Application of the nonlinear Blinder-Oaxaca decomposition to study racial/ethnic disparities in antiobesity medication use in the United States

Socioeconomic inequality and urban-rural disparity of antenatal care visits in Bangladesh: A trend and decomposition analysis

BACKGROUND

Socioeconomic inequality in antenatal care visits is a great concern in developing countries including Bangladesh; however, there is a scarcity of investigation to assess the factors of inequality and these changes over time. In this study, we investigated the trend of socioeconomic inequalities (2004-2017) in 1+ANC and 4+ANC visits, and extracted determinants contributions to the observed inequalities and urban-rural disparities in Bangladesh over the period from 2011 to 2017.

METHODS

The data from the Bangladesh Demographic and Health Surveys (BDHS) conducted in 2004, 2007, 2011 and 2017 were analyzed in this study. The analysis began with exploratory and bivariate analysis, followed by the application of logistic regression models. To measure the inequalities, the Erreygers concentration index was used, and regression-based decomposition analyses were utilized to unravel the determinant's contribution to the observed inequalities. The Blinder-Oaxaca type decomposition is also used to decompose the urban-rural disparity into the factors.

RESULTS

Our analysis results showed that the prevalence of 1+ANC and 4+ANC visits has increased across all the determinants, although the rate of 4+ANC visits remains notably low. The magnitudes of socioeconomic inequality in 4+ANC visits represented an irregular pattern at both the national and urban levels, whereas it increased gradually in rural Bangladesh. However, inequalities in 1+ANC visits declined substantially after 2011 across the national, rural and urban areas of Bangladesh. Decomposition analyses have suggested that wealth status, women's education, place of residence (only for 4+ANC visits), caesarean delivery, husband education, and watching television (TV) are the main determinants to attribute and changes in the level of inequality and urban-rural disparity between the years 2011 and 2017.

CONCLUSIONS

According to the findings of our study, it is imperative for authorities to ensure antenatal care visits are more accessible for rural and underprivileged women. Additionally, should focus on delivering high-quality education, ensuring the completion of education, reducing income disparity as well as launching a program to enhance awareness about health facilities, and the impact of caesarean delivery.

Social and facilitating influences in fintech user intention and the fintech gender gap

Given the advances in technology, Fintech is an invaluable tool which allows unbanked people to access financial services when social, cultural, economic and technological factors affect their user intentions (UI). Despite the great importance of the role of social and facilitating influences in the adoption of Fintech services, little research has been conducted on how and what influences affect Fintech user intention (FUI) and whether there is a gender gap in FUI. Therefore, this study aims to help formulate effective Fintech policies and close the gender gap by investigating the role of social and facilitating influences and sociodemographic variables in FUI. The study sample comprised 237 participants, and the data were collected through interviews with the use of a structured questionnaire in Chattogram, Bangladesh. The collected data were analysed employing exploratory factor analysis and an ordered logistic regression model. The study also examined the Fintech gender gap by applying the Blinder Oaxaca decomposition model. The results reveal that image, compatibility and the experiences of Fintech use are the positive and significant predictors of FUI, with the perceived social norm for adopting Fintech being non-informative for users. There is a significant interaction between user compatibility and experience of use in relation to Fintech. Interestingly, perceived behavioural control negatively influenced females to adopt Fintech. Furthermore, the study found a gender gap in FUI. The findings have managerial implications.

Decomposing differences in the chronic disease condition between rural and urban older adults in China: a cross-sectional analysis

Background

With the increasing in aging in China, there has been an increase in older adults suffering from chronic diseases. However, little is known about the differences in chronic disease conditions between rural and urban older adults. The objective of this study is to identify chronic disease conditions and investigate the factors that cause differences in chronic disease conditions between urban and rural older adults.

Methods

The data are from the fourth wave of the China Health and Retirement Longitudinal Study. The coarsened exact matching (CEM) method was used to reduce the biases for a comparative study. After the CEM method, this study included 5,927 participants aged 60 and above. Chronic disease condition was used as the indicator to measure the health of older adults. Specifically, Fairlie's decomposition analysis was carried out to discover the differences in chronic disease conditions between urban and rural older adults.

Results

The study showed that the proportion of those suffering from chronic diseases was significantly higher among urban older adults (51.26%) than rural older adults (46.56%). In those suffering from chronic diseases, there were significant differences in gender, education level, minorities, religiosities, duration of sleep, drinking alcohol, social activity, insurance, and socioeconomic status between rural and urban older adults, while in those not suffering from chronic diseases, there were significant differences in age, education level, marital status, drinking alcohol, social activity, insurance, region, and socioeconomic status between rural and urban older adults. For rural older adults, those who were widowers [Odds ratios (OR): 1.267], who drink alcohol (OR: 1.421), and having government medical insurance (OR: 4.869) had higher odds of having chronic diseases. However, those who were in high school and above (OR: 0.802), reporting a duration of sleep of 4-8 h (OR: 0.745) or above 8 h (OR: 0.649), having social activity (OR: 0.778), and having the most affluent socioeconomic status (OR: 0.778) had lower odds of having chronic diseases. As for urban older adults, those who were aged 65-74 years (OR: 1.246) and had government medical insurance (OR: 2.362) had higher odds of having chronic diseases. Fairlie's decomposition analysis indicated that 23.57% of the differences in chronic diseases conditions could be traced to duration of sleep, drinking alcohol, social activity, and region.

Conclusion

This study illustrated that the proportion of chronic diseases was higher among urban older adults than rural older adults. Considering duration of sleep, drinking alcohol, region, social activity, and region, the study demonstrated health differences between urban and rural older adults and provided evidence for policy-making to narrow the health gap between urban and rural areas.

Equity in Obesity Review

Obesity disproportionately affects racial and ethnic minoritized populations and those of lower socioeconomic status. Similarly, disparities exist in the development of its downstream consequences, such as type 2 diabetes and hypertension. The causes of these disparities are multifactorial and are influenced by structural factors such as segregation and healthcare access, and individual-level factors such as weight stigma. Interventions to decrease disparities in obesity should consider macro-level, community, and individual-level factors that might reduce disparities and improve equity in obesity care. Clinicians must also recognize the chronic nature of obesity, and how bias and stigma may impact patient care.

Exploring racial and ethnic disparities in medication adherence among Medicare comprehensive medication review recipients

Background

There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services.

Objectives

To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics.

Methods

The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities.

Results

Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33–1.45), 27% (OR = 1.27, 95% CI = 1.22–1.32), and 43% (OR = 1.43, 95% CI = 1.39–1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14–1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B–W) diabetes, B–W hypertension, B–W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender.

Conclusions

A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence.

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This retrospective study used 100% of the 2017 Medicare claims including MTM data.

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Racial/ethnic disparity in medication adherence was identified among CMR recipients.

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Blacks were more likely than Whites to be nonadherent to all medications studied.

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Hispanics were more likely than Whites to be hyperlipidemia medication nonadherent.

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Observed characteristics explained close to 15% of the identified disparity.

A detailed explanation and graphical representation of the Blinder-Oaxaca decomposition method with its application in health inequalities

This paper introduces the Blinder-Oaxaca decomposition method to be applied in explaining inequality in health outcome across any two groups. In order to understand every aspect of the inequality, multiple regression model can be used in a way to decompose the inequality into contributing factors. The method can therefore be indicated to what extent of the difference in mean predicted outcome between two groups is due to differences in the levels of observable characteristics (acceptable and fair). Assuming the identical characteristics in the two groups, the remaining inequality can be due to differential effects of the characteristics, maybe discrimination, and unobserved factors that not included in the model. Thus, using the decomposition methods can identify the contribution of each particular factor in moderating the current inequality. Accordingly, more detailed information can be provided for policy-makers, especially concerning modifiable factors. The method is theoretically described in detail and schematically presented. In the following, some criticisms of the model are reviewed, and several statistical commands are represented for performing the method, as well. Furthermore, the application of it in the health inequality with an applied example is presented.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies

Background

The prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences.

Methods

Unbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences.

Results

The CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas.

The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly.

Conclusions

Compared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10887-6.

Black Lives Matter: A Decomposition of Racial Inequalities in Oral Cancer Screening

Simple Summary

Black Lives Matter has highlighted the increased social discrepancies that exist not only in the context of social justice but also in public health. Oral cancer screening is not exempt from disparity, with Black Americans less likely to seek screening leading to higher incidence and worse outcomes of oropharyngeal cancers. We investigate interaction analysis and Blinder–Oaxaca decomposition as tools to guide policy to address this disparity. Using National Health and Nutrition Examination Survey (NHANES) data from 2011–2018 we find that being both in poverty and Black results in sub-additive interaction, which is further deconstructed into differences in higher education levels and poverty status.

Abstract

(1) Background: The Black Lives Matter movement has highlighted the discrepancies in public health in regard to race. This study aims to investigate tools that can be used to analyze and investigate this discrepancy, which can be applied to policymaking. (2) Methods: National Health and Nutrition Examination Survey (NHANES) data from 2011–2018 was combined (N = 22,617) to investigate discrepancies of oral cancer screening in Black Americans. We give examples of counterfactual techniques that can be used to guide policy. Inverse probability treatment weighting (IPTW) was used to remove all measured confounding in an interaction analysis to assess the combined effect of socioeconomic status and race. Blinder–Oaxaca decomposition was then used to investigate the intervenable factors associated with differences in race. (3) Results: Sub-additive interaction was found on additive and multiplicative scales when all measured confounding was removed via IPTW (relative excess risk due to interaction (RERI)(OR) = −0.55 (−0.67–−0.42)). Decomposition analysis found that 32% of the discrepancy could be explained by characteristics of higher education and poverty status. (4) Conclusions: Black Americans in poverty are less likely to seek oral cancer screening than the additive likelihood would suggest. Blinder–Oaxaca decomposition is a strong tool to use for guiding policy as it quantifies clear breakdowns of what intervenable factors there are that would improve the discrepancy the most.

Protocol for studying racial/ethnic disparities in depression care using joint information from participant surveys and administrative claims databases: an observational cohort study

INTRODUCTION

Current evidence indicates that older racial/ethnic minorities encounter disparities in depression care. Because late-life depression is common and confers major adverse health consequences, it is imperative to reduce disparities in depression care. Thus, the primary objectives of this protocol are to: (1) quantify racial/ethnic disparities in depression treatment and (2) identify and quantify the magnitude of these disparities accountable for by a multifactorial combination of patient, provider and healthcare system factors.

METHODS AND ANALYSIS

Data will be derived from the Vitamin D and Omega-3 Trial-Depression Endpoint Prevention (VITAL-DEP) study, a late-life depression prevention ancillary study to the VITAL trial. A total of 25 871 men and women, aged 50+ and 55+ years, respectively, were randomised in a 2×2 factorial randomised trial of heart disease and cancer prevention to receive vitamin D and/or fish oil for 5 years starting from 2011. Most participants were aged 65+ years old at randomisation. Medicare claims data for over 19 000 VITAL/VITAL-DEP participants were linked to conduct our study.The major study outcomes are depression treatment (antidepressant use and/or receipt of psychotherapy services) and adherence to medication treatment (antidepressant adherence and acceptability). The National Academy of Medicine framework for studying racial disparities was leveraged to select patient-level, provider-level and healthcare system-level variables and to address their potential roles in depression care disparities. Blinder-Oaxaca regression decomposition methods will be implemented to quantify and identify correlates of racial/ethnic disparities in depression treatment and adherence.

ETHICS AND DISSEMINATION

This study received Institutional Review Board (IRB) approval from the Partners Healthcare (PHS) IRB, protocol# 2010P001881. We plan to disseminate our results through publication of manuscripts patient engagement activities, such as study newsletters regularly sent out to VITAL participants, and presentations at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT01696435.

Catastrophic health expenditure and impoverishment for type 2 diabetes mellitus patients in a multiethnic province in China using a Blinder-Oaxaca decomposition: A cross-sectional study

This study aimed to compare the catastrophic health expenditure (CHE) and impoverishment of type 2 diabetes mellitus (T2DM) patients between 2 ethnic groups and explore the contribution of associated factors to ethnic differences in CHE and impoverishment in Ningxia Hui Autonomous Region, China.A cross-sectional study was conducted in 2 public hospitals from October 2016 to June 2017. Data were collected by interviewing eligible Hui and Han T2DM inpatients and reviewing the hospital electronic records. Both CHE and impoverishment were measured by headcount and gap. The contributions of associated factors to ethnic differences were analyzed by the Blinder-Oaxaca decomposition technique.Both the CHE and impoverishment of Hui patients before and after reimbursement were significantly higher than those of Han patients. The ethnic differences in CHE and impoverishment headcount after reimbursement were 11.9% and 9.8%, respectively. The different distributions of associated factors between Hui and Han patients contributed to 60.5% and 35.7% of ethnic differences in CHE and impoverishment, respectively. Household income, occupation, and region were significant contributing factors.Hui T2DM patients suffered greater CHE and impoverishment than Han patients regardless of reimbursements from health insurance. Differences in socioeconomic status between Hui and Han patients were the main factors behind the ethnic differences.

Decomposing Gender Disparity in Total Physical Activity among Iranian Adults

OBJECTIVES

While gender differences in physical activity (PA) have been reported, their origin is not well understood. The present study aimed to identify factors contributing to this disparity.

METHODS

This was a population-based cross-sectional study based on the 2011 surveillance of risk factors of non-communicable diseases that was conducted among Iranian adults. Multi-staged sampling was performed to obtain the required study sample. The primary outcome was gender differences in the prevalence of sufficient physical activity (SPA). Total physical activity (TPA) was calculated as metabolic equivalents (MET) per minute during a typical week, as recommended by the World Health Organization. On this basis, achieving 600 MET-min/wk or more was defined as SPA. The nonlinear Blinder-Oaxaca decomposition technique was used to explain the disparity.

RESULTS

The predicted gap was 19.50%. About one-third of the gap was due to differences in the level of observable covariates. Among them, work status contributed the most (29.61%). A substantial portion of the gap remained unexplained by such differences, of which about 40.41% was related to unobservable variables. The differential effects of standard of living, ethnicity, and smoking status made the largest contribution, accounting for 37.36, 35.47, and 28.50%, respectively.

CONCLUSIONS

Interventions to reduce the gender gap in PA should focus on increasing TPA among housewives and women with chronic diseases, as well as those with a higher standard of living. In addition, it is essential to explore the impact of ethnicity and smoking status on women’s TPA in order to promote health.

Weight loss drugs and lifestyle modification: Perceptions among a diverse adult sample

OBJECTIVES

Explore how adults from diverse racial and socioeconomic backgrounds perceive the use of weight loss drugs (prescription, over-the counter, herbals and supplements) and lifestyle modification.

METHODS

Individual, face-to-face, semi-structured interviews were conducted with persons presenting to an academic hospital-affiliated outpatient pharmacy serving ethnic minorities and low income individuals.

RESULTS

Fifty persons were interviewed, including 21 African Americans, 11 Hispanics and 17 low-income individuals (annual income <$20,000), of whom 33 self-reported as overweight or obese. Ever-users (14/50) and nonusers (36/50) of weight loss drugs expressed a belief in the importance of diet and exercise, but were not necessarily doing so themselves. Fear of side effects and skepticism towards efficacy of drugs deterred use. Some expressed concern over herbal product safety; others perceived herbals as natural and safe. Drugs were often viewed as a short-cut and not a long-term weight management solution.

CONCLUSION

A range of concerns related to the safety and efficacy of weight loss drugs were expressed by this lower income, ethnically diverse population of underweight to obese adults.

PRACTICE IMPLICATIONS

There is need and opportunity for healthcare providers to provide weight loss advice and accurate information regarding the safety and efficacy of various types of weight loss approaches.

Characteristics of patients potentially eligible for pharmacotherapy for weight loss in primary care practice in the United States

Objective

To describe the characteristics of real‐world patients potentially eligible for adjunctive pharmacotherapy for weight loss.

Methods

Patients from the GE Centricity electronic medical record database were selected if they had body mass index (BMI) ≥30 or ≥27 to <30 kg m⁻² with ≥1 obesity‐associated comorbidity (hypertension, dyslipidemia, or type 2 diabetes) from 2002–2011; were aged ≥18 years and had ≥12 months of continuous enrollment before and after the date of first eligible BMI recorded (index date). Descriptive statistics and logistic regression were used for analysis.

Results

Of the 1,835,541 patients with overweight or obesity included, comorbidities were common (hypertension [55.4%], dyslipidemia [36.1%] and type 2 diabetes [13.4%]). The percentage of patients who received pharmacotherapy for weight loss was 0.7% within 12 months after the index date. Patients who received pharmacotherapy had higher BMI (median, 33.6 vs. 31.3 kg m⁻²), were younger (median, 42 vs. 52 years), primarily women (84.3 vs. 58.2%), commercially insured (70.1 vs. 50.4%) and had more frequent use of antidepressants (30.8 vs. 14.1%) and non‐steroidal anti‐inflammatory drugs (21.7 vs. 12.0%) than those who did not at baseline (all P values < 0.0001).

Conclusions

Few eligible patients received pharmacotherapy for weight loss. Patients who received pharmacotherapy tended to be heavier, younger, female, commercially insured, and used more antidepressants and non‐steroidal anti‐inflammatory drugs.

Decomposing racial/ethnic disparities in influenza vaccination among the elderly

While persistent racial/ethnic disparities in influenza vaccination have been reported among the elderly, characteristics contributing to disparities are poorly understood. This study aimed to assess characteristics associated with racial/ethnic disparities in influenza vaccination using a nonlinear Oaxaca-Blinder decomposition method. We performed cross-sectional multivariable logistic regression analyses for which the dependent variable was self-reported receipt of influenza vaccine during the 2010-2011 season among community dwelling non-Hispanic African-American (AA), non-Hispanic White (W), English-speaking Hispanic (EH) and Spanish-speaking Hispanic (SH) elderly, enrolled in the 2011 Medicare Current Beneficiary Survey (MCBS) (un-weighted/weighted N=6,095/19.2 million). Using the nonlinear Oaxaca-Blinder decomposition method, we assessed the relative contribution of seventeen covariates - including socio-demographic characteristics, health status, insurance, access, preference regarding healthcare, and geographic regions - to disparities in influenza vaccination. Unadjusted racial/ethnic disparities in influenza vaccination were 14.1 percentage points (pp) (W-AA disparity, p<0.001), 25.7 pp (W-SH disparity, p<0.001) and 0.6 pp (W-EH disparity, p>.8). The Oaxaca-Blinder decomposition method estimated that the unadjusted W-AA and W-SH disparities in vaccination could be reduced by only 45% even if AA and SH groups become equivalent to Whites in all covariates in multivariable regression models. The remaining 55% of disparities were attributed to (a) racial/ethnic differences in the estimated coefficients (e.g., odds ratios) in the regression models and (b) characteristics not included in the regression models. Our analysis found that only about 45% of racial/ethnic disparities in influenza vaccination among the elderly could be reduced by equalizing recognized characteristics among racial/ethnic groups. Future studies are needed to identify additional modifiable characteristics causing disparities in influenza vaccination.