Study on Global Ageing and Adult Health (SAGE), we estimate both (natural) direct and indirect effects of parental education on functional limitations in later life. Results: We observed a significant indirect and positive effect of parental education on functional health. Contrary to prior literature, we documented adverse direct effect of parental education on later life functional health. The direct effect is statistically significant only for father's education, and is greater, though not statistically significantly so, for women than men. Discussion: The intersection of gender status and interrelated social stratification documented by this study highlights the need for gender-sensitive life course research. Such research can enhance our understanding of the ways patriarchal social systems produce heterogeneous effects of interrelated structural factors on later life health for men and women.

Is the single self-rated health item reliable in India? A construct validity study

Introduction

In high-income countries, the self-rated health (SRH) item is used in health surveys to capture the population’s general health because of its simplicity and satisfactory validity and reliability. Despite scepticism about its use in low-income and middle-income countries, India implemented the SRH item in many of its demographic and population health surveys, but evidence of its validity is lacking. The objective was to assess the construct validity of the SRH item in India.

Methods

Data for 4492 men and 4736 women from the Indian sample of the World Health Survey (2003) were used. Overall, 43 health status indicators were grouped into health dimensions (physical, mental and functional health, chronic diseases, health behaviours) and the SRH item was regressed on these indicators by using sex-stratified multivariable linear regressions, adjusted with demographic and socioeconomic variables.

Results

Respondents (participation rate 95.6%; mean age 38.9 years) rated their health as very good (21.8%), good (36.4%), moderate (26.6%), bad (13.2%) or very bad (2.0%). Among men, the adjusted explained SRH variance by health dimensions ranged between 18% and 41% (physical 33%, mental 32%, functional health 41%, chronic diseases 23%, health behaviours 18%). In multivariable models, the overall explained variance increased to 45%. The 43 health status indicators were associated with SRH and their effect sizes were in the expected direction. Among women, results were similar (overall explained variance 48%).

Conclusion

The SRH item has satisfactory construct validity and may be used to monitor health status in demographic and population health surveys of India.