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Woodward A, Walters K, Davies N, Nimmons D, Protheroe J, Chew‐Graham CA, Stevenson F, Armstrong M. Barriers and facilitators of self-management of diabetes amongst people experiencing socioeconomic deprivation: A systematic review and qualitative synthesis. Health Expect 2024; 27:e14070. [PMID: 38751247 PMCID: PMC11096776 DOI: 10.1111/hex.14070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The number of people living with diabetes is rising worldwide and a higher prevalence of diabetes has been linked to those experiencing socioeconomic deprivation. Self-management strategies are vital and known to reduce the risks of long-term complications amongst people living with diabetes. Lack of knowledge about self-care activity required to manage diabetes is a key barrier to successful self-management. Self-management interventions can be less effective in socioeconomically deprived populations which can increase the risk of exacerbating health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management of diabetes amongst people who are socioeconomically disadvantaged. METHODS MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions amongst socioeconomically disadvantaged populations. Relevant papers which focused on diabetes were identified. Data were coded and thematically synthesised using NVivo. FINDINGS From the search results, 79 qualitative studies were identified after full-text screening and 26 studies were included in the final thematic analysis. Two overarching analytical themes were identified alongside a set of subthemes: (1) Socioeconomic barriers to diabetes self-management; healthcare costs, financial costs of healthy eating, cultural influences, living in areas of deprivation, competing priorities and time constraints, health literacy, (2) facilitators of diabetes self-management; lifestyle and having goals, support from healthcare providers, informal support. DISCUSSION Self-management of diabetes is challenging for people experiencing socioeconomic deprivation due to barriers associated with living in areas of deprivation and financial barriers surrounding healthcare, medication and healthy food. Support from healthcare providers can facilitate self-management, and it is important that people with diabetes have access to interventions that are designed to be inclusive from a cultural perspective as well as affordable. PATIENT OR PUBLIC CONTRIBUTION A patient advisory group contributed to the research questions and interpretation of the qualitative findings by reflecting on the themes developed.
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Affiliation(s)
- Abi Woodward
- Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Kate Walters
- Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Nathan Davies
- Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Danielle Nimmons
- Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | | | | | - Fiona Stevenson
- Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Megan Armstrong
- Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
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Okoli GN, Neilson CJ, Grossman Moon A, Kimmel Supron H, Soos AE, Grewal A, Etsell K, Alessi-Severini S, Richardson C, Harper DM. Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis. Vaccine 2024:S0264-410X(24)00601-7. [PMID: 38796328 DOI: 10.1016/j.vaccine.2024.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/08/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower. METHODS We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated. RESULTS We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening. CONCLUSIONS These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.
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Affiliation(s)
- George N Okoli
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | | | | | | | - Alexandra E Soos
- University of Michigan Medical School, University of Michigan, Michigan, USA
| | - Avneet Grewal
- University of Michigan Medical School, University of Michigan, Michigan, USA
| | - Katharine Etsell
- University of Michigan Medical School, University of Michigan, Michigan, USA
| | - Silvia Alessi-Severini
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Caroline Richardson
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Diane M Harper
- Departments of Family Medicine and Obstetrics & Gynecology, University of Michigan, Michigan, USA
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Moon MH, Choi MH. Association between household income and mental health among adults during the COVID-19 pandemic in Korea: Insights from a community health survey. PLoS One 2024; 19:e0289230. [PMID: 38603729 PMCID: PMC11008867 DOI: 10.1371/journal.pone.0289230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/15/2024] [Indexed: 04/13/2024] Open
Abstract
People of low socioeconomic status are vulnerable to health problems during disasters such as the COVID-19 pandemic. Using data from the 2019 and 2021 Korea Community Health Survey, this study analyzed the associations between Korean adults' mental health and their national and regional-level household incomes during the pandemic. The prevalence of perceived stress and depression experience for each risk factor category was calculated through univariate analyses. A multivariate logistic regression analysis helped identify the association between two types of income levels (national or regional) and perceived stress and experience of depression. Additionally, we investigated the effect of income levels by subgroup (gender and residential area) on perceived stress and the experience of depression. During the pandemic, the crude prevalence of an experience of depression was higher (6.24% to 7.2%) but that of perceived stress remained unchanged. Regarding regional-income based mental health disparities, even after adjusting for each independent variable, perceived stress (2019 odds ratio (OR): 1.26, 95% confidence interval (CI):1.26-1.27, 2021 OR: 1.32, 95% CI: 1.32-1.32) and experience of depression (2019 OR: 1.56, 95% CI: 1.55-1.56, 2021 OR: 1.63, 95% CI: 1.63-1.64) increased as the income level decreased. The perceived stress based on the two income levels was higher in women than in men. For both income levels, the experience of depression of women was higher than that of men before COVID-19 and vice versa during the COVID-19 period. National income had a more pronounced effect on mental health in urban areas than in rural areas. Contrarily, the effect of regional income level on mental health was not consistent across residential areas (urban and rural areas). Our findings demonstrated that mental health disparities based on income level were more likely to occur during the COVID-19 pandemic and are better reflected through disparities in regional income levels.
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Affiliation(s)
- Min Hui Moon
- Department of Preventive and Occupational & Environmental Medicine, Medical College, Pusan National University, Yangsan, Republic of Korea
- Office of Public Healthcare Service, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Min Hyeok Choi
- Department of Preventive and Occupational & Environmental Medicine, Medical College, Pusan National University, Yangsan, Republic of Korea
- Office of Public Healthcare Service, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Ramos SD, Kannout L, Khan H, Klasko-Foster L, Chronister BN, Du Bois S. A Neighborhood-level analysis of mental health distress and income inequality as quasi-longitudinal risk of reported COVID-19 infection and mortality outcomes in Chicago. DIALOGUES IN HEALTH 2023; 2:100091. [PMID: 36530218 PMCID: PMC9731648 DOI: 10.1016/j.dialog.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 12/02/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
Extant literature investigates the impact of COVID-19 on mental health outcomes, however there is a paucity of work examining mental health distress as a risk factor for COVID-19 outcomes. While systemic variables like income inequality relate to both mental health and COVID-19, more work is needed to test theoretically informed models including such variables. Using a social-ecological framework, we aimed to address these gaps in the literature by conducting a neighborhood-level analysis of potential mental health distress and systemic- (income inequality) level predictors of reported COVID-19 infection and mortality over time in Chicago. Neighborhood-level comparisons revealed differences in mental health distress, income inequality, and reported COVID-19 mortality, but not reported COVID-19 infection. Specifically, Westside and Southside neighborhoods generally reported higher levels of mental health distress and greater concentration of poverty. The Central neighborhood showed a decline in reported mortality rates over time. Multi-level negative binomial models established that Zip-codes with greater mental health distress were at increased reported COVID-19 infection risk, yet lower mortality risk; Zip-codes with more poverty were at increased reported COVID-19 infection risk, yet lower mortality risk; and Zip-codes with the highest percentage of People of Color were at decreased risk of reported COVID-19 mortality. Taken together, these findings substantiate Chicago neighborhood-level disparities in mental health distress, income inequality, and reported COVID-19 mortality; identify unique differential associations of mental health distress and income inequality to reported COVID-19 infection and reported mortality risk; and, offer an alternative lens towards understanding COVID-19 outcomes in terms of race/ethnicity.
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Affiliation(s)
- Stephen D. Ramos
- University of California San Diego, Division of Infectious Diseases and Global Public Health, Department of Medicine, San Diego, CA 92093, USA
- San Diego State University, SDSU Research Foundation, San Diego, CA 92120, USA
| | - Lynn Kannout
- Illinois Institute of Technology, Department of Psychology, Chicago, IL 60616, USA
| | - Humza Khan
- Illinois Institute of Technology, Department of Psychology, Chicago, IL 60616, USA
| | - Lynne Klasko-Foster
- Brown University, Department of Psychiatry and Human Behavior, Providence, RH 02912, USA
| | - Briana N.C. Chronister
- Herbert Wertheim School of Public Health, University of California San Diego, San Diego, CA 92093, USA
- School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Steff Du Bois
- Illinois Institute of Technology, Department of Psychology, Chicago, IL 60616, USA
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Najarian M, Goudie A, Bona JP, Rezaeiahari M, Young SG, Bogulski CA, Hayes CJ. Socioeconomic Determinants of Remote Patient Monitoring Implementation Among Rural and Urban Hospitals. Telemed J E Health 2023; 29:1624-1633. [PMID: 37010391 PMCID: PMC11074434 DOI: 10.1089/tmj.2022.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 04/04/2023] Open
Abstract
Introduction: Remote patient monitoring (RPM) is a form of telehealth that improves quality of care for chronic disease treatment and reduces hospital readmission rates. Geographical proximity to health care is important for individuals of low socioeconomic status (SES) who face additional financial and transportation barriers. The goal of this study was to assess the association between social determinants of health and adoption of RPM. Methods: This cross-sectional study analyzed data from hospitals that responded to the American Hospital Association's Annual Survey (2018) and spatially linked census tract-level environmental and social determinants of health obtained from the Social Vulnerability Index (2018). Results: A total of 4,206 hospitals (1,681 rural and 2,525 urban hospitals) met study criteria. Rural hospitals near households in the lower middle quartile SES were associated with a 33.5% lower likelihood of having adopted RPM for chronic care management compared with rural hospitals near households in the highest quartile SES (adjusted odds ratios [aOR] = 0.665; 95% confidence interval [CI]: 0.453-0.977). Urban hospitals near households in the lowest quartile SES were associated with a 41.9% lower likelihood of having adopted RPM for chronic care management compared with urban hospitals near households in the highest quartile SES (aOR = 0.581; 95% CI: 0.435-0.775). Similar trends in accessibility were found with RPM for postdischarge services among urban hospitals. Conclusion: Our findings highlight the importance of hospital responsibility and state and federal policy approaches toward ensuring equitable access to RPM services for patients characterized by lower SES.
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Affiliation(s)
- Matthew Najarian
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Anthony Goudie
- Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jonathan P. Bona
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mandana Rezaeiahari
- Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sean G. Young
- Department of Environmental Health Sciences, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Cari A. Bogulski
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Corey J. Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Psychiatry and Behavioral Sciences and University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Scanzera AC, Sherrod RM, Potharazu AV, Nguyen D, Beversluis C, Karnik NS, Chan RVP, Kim SJ, Krishnan JA, Musick H. Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting. Transl Vis Sci Technol 2023; 12:11. [PMID: 37831446 PMCID: PMC10587857 DOI: 10.1167/tvst.12.10.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/12/2023] [Indexed: 10/14/2023] Open
Abstract
Purpose To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department. Methods Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0-1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals. Results There were four main themes-transportation, time burden, social support, and economic situation-all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition. Conclusions A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation. Translational Relevance Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.
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Affiliation(s)
- Angelica C. Scanzera
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
| | - R. McKinley Sherrod
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
| | - Archit V. Potharazu
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
- College of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Diana Nguyen
- Institute of Design, Illinois Institute of Technology, Chicago, Illinois, USA
| | - Cameron Beversluis
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
| | - Niranjan S. Karnik
- Institute for Juvenile Research, University of Illinois Chicago, Chicago, Illinois, USA
| | - Robison V. P. Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
| | - Sage J. Kim
- Division of Health Policy, School of Public Health, University of Illinois Chicago, Chicago, Illinois, USA
| | - Jerry A. Krishnan
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
| | - Hugh Musick
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
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PLANEY ARRIANNAMARIE, PLANEY DONALDA, WONG SANDY, MCLAFFERTY SARAL, KO MICHELLEJ. Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018. Milbank Q 2023; 101:922-974. [PMID: 37190885 PMCID: PMC10509521 DOI: 10.1111/1468-0009.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 12/19/2022] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes. CONTEXT The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. METHODS To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models. FINDINGS We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. CONCLUSIONS Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.
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Scanzera AC, Nyenhuis SM, Rudd BN, Ramaswamy M, Mazzucca S, Castro M, Kennedy DJ, Mermelstein RJ, Chambers DA, Dudek SM, Krishnan JA. Building a new regional home for implementation science: Annual Midwest Clinical & Translational Research Meetings. J Investig Med 2023; 71:567-576. [PMID: 37002618 PMCID: PMC11337947 DOI: 10.1177/10815589231166102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
The vision of the Central Society for Clinical and Translational Research (CSCTR) is to "promote a vibrant, supportive community of multidisciplinary, clinical, and translational medical research to benefit humanity." Together with the Midwestern Section of the American Federation for Medical Research, CSCTR hosts an Annual Midwest Clinical & Translational Research Meeting, a regional multispecialty meeting that provides the opportunity for trainees and early-stage investigators to present their research to leaders in their fields. There is an increasing national and global interest in implementation science (IS), the systematic study of activities (or strategies) to facilitate the successful uptake of evidence-based health interventions in clinical and community settings. Given the growing importance of this field and its relevance to the goals of the CSCTR, in 2022, the Midwest Clinical & Translational Research Meeting incorporated new initiatives and sessions in IS. In this report, we describe the role of IS in the translational research spectrum, provide a summary of sessions from the 2022 Midwest Clinical & Translational Research Meeting, and highlight initiatives to complement national efforts to build capacity for IS through the annual meetings.
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Affiliation(s)
- Angelica C. Scanzera
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, 1855 W. Taylor Street, Chicago, IL 60612, United States
| | - Sharmilee M. Nyenhuis
- Department of Pediatrics, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637
| | - Brittany N. Rudd
- Institute for Juvenile Research, University of Illinois Chicago, 1747 W. Roosevelt Rd., Chicago, IL 60612
| | - Megha Ramaswamy
- KU Medical Center, University of Kansas, 3901 Rainbow Boulevard, Kansas City, KS 66160
| | - Stephanie Mazzucca
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130
| | - Mario Castro
- KU Medical Center, University of Kansas, 3901 Rainbow Boulevard, Kansas City, KS 66160
| | - David J. Kennedy
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Ave, Toledo, OH 43614
| | - Robin J. Mermelstein
- Institute for Health Research and Policy, University of Illinois Chicago, 1747 W. Roosevelt Road, Chicago, IL 60612
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, 37 Convent Drive, Bethesda, MD 20814
| | - Steven M. Dudek
- . Department of Medicine, University of Illinois Chicago, 840 S. Wood Street., Chicago, IL 60612
| | - Jerry A. Krishnan
- . Department of Medicine, University of Illinois Chicago, 840 S. Wood Street., Chicago, IL 60612
- Population Health Sciences Program, University of Illinois Chicago, 1220 S. Wood Street, Chicago, IL 60612, United States
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Scanzera AC, Beversluis C, Potharazu AV, Bai P, Leifer A, Cole E, Du DY, Musick H, Chan RVP. Planning an artificial intelligence diabetic retinopathy screening program: a human-centered design approach. Front Med (Lausanne) 2023; 10:1198228. [PMID: 37484841 PMCID: PMC10361413 DOI: 10.3389/fmed.2023.1198228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Diabetic retinopathy (DR) is a leading cause of vision loss in the United States and throughout the world. With early detection and treatment, sight-threatening sequelae from DR can be prevented. Although artificial intelligence (AI) based DR screening programs have been proven to be effective in identifying patients at high risk of vision loss, adoption of AI in clinical practice has been slow. We adapted the United Kingdom Design Council's Double-Diamond model to design a strategy for care delivery which integrates an AI-based screening program for DR into a primary care setting. Methods from human-centered design were used to develop a strategy for implementation informed by context-specific barriers and facilitators. The purpose of this community case study is to present findings from this work in progress, including a system of protocols, educational documents and workflows created using key stakeholder input.
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Affiliation(s)
- Angelica C. Scanzera
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, United States
| | - Cameron Beversluis
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, IL, United States
| | - Archit V. Potharazu
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, IL, United States
| | - Patricia Bai
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, United States
| | - Ariel Leifer
- Department of Family and Community Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Emily Cole
- W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, United States
| | - David Yuzhou Du
- Segal Design Institute, Northwestern University, Evanston, IL, United States
| | - Hugh Musick
- Institute for Healthcare Delivery Design, Office of Population Health Sciences, University of Illinois Chicago, Chicago, IL, United States
| | - R. V. Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, United States
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Nontarak J, Vichitkunakorn P, Waleewong O. Inequalities in access to new medication delivery services among non-communicable disease patients during the COVID-19 pandemic: findings from nationally representative surveys in Thailand. Int J Equity Health 2023; 22:38. [PMID: 36849923 PMCID: PMC9970126 DOI: 10.1186/s12939-023-01845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/18/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND This study describes the inequalities in access to a medication delivery service (MDS) during the COVID-19 pandemic and identifies the social determinants of health-related inequalities among non-communicable disease (NCD) patients. METHODS Data were obtained from a study on the impact of health behaviours and modifications in health behaviours during the COVID-19 pandemic in the Thai population in 2021. The participants were recruited from Bangkok and all four regions of Thailand. The concentration index was used to examine the inequality among income quintiles, which were standardised by age, sex, living area, job type, health insurance scheme, and education level. Logistic regression was used to examine the associations between socio-demographics and access to regular services and new NCD MDSs, adjusted for age, sex, and other covariates. RESULTS Among 1,739 NCD patients, greater income inequalities in accessing regular NCD services and collecting medicines at registered pharmacies during the COVID-19 pandemic were observed, for which the concentration index indicated utilisation inequalities in favour of richer households. In contrast, receiving medicine at primary care centres, by postal delivery, and delivered by village health volunteers were the new NCD MDSs, which favoured less wealthy households. NCD patients living in rural areas were more likely to access new NCD MDSs, compared to those in urban areas (adjusted odds ratio = 2.30; 95% confidence interval [CI]: 1.22-4.34). Significant associations with receiving medicine at hospitals were also observed for the income quintiles. Individuals in the lowest and 2nd lowest income quintiles were more likely to access new MDSs than those in the richest quintiles. CONCLUSIONS This study highlighted a disproportionate concentration of access to new NCD MDSs during the COVID-19 pandemic in Thailand, which was more concentrated in lower-income groups. The government should further study and integrate MDSs with the highest cost benefits into nationwide regular systems, while addressing systematic barriers to access to these services, such as the lack of shared health data across health facilities and tele pharmacy equipment. This will promote access to public services among patients in the less advantaged groups and reduce the health inequality gap.
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Affiliation(s)
- Jiraluck Nontarak
- Department of Epidemiology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Polathep Vichitkunakorn
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Orratai Waleewong
- International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand
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Wang D, Xie S, Wu J, Sun B. The trend in quality of life of Chinese population: analysis based on population health surveys from 2008 to 2020. BMC Public Health 2023; 23:167. [PMID: 36694154 PMCID: PMC9873389 DOI: 10.1186/s12889-023-15075-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Quality of life (QoL) is one of the most important indicators for evaluating an individual's overall health status. However, evidence exploring the trend in QoL of the Chinese population is still lacking. This study aimed to investigate the trend in QoL of the Chinese population measured by the EQ-5D from 2008 to 2020, as well as compare the changing trends in QoL categorized by populations with different socio-demographic characteristics. METHODS Data were obtained from the 2008, 2013, and 2020 waves of the Health Services Surveys conducted in Tianjin, China. Respondents completed the EQ-5D (EQ-5D-3L in 2008 and 2013 and EQ-5D-5L in 2020) through face-to-face interviews or self-administration. Responses of the EQ-5D-3L in 2008 and 2013 were mapped onto the EQ-5D-5L responses, and then converted to utility values using the Chinese value set. The trend in QoL was explored by comparing the percentage of any reported problems on each EQ-5D dimension and the corresponding utility values across the three waves. Subgroup analyses were performed to compare trends in utility values stratified by socio-demographic indicators. The effect of the time variable (year) on utility values was assessed by multiple linear regression analyses using the pooled data. RESULTS By analyzing and comparing the three waves of the data (N = 25,939 in the 2008 wave, N = 22,138 in 2013, and N = 19,177 in 2020), an upward trend was observed in the percentages of reporting problems on all five dimensions (p < 0.001), resulting in a decreasing trend in utility values (2008: 0.948, 2013: 0.942, 2020: 0.939, p < 0.001). Utility values declined more over time among the female, the elder, the recipients of medical assistance, the widowed, the unemployed, and respondents with primary or lower education. The effect of the year (Coef. for 2013 = - 0.009, p < 0.001; Coef. for 2020 = - 0.010, p < 0.001) confirmed the downward trend in the utility values. CONCLUSIONS The overall QoL of the Chinese population decreased over the period from 2008 to 2020. The QoL of the disadvantaged or vulnerable populations in terms of socioeconomic characteristics declined more over time.
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Affiliation(s)
- Dingyao Wang
- grid.33763.320000 0004 1761 2484School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072 China ,grid.33763.320000 0004 1761 2484Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Shitong Xie
- grid.33763.320000 0004 1761 2484School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072 China ,grid.25073.330000 0004 1936 8227Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072, China. .,Center for Social Science Survey and Data, Tianjin University, Tianjin, China.
| | - Bei Sun
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, 300072, China.
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12
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Mitchell J, Li X, Decker PJ. Community-Level Characteristics of Timely PCP Follow-Up Care and Post-Discharge ER Usage. Hosp Top 2023; 101:1-8. [PMID: 34308782 DOI: 10.1080/00185868.2021.1955061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achieving equitable access has been a central goal in healthcare for years; access by low-income Americans is a major concern for policymakers. We examined the differences in post-discharge primary care follow-up visits and 30-day post discharge ER visits across several characteristics. The results suggest that higher housing density, percent minority population, percent unemployed, and percent uninsured point to lower rates of PCP follow-up care and higher rates of post-discharge ER visits. These findings have implications for developing cost-effective programs targeting hospital to PCP communication, especially in densely populated areas.
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Affiliation(s)
- Jordan Mitchell
- Healthcare Administration Program, University of Houston-Clear Lake, Houston, TX, USA
| | - Xiao Li
- Healthcare Administration Program, University of Houston-Clear Lake, Houston, TX, USA
| | - Phillip J Decker
- Healthcare Administration Program, University of Houston-Clear Lake, Houston, TX, USA
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13
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Simoncic V, Deguen S, Enaux C, Vandentorren S, Kihal-Talantikite W. A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192416592. [PMID: 36554473 PMCID: PMC9779203 DOI: 10.3390/ijerph192416592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 05/12/2023]
Abstract
Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.
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Affiliation(s)
- Valentin Simoncic
- LIVE UMR 7362 CNRS (Laboratoire Image Ville Environnement), University of Strasbourg, 67100 Strasbourg, France
- Correspondence:
| | - Séverine Deguen
- Equipe PHARes Population Health Translational Research, Inserm CIC 1401, Bordeaux Population Health Research Center, University of Bordeaux, 33076 Boedeaux, France
| | - Christophe Enaux
- LIVE UMR 7362 CNRS (Laboratoire Image Ville Environnement), University of Strasbourg, 67100 Strasbourg, France
| | - Stéphanie Vandentorren
- Equipe PHARes Population Health Translational Research, Inserm CIC 1401, Bordeaux Population Health Research Center, University of Bordeaux, 33076 Boedeaux, France
- Santé Publique France, French National Public Health Agency, 94410 Saint-Maurice, France
| | - Wahida Kihal-Talantikite
- LIVE UMR 7362 CNRS (Laboratoire Image Ville Environnement), University of Strasbourg, 67100 Strasbourg, France
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14
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Jung YH, Jeong SH, Park EC, Jang SI. The impact of entering poverty on the unmet medical needs of Korean adults: a 5-year cohort study. BMC Public Health 2022; 22:1879. [PMID: 36207716 PMCID: PMC9547477 DOI: 10.1186/s12889-022-14251-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 09/27/2022] [Indexed: 11/14/2022] Open
Abstract
Background Studies on the effects of poverty on unmet medical needs are limited. Therefore, this study aimed to identify the impact of entering poverty on the unmet medical needs of South Korean adults. Methods This study used data from the Korea Health Panel Survey (2014–2018) and included 10,644 adults. Logistic regression was used to examine the impact of entering poverty on unmet medical needs (poverty status: no → no, yes → no, no → yes, yes → yes; unmet medical needs: no, yes). Poverty line was considered to be below 50% of the median income. Results When entering poverty, the proportion of unmet medical needs was 22.8% (adjusted odds ratio [AOR] 1.17, 95% confidence interval [CI] 1.01–1.36). Men (AOR 1.29, 95% CI 1.02–1.64), rural dwellers (AOR 1.24, 95% CI 1.01–1.50), and national health insurance (NHI) beneficiaries (AOR 1.21, 95% CI 1.04–1.42) were susceptible to unmet medical needs and entering poverty. Poverty line with below-median 40% had an AOR of 1.48 (95% CI 1.28–1.71). For the cause of unmet medical needs, the AORs were 1.50 for poverty (95% CI 1.16–1.94) and 1.08 for low accessibility to health care and information (95% CI 0.79–1.48). Conclusions Entering poverty had the potential to adversely affect unmet medical needs. Men, rural dwellers, and NHI beneficiaries were vulnerable to unmet medical needs after entering poverty. Rigid definitions of poverty and inaccessibility to health care and information increase the likelihood of unmet medical needs and poverty. Society must alleviate unmet medical needs due to the increase in the population entering poverty.
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Affiliation(s)
- Yun Hwa Jung
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sung Hoon Jeong
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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15
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Solomon SD, Shoge RY, Ervin AM, Contreras M, Harewood J, Aguwa UT, Olivier MMG. Improving Access to Eye Care: A Systematic Review of the Literature. Ophthalmology 2022; 129:e114-e126. [PMID: 36058739 DOI: 10.1016/j.ophtha.2022.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature. CLINICAL RELEVANCE Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age). METHODS A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria. RESULTS Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH. CONCLUSIONS The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.
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Affiliation(s)
- Sharon D Solomon
- School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Ruth Y Shoge
- School of Optometry, University of California Berkeley, Berkeley, California
| | - Ann Margret Ervin
- School of Medicine, Johns Hopkins University, Baltimore, Maryland; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Melissa Contreras
- College of Optometry, Marshall B. Ketchum University, Fullerton, California
| | | | - Ugochi T Aguwa
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mildred M G Olivier
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, Illinois
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16
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Chen C, Xu RH, Wong ELY, Wang D. The association between healthcare needs, socioeconomic status, and life satisfaction from a Chinese rural population cohort, 2012–2018. Sci Rep 2022; 12:14129. [PMID: 35986077 PMCID: PMC9391494 DOI: 10.1038/s41598-022-18596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/16/2022] [Indexed: 11/24/2022] Open
Abstract
This study aimed to examine the prevalence of unmet healthcare needs and clarify its impact on socioeconomic status (SES) and life satisfaction in a longitudinal cohort of the Chinese rural population. Data used in this study were obtained from a nationally representative sample of 1387 eligible rural residents from the Chinese Family Panel Studies. Generalized estimating equation (GEE) logistic regression models were used to examine the factors associated with unmet healthcare needs and the impact of unmet healthcare needs on respondents’ perceived SES and life satisfaction. Approximately 34.6% of respondents were male, 18.2% were ≤ 40 years, and 66.7% had completed primary education or below. Around 19% and 32.6% of individuals who healthcare needs were met reported an above average socioeconomic status and life satisfaction, respectively in the baseline survey. GEE models demonstrated that unmet healthcare needs were significantly associated with low perceived SES (Odds ratio = 1.57, p < 0.001) and life satisfaction (Odds ratio = 1.23, p = 0.03) adjusted by covariates. Respondents who were older, reported moderate or severe illness, and with chronic conditions were more likely to report the unmet healthcare needs.Unmet healthcare needs are longitudinally associated with low SES and life satisfaction among the Chinese rural population, the disparity in access to healthcare exists among this population.
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17
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Berkeley Unified Numident Mortality Database: Public administrative records for individual-level mortality research. DEMOGRAPHIC RESEARCH 2022. [DOI: 10.4054/demres.2022.47.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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18
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Grand-Guillaume-Perrenoud JA, Origlia P, Cignacco E. Barriers and facilitators of maternal healthcare utilisation in the perinatal period among women with social disadvantage: A theory-guided systematic review. Midwifery 2022; 105:103237. [PMID: 34999509 DOI: 10.1016/j.midw.2021.103237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Women with social disadvantage have poorer perinatal outcomes compared to women in advantaged social positions, which may be linked to poorer healthcare utilisation. Disadvantaged groups may experience a greater diversity of barriers (e.g., feeling embarrassed about pregnancy, lack of transportation) or barriers judged to be particularly difficult (e.g., embarrassment about pregnancy). They may also experience barriers more frequently (e.g., depression). Using Levesque et al.'s (2013) framework of healthcare access, our review identifies the barriers and facilitators that affect maternal healthcare utilisation in the perinatal period among women with social disadvantage in high-income nations. OBJECTIVES Our review searches for the barriers and facilitators affecting maternal healthcare utilisation in the perinatal period, from pregnancy to the first year postpartum, among women with social disadvantage (Prospero registration CRD42020151506). DESIGN We conducted a theory-guided systematic review. PubMed, Embase, MEDLINE, PsycINFO, and Social Science Citation Index databases were searched for publications between 1999 and 2018. FINDINGS 37 articles out of 12'972 were included in the qualitative synthesis. 19 domains of barriers and facilitators were extracted. Domains on the provider side includes 'information regarding available treatments' and 'trustful relationships.' On the user-side, domains include 'awareness of pregnancy' and 'unplanned/unwanted pregnancy' KEY CONCLUSIONS: Provider- and user-side characteristics interact to affect access. User-side characteristics that pose a barrier can be offset by provider-side characteristics that lower barriers to access. IMPLICATIONS FOR PRACTICE User-side characteristics (e.g., lack of awareness of pregnancy) play an important role in the initial steps toward access. Among women with social disadvantage, reducing barriers may require active outreach on the part of providers.
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Affiliation(s)
| | - Paola Origlia
- Bern University of Applied Sciences, Department of Health Professions, Division of Midwifery, Murtenstrasse 10, 3008 Bern, Switzerland.
| | - Eva Cignacco
- Bern University of Applied Sciences, Department of Health Professions, Division of Midwifery, Murtenstrasse 10, 3008 Bern, Switzerland.
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19
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Factors Influencing Unmet Healthcare Needs among Older Korean Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136862. [PMID: 34206778 PMCID: PMC8297300 DOI: 10.3390/ijerph18136862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to determine factors that influence the unmet healthcare needs of older women in Korea and to examine differences in the reasons for these unmet healthcare needs according to age and residential area. We analyzed data from the 2018 Korea Community Health Survey and enrolled 42,698 older Korean women in this study. Residential area, living arrangement, income, education, basic livelihood subsidy, activity of daily living, subjective health status, hypertension and diabetes, unmet healthcare needs, and the reasons healthcare needs were not met were assessed. Logistic regression analysis was performed to identify factors that influenced unmet healthcare needs. Chi-square tests were used to identify reasons for unmet healthcare needs according to age group and residential area. Of the participants, 4151 (9.7%) reported unmet healthcare needs over the past year. The primary reason participants could not use health services was "inconvenient transportation" (38.4%), followed by "financial burden" (28.4%) and "symptoms not severe" (16.8%). There were significant differences in "financial burden", "difficulty making appointments", "inconvenient transportation", and "symptoms not severe" according to both age group and residential area. Factors that influenced unmet healthcare needs were residential area, living alone, lower family income, lower educational level, basic livelihood subsidy, difficult activities of daily living, hypertension and diabetes, and poor subjective health. Older women in Korea living alone in urban and rural areas had more unmet healthcare needs of than those who lived with other people. To address the unmet healthcare needs of older Korean women, transportation and medical facilities need to be improved or established.
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Huang Y, Heflin CM, Validova A. Material hardship, perceived stress, and health in early adulthood. Ann Epidemiol 2020; 53:69-75.e3. [PMID: 32949721 PMCID: PMC7494502 DOI: 10.1016/j.annepidem.2020.08.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 12/17/2022]
Abstract
Purpose We examined the associations between material hardship and health outcomes in early adulthood and the extent to which these associations are mediated by perceived stress. Methods We used wave I and IV of the National Longitudinal Study of Adolescent Health, a nationally representative survey of young adults aged 18–34 years old (n = 13,313). Multivariate logistic regression and decomposition methods were used to evaluate the associations between types and depth of material hardship (food, bill-paying, and health resource hardship), health outcomes (self-rated health, depression, sleep problems, and suicidal thoughts) in early adulthood, and the extent to which these associations were mediated by perceived stress. Results The adjusted odds of fair or poor health status, depression, sleep problems, and suicidal thoughts were higher among individuals with material hardship than counterparts without. A considerable proportion of the association between material hardship and health outcomes was attributable to perceived stress. Conclusions Material hardship is associated with adverse health outcomes in early adulthood, and these relationships are robust after accounting for various sociodemographic characteristics and family background. Perceived stress accounted for a sizable portion of the effects of material hardship on health. Public Health Implications Efforts to promote health equity in young adults should focus on material hardship and associated stressful conditions.
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Affiliation(s)
- Ying Huang
- Department of Demography, University of Texas at San Antonio, San Antonio.
| | - Colleen M Heflin
- Maxwell School of Public Affairs and Citizenship, Syracuse University, Syracuse, NY
| | - Asiya Validova
- Department of Demography, University of Texas at San Antonio, San Antonio
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Mitrasevic M, Radovanovic S, Radevic S, Maricic M, Macuzic IZ, Kanjevac T. The Unmet Healthcare Needs: Evidence from Serbia. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:1650-1658. [PMID: 33643939 PMCID: PMC7898096 DOI: 10.18502/ijph.v49i9.4081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background We aimed to determine the socio-economic factors associated with unmet healthcare needs of the population aged 20 and over in Serbia. Methods We used data from the 2013 National Health Survey (NHS) of the population of Serbia. We focused only on the data concerning the population aged 20 and over. The final sample thus included 13,765 participants. The logistic regression was used to examine the socio-economic factors associated with unmet health care needs. Results According to the data obtained in this study, 26.2% of the population aged 20 and over reported unmet health care needs during the previous 12 months. The multivariate analysis shows that significant indicators of unmet healthcare needs include: gender, age, marital status, level of education, financial and employment status. Conclusion Females, the elderly and those with the lowest levels of education and household income, as well as those who are divorced and unemployed are at highest risk of unmet healthcare needs. Different policies and approaches should be taken into consideration when it comes to vulnerable population groups in order to reduce the currently existing gaps to a minimum and provide more equal opportunities for health care to all citizens.
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Affiliation(s)
- Milos Mitrasevic
- Department for Organization, Planning, Evaluation and Medical Informatics, Clinical Center Kragujevac, Kragujevac, Serbia
| | - Snezana Radovanovic
- Department of Social Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Svetlana Radevic
- Department of Social Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Milena Maricic
- High Medical College of Professional Health Studies, Belgrade, Serbia
| | - Ivana Zivanović Macuzic
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Tatjana Kanjevac
- Department of Dentistry, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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22
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Kim JY, Kim DI, Park HY, Pak Y, Tran PNH, Thai TT, Thuy MTT, Dung DV. Unmet Healthcare Needs and Associated Factors in Rural and Suburban Vietnam: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176320. [PMID: 32878012 PMCID: PMC7503302 DOI: 10.3390/ijerph17176320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to examine the current utilization of healthcare services, exploring unmet healthcare needs and the associated factors among people living in rural Vietnam. This cross-sectional study was conducted with 233 participants in a rural area. The methods included face-to-face interviews using a structured questionnaire, and anthropometric and blood pressure measurements. We considered participants to have unmet health needs if they had any kind of health problem during the past 12 months for which they were unable to see a healthcare provider. Multivariate logistic regression analysis was performed to determine the factors associated with unmet healthcare needs. Of the participants, 18% (n = 43) had unmet healthcare needs, for reasons like transportation (30%), a lack of available doctors or medicine (47%), and communication issues with healthcare providers (16%). The multivariate logistic regression showed that living in a rural area, having stage 2 hypertension, and having insurance were associated with unmet healthcare needs. To better meet the healthcare needs in rural or suburban areas of Vietnam, allocation of adequate healthcare resources should be distributed in rural areas and insurance coverage for personalized healthcare needs might be required. Efforts should focus on availability of medicine, improvement of transportation systems, and communication skills of healthcare providers to improve access to healthcare services.
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Affiliation(s)
- Ju Young Kim
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.Y.K.); (D.I.K.); (H.Y.P.)
| | - Dae In Kim
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.Y.K.); (D.I.K.); (H.Y.P.)
| | - Hwa Yeon Park
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.Y.K.); (D.I.K.); (H.Y.P.)
| | - Yuliya Pak
- Office of External Affairs, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Phap Ngoc Hoang Tran
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 72714, Vietnam; (P.N.H.T.); (T.T.T.); (M.T.T.T.)
| | - Truc Thanh Thai
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 72714, Vietnam; (P.N.H.T.); (T.T.T.); (M.T.T.T.)
| | - Mai Thi Thanh Thuy
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 72714, Vietnam; (P.N.H.T.); (T.T.T.); (M.T.T.T.)
| | - Do Van Dung
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 72714, Vietnam; (P.N.H.T.); (T.T.T.); (M.T.T.T.)
- Correspondence: ; Tel.: +84-91-838-2253
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Seasonal influenza vaccination in older people: A systematic review and meta-analysis of the determining factors. PLoS One 2020; 15:e0234702. [PMID: 32555628 PMCID: PMC7302695 DOI: 10.1371/journal.pone.0234702] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/02/2020] [Indexed: 11/30/2022] Open
Abstract
Background/Objectives Despite influenza vaccination programs in various jurisdictions, seasonal influenza vaccine (SIV) uptake remains suboptimal among older people (≥65years old), an important subpopulation for influenza vaccination. We sought to summarize determinants of SIV uptake (any vaccine receipt) and vaccination adherence (receipt of vaccine in two or more seasons in sequence) among older people. Methods We searched for population-based studies conducted in community-dwelling older people (irrespective of their health status) from 2000–2019. Two reviewers independently selected publications for inclusion. One reviewer extracted data from the included studies; a second checked the extracted data for errors. Disagreements were resolved by discussion and consensus, or a third reviewer. We were interested in the determinants of SIV uptake and vaccination adherence. Where appropriate, we pooled adjusted results using the inverse variance, random-effects method and reported the odds ratios (OR) and their 95% confidence intervals (CI). Results Out of 11,570 citations screened, we included 34 cross-sectional studies. The following were associated with increased SIV uptake: being older (OR 1.52, 95%CI 1.38–1.67 [21 studies]), white (1.30, 1.14–1.49 [10 studies]), married (1.23, 1.17–1.28 [9 studies]), non-smoker (1.28, 1.11–1.47 [7 studies]), of a higher social class (1.20, 1.06–1.36 [2 studies]), having a higher education (1.12, 1.04–1.21 [14 studies]), having a higher household income (1.11, 1.05–1.18 [8 studies]), having a chronic illness (1.53, 1.44–1.63 [16 studies]), having poor self-assessed health (1.23, 1.02–1.40 [9 studies]), having a family doctor (2.94, 1.79–4.76 [2 studies]), and having health insurance (1.58, 1.13–2.21 [6 studies]). The influence of these factors varied across geographical regions. Being older (1.26, 1.11–1.44 [2 studies]) was also associated with increased vaccination adherence. Conclusions Several factors may determine SIV uptake and vaccination adherence among older people. More studies are needed to provide a stronger evidence base for planning more effective influenza vaccination programs.
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Simon L, Choi SE, Ticku S, Fox K, Barrow J, Palmer N. Association of income inequality with orthodontic treatment use. J Am Dent Assoc 2020; 151:190-196. [PMID: 32130948 DOI: 10.1016/j.adaj.2019.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Income inequality has been associated with worse oral health outcomes and reduced dental care use. It is unknown whether income inequality may motivate people to seek orthodontic treatment. METHODS This was a logistic mixed-effects model of deidentified claims from a private insurer in the United States with enrolled members having at least 1 orthodontic visit in the calendar year as the dependent variable. Total number of dental visits, age, and sex were individual-level covariates. Median household income, Gini coefficient, female population proportion, number of practicing dentists and orthodontists, population size, and population density were zip code-level covariates. RESULTS A total of 1,860,709 people had at least 1 orthodontic claim. Adjusting for population demographics, the Gini index was significantly positively associated with orthodontic use for children but not for adults (odds ratio, 1.69 for children; P < .0001). Being female was the strongest predictor of orthodontic use for adults and was a significant predictor of use for children (odds ratio, 1.50 and 1.45, respectively; P < .0001). CONCLUSIONS The Gini index is associated with orthodontic use in children in a privately insured population. Individual characteristics are more predictive of orthodontic use among privately insured adults. PRACTICAL IMPLICATIONS Demographic and economic traits of communities can affect oral health care use; effects on orthodontic use may be more dramatic than on other forms of oral health care.
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Alexander K, Clary-Muronda V, Smith JM, Ward J. The Relationship Between Past Experience, Empathy, and Attitudes Toward Poverty. J Nurs Educ 2020; 59:158-162. [PMID: 32130418 DOI: 10.3928/01484834-20200220-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Nursing educators commonly place service-learning and simulation experiences in prelicensure public health nursing courses. These experiences have varying degrees of success in targeting gaps in students' knowledge and attitudes regarding vulnerable populations. This study sought to identify factors that are associated with attitudes toward poverty and empathy scores of senior-level prelicensure nursing students to improve pedagogy in public health nursing courses. METHOD A cross-sectional comparison of senior-level nursing students from traditional and accelerated cohorts at a college of nursing was conducted. RESULTS Students with prior volunteer experience reported lower empathy scores compared with students who did not have prior volunteer experience (t[102] = -1.9, p < .05). CONCLUSION Nursing educators should engage students in identifying and evaluating their personal background related to poverty when beginning a public health nursing course to address bias and create shared knowledge. [J Nurs Educ. 2020;59(3):158-162.].
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The association between relative income and depressive symptoms in adults: Findings from a nationwide survey in Korea. J Affect Disord 2020; 263:236-240. [PMID: 31818782 DOI: 10.1016/j.jad.2019.11.149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/14/2019] [Accepted: 11/30/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Subjective income inadequacy may be associated with poorer mental health as income comparisons with others can decrease feelings of happiness. This study investigated the association between relative income and depressive symptoms in Korean adults. METHODS Data from the 2017 Korea Community Health Survey were used. Relative income was measured by comparing household and community income. Household income was calculated using equalized household income and community income based on the mean income level of the 253 local communities. Relative income was categorized into the high (community < household), middle (community = household), and low (community > household) groups. Analysis was conducted through multivariate logistic regression analysis. RESULTS Of a total of 201,326 study participants, 12,508 (6.2%) individuals had depressive symptoms. Compared to the high relative income group, the middle [Odds Ratio (OR): 1.23, 95 percent Confidence Interval (CI): 1.16-1.29] and the low (OR 1.58, 95% CI 1.50-1.66) groups showed gradually higher likelihoods of depressive symptoms. Such differences were magnified in individuals with low absolute household income or with experiences of unmet need. CONCLUSION Individuals with lower or equal household than community income had higher likelihoods of depressive symptoms, with such differences augmenting in those with low absolute income or experiences of unmet need. The findings infer the importance of monitoring individuals at poorer relative income standings in addressing mental health.
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Skogen JC, Bøe T, Thørrisen MM, Riper H, Aas RW. Sociodemographic characteristics associated with alcohol consumption and alcohol-related consequences, a latent class analysis of The Norwegian WIRUS screening study. BMC Public Health 2019; 19:1364. [PMID: 31651277 PMCID: PMC6814033 DOI: 10.1186/s12889-019-7648-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/20/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND For alcohol, the association with socioeconomic status (SES) is different than for other public health challenges - the associations are complex, and heterogeneous between socioeconomic groups. Specifically, the relationship between alcohol consumption per se and adverse health consequences seems to vary across SES. This observation is called the 'alcohol harm paradox'. This study aims to describe different patterns of alcohol use and potential problems. Next, the associations between sub-groups characterized by different patterns of alcohol use and potential problems, and age, gender, educational level, full-time employment, occupational level and income is analysed. METHODS Employing data from the ongoing cross-sectional WIRUS-study, N = 4311 participants were included in the present study. Individual response patterns of the ten-item Alcohol Use Disorders Identification Test (AUDIT) were analysed and latent class analysis (LCA) was used to identify latent groups. Next, the associations between the classes identified in the best fitting LCA-model and sociodemographic factors were analysed and presented. RESULTS We identified three classes based on the response patterns on AUDIT. Class 1 was characterised by low-level alcohol consumption and very low probability of negative alcohol-related consequences related to their alcohol consumption. Class 2 was characterised by a higher level of consumption, but despite this, class 2 also had a relatively low probability of reporting negative alcohol-related consequences. Class 3, however, was characterised by high levels of alcohol consumption, and a high probability of reporting negative consequences of their consumption. The classes identified were systematically differentially associated with the included measures of SES, with class 3 characterised by younger age, more males and lower educational attainment. CONCLUSIONS Our findings highlight the interconnectedness of alcohol consumption and alcohol-related consequences. Furthermore, the identified classes and SES yields further insights into to intricate relationship between various socioeconomic factors, alcohol use patterns and related negative consequences.
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Affiliation(s)
- Jens Christoffer Skogen
- Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway. .,Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway. .,Alcohol & Drug Research Western Norway, Stavanger University Hospital, Stavanger, Norway.
| | - Tormod Bøe
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Mikkel Magnus Thørrisen
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Occupational Therapy, Prosthetics and Orthotics, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Heleen Riper
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Randi Wågø Aas
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Occupational Therapy, Prosthetics and Orthotics, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
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Okoli GN, Abou-Setta AM, Neilson CJ, Chit A, Thommes E, Mahmud SM. Determinants of Seasonal Influenza Vaccine Uptake Among the Elderly in the United States: A Systematic Review and Meta-Analysis. Gerontol Geriatr Med 2019; 5:2333721419870345. [PMID: 31453267 PMCID: PMC6698992 DOI: 10.1177/2333721419870345] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the availability of a universal influenza
vaccination program in the United States and Canada, seasonal influenza vaccine
(SIV) uptake among the elderly remains suboptimal. Understanding the factors
that determine SIV uptake in this important population subgroup is essential for
designing effective interventions to improve seasonal influenza vaccination
among the elderly. We evaluated the determinants of SIV uptake in the elderly in
the United States and Canada. Methods: We systematically searched
relevant bibliographic databases and websites from 2000 to 2017 for
population-based clinical trials or observational studies conducted in
community-based elderly individuals in the United States or Canada, irrespective
of health status. Two reviewers independently screened the identified citations
for eligibility using a two-stage sifting approach to review the title/abstract
and full-text article. We gathered data on determinants of uptake (any vaccine
receipt) and adherence (receipt of vaccine in more than one season) to seasonal
influenza vaccination. Where possible, we pooled the data using inverse variance
methods to minimize the variance of the weighted average. Results:
Five cross-sectional studies on SIV uptake (none on adherence) from the United
States met our eligibility criteria. Being older (pooled odds ratio [POR] =
1.44, 95% Confidence Interval [CI] = 1.11, 1.86); White (POR = 1.33, 95% CI =
[1.10, 1.64]); and having higher income (POR = 1.06, 95% CI = [1.04, 1.09]); and
health insurance (POR = 1.40, 95% CI = [1.25, 1.55]) were associated with
increased SIV uptake. Conclusion: Older, ethnically White, higher
income elderly individuals with access to health insurance coverage and a
regular health care provider have higher SIV uptake in the United States. There
was limited evidence for other socioeconomic and health-related determinants.
Further studies are needed to provide an evidence base for planning more
effective influenza vaccination programs in the United States.
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Affiliation(s)
- George N. Okoli
- University of Manitoba, Winnipeg,
Canada
- George N. Okoli, George & Fay Yee Centre
for Healthcare Innovation, Max Rady College of Medicine, Rady Faculty of Health
Sciences, University of Manitoba, 753 McDermot Avenue, Winnipeg, Manitoba,
Canada R3E 0T6.
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