Disparities in unmet health service needs among people with disabilities in China

Effectiveness of targeted financial aid on disability welfare for the ageing population in China: A quasi-experiment study

Background

Addressing the problem of disabilities and disability deterioration is a key task for healthy ageing. Financial aid has been an effective measure for vulnerable groups, especially ageing people with disabilities. However, the effects of targeted financial aid on preventing disability deterioration remain unknown. The Chinese government launched a targeted financial aid programme aimed at people with disabilities. In this study, we investigated the causal effects of such targeted financial aid on disability deterioration prevention for elderly people with disabilities in China.

Methods

The data set used in this study included 36 640 elderly individuals with disabilities in China between 2016-19. We constructed a quasi-experiment approach and used a difference-in-differences (DID) method to examine the counterfactual differences between the treatment group in four cities that implemented such targeted financial aid in 2018 and the control group in three cities that did not adopt the policy over the study period. We employed propensity score matching (PSM) jointly with DID to mitigate selective bias. For sensitivity analysis, we conducted supplementary analyses on alternative samples, focusing on each of the treated cities respectively. Besides the main outcome, we also used fixed effect models to test the impact of such financial aid on rehabilitation access.

Results

The targeted financial aid significantly reduced the possibility of disability deterioration for elderly people with severe disabilities (0.26%; P < 0.001). Using PSM-DID models, the impact remained significant (0.33%; P < 0.001). Moreover, financial aid was significantly related to their access to rehabilitation services (12.71%; P < 0.001). Further analysis showed the heterogenous effects of targeted financial aid across individual demographic and socioeconomic factors, as well as communities with and without rehabilitation facilities.

Conclusions

Targeted financial aid had a positive impact on preventing disability deterioration among elderly individuals aged ≥65 years with severe disabilities. Moreover, rehabilitation care had a potential mediating role in the relationship between targeted financial aid and disability deterioration prevention. This study highlights the effectiveness of targeted financial aid in preventing disability deterioration and improving rehabilitation care for people with disabilities.

Inequalities changes in health services utilization among middle-aged and older adult disabled people in China: based on CHARLS 2011-2018

Background

Multiple intersections, including socioeconomic inequalities, influence health equity for disabled people and sub-populations. However, this association has not been sufficiently analyzed among Chinese-impaired persons. This study aimed to investigate the health services utilization and inequalities in middle and older adult persons with disabilities and subgroups.

Methods

The China Health and Retirement Longitudinal Study (CHARLS) database in 2011, 2013, 2015, and 2018 were used. Health services utilization was measured by outpatient, inpatient, and self-treatment service utilization. Types of disabilities were classified into six categories. The pooled cross-section regression, concentration index, horizontal inequity index, and concentration index decomposition were used to evaluate inequalities and explore their main contributing factor.

Results

The utilization and non-utilization of healthcare services showed variations across years (p < 0.05). The CIs and HIs for inpatient health service utilization were positive for all years and disability types. The total CIs of inpatient utilization were the highest (0.248). The highest disparities in utilization of inpatient services were for physical disabilities (0.4515 for CI in 2011), and the highest in self-treatment services were for intellectual disability (0.1538 for CI in 2011). The expenditure factor was the main contributor to inequalities. Chronic disease, educational level, and health insurance factors also contribute to the utilization inequalities.

Conclusion

Policies should promote medical insurance and assistance for disabled people with serious impairment and poor. It is crucial to improve the provision of basic medical services, including meeting the demand for varied disabilities and the accessibility of facilities and equipment to enhance the access and well-being of people with disabilities.

Effects of spatial accessibility of community health services on the activities of daily living among older adults in China: a propensity score matching study

Background

The Chinese government proposes to establish a hierarchical diagnosis and treatment system, and attaches great importance to community health services. Under the background of population aging and the increase of older adults with disability, this study aimed to analyze the effect of spatial accessibility of community health services on the activities of daily living (ADL) among older adults in China.

Methods

A research sample of 7,922 older adults from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) data in 2018 was adopted. There were 2,806 participants in the treatment group and 5,116 participants in the control group. The propensity score matching method was adopted to match the treatment and control groups to calculate the values of average treatment effects on treated (ATT).

Results

The results of kernel density matching method showed that the factual ADL score of the treatment group was 10.912, the counterfactual ADL score of the control group was 10.694, and the ATT value was 0.218 (p < 0.01). The spatial accessibility of community health services could significantly improve the activities of daily living among older adults in China. Meanwhile, there was urban-rural heterogeneity in the impact of spatial accessibility of community health services on the activities of daily living of older adults in China. The effect value in urban samples (ATT = 0.371, p < 0.01) was higher than that in rural samples (ATT = 0.180, p < 0.01).

Conclusion

Spatial accessibility of community health services could improve the activities of daily living among older adults in China. The Chinese government should take actions to improve the distribution of community health service resources.

Are physically disabled people at high risk of coronary heart disease among disabled population - Evidence from 7.5-year retrospective cohort study

OBJECTIVES

Previous cross-sectional studies suggested that people with physical disabilities (one of the subgroups of disabled people) are associated with an increased risk of cardiovascular diseases (CVD) than healthy peers. However, a longitudinal cohort of disabled people exhibited a different trend, in which the study populations were similar in health inequalities. We aimed to examine whether physical disability was associated with an increased risk of coronary heart disease (CHD) among disabled people.

STUDY DESIGN AND SETTING

This retrospective cohort study from the Shanghai Health Examination Program included a total of 6419 disabled adults (50.77 [9.88] age) with complete electronic health records and were free of CHD at baseline (2012) were followed-up for a 7.5-year period until 2019. The physical disability and non-physical disability subgroups were characterized based on the Disability Classification and Grading Standard (GB/T 26341-2010). Multivariable Cox regression analyses were used to evaluate adjusted hazard ratios (HR) for subsequent CHD, while Kaplan-Meier curves was used to assess the proportional hazards assumption. We conducted subgroup analyses based on gender, levels of disability, and baseline blood pressure.

RESULTS

Kaplan-Meier analysis revealed a higher incidence of CHD in the physical disability group compared to the non-physical disability group during the 7.5-year follow-up period (P < 0.05). Subjects with physical disabilities exhibited an increased risk for subsequent CHD occurrence (HR: 1.12; 95% CI: 1.03-1.31), compared to the non-physical subgroup after adjustments for confounders. The sensitivity analysis conducted on subgroups according to gender and disability severity indicated that moderate physical disability and female physical disability were associated with a higher prevalence of CHD, which was confirmed by multi-adjusted regression analysis. The spline curves of BP and CHD indicated that the physical disability group displayed lower SBP and DBP thresholds of 120 mmHg and SBP, respectively.

CONCLUSION

Within the disabled population, individuals with physical disability are at higher risk of developing CHD, and it is plausible that their optimal BP threshold for CHD prevention may need to be set at a lower level. Further research is essential to investigate BP management among individuals with physical disabilities and its influence on cardiovascular-related adverse events.

A comparison of factors associated with unmet healthcare needs in people with disabilities before and after COVID-19: a nationally representative population-based study

BACKGROUND

People with disabilities, who require numerous healthcare services, are vulnerable to unmet healthcare needs. This study aimed to investigate and identify the factors that influence unmet healthcare needs among people with disabilities and to compare these factors before and after the COVID-19 pandemic in South Korea.

METHODS

A propensity score matching analysis was conducted using two datasets from the National Survey of Disabled Persons collected in 2017 and 2020. The participants were matched based on variables known to influence healthcare utilization. Based on the Andersen model, logistic regression was performed to analyze the key characteristics of the factors associated with unmet healthcare needs, including predisposing, enabling, and need factors.

RESULTS

Propensity score matching resulted in the inclusion of 1,884 participants in each group: an experimental group and control group. Before COVID-19, factors associated with unmet healthcare needs included sex, age, marital status, and education level (predisposing factors), instrumental activities of daily living dependency, satisfaction with medical staff's understanding of disability, satisfaction with medical institutional facilities and equipment (enabling factors), subjective health status, and depressive symptoms (need factors). After COVID-19, factors included physical disability, instrumental activities of daily living dependency, and discrimination (enabling factors), and subjective health status, chronic diseases, depressive symptoms, and regular medical care (need factors). No significant predisposing factors affecting unmet healthcare needs were identified after COVID-19.

CONCLUSIONS

This study compared the factors affecting unmet healthcare needs among people with disabilities before and after COVID-19. Recognizing the different factors associated with unmet healthcare needs before and after COVID-19, (e.g., sex, type of disability, satisfaction with medical staff's understanding of disabilities, medical institutional facilities and equipment considering the disabled, discrimination, chronic diseases, and regular medical care) may help governments and policymakers establish strategies to reduce and prevent unmet healthcare needs during and a future crisis.

Universal health coverage in China part 1: progress and gaps

Over the past 2 decades, China has made remarkable progress in health-care service coverage, especially in the areas of reproductive, maternal, newborn, and child health, infectious diseases, and service capacity and access. In these areas, coverage is comparable to those in high-income countries. Inequalities of service coverage in these areas have been reduced. However, there remain large gaps in the service coverage of chronic diseases. There has been little progress in controlling risk factors of chronic diseases in the past 10 years. Service coverage for most chronic conditions is lower than in high-income countries. Moreover, China has disproportionately high incidences of catastrophic health expenditure compared with countries with similar economic development. This paper comprehensively evaluates China's progress towards universal health coverage by identifying the achievements and gaps in service coverage and financial risk protection that are crucial to achieve universal health coverage goals by 2030.

The association of a disability-targeted cash transfer programme with disability status and health-care access: a quasi-experimental study using a nationwide cohort of 4·3 million Chinese adults living with severe disabilities

BACKGROUND

Cash transfer is a crucial policy tool to address inequality. The objective of this study was to investigate the association between China's disability-targeted cash transfer programme and disability status, as well as equitable access to rehabilitation and medical services.

METHODS

For this quasi-experimental study, we drew data from the nationwide administrative cohort of individuals with disabilities between Jan 1, 2015, and Dec 31, 2019. Individuals were enrolled in the cohort if they were aged 18 years or older, had severe disabilities as defined by the Chinese Government, and had available cash transfer information for at least 4 consecutive years, without having started receiving cash transfer benefits at the time of enrolment. We used a quasi-experimental design with propensity score matching to estimate the effects of cash transfers on disability status, access to rehabilitation services, and access to medical treatment. The primary outcomes were development of new disability and reduction of existing disabilities. Secondary outcomes were use of rehabilitation services, financial barriers as a major obstacle to accessing rehabilitation services, use of medical services by individuals who had an illness in the previous 2 weeks, and financial barriers as a major obstacle to accessing medical services.

FINDINGS

From an initial pool of 51 356 125 individuals with disabilities registered in the administrative system, 2 686 024 individuals were eligible for analysis, of whom 2 165 335 (80·6%) were cash transfer beneficiaries and 520 689 (19·4%) non-beneficiaries. After propensity score matching, the cohort included 4 330 122 adults with severe disabilities. Cash transfer beneficiaries had significantly lower odds of developing new disabilities over time than non-beneficiaries (odds ratio [OR] 0·90, 95% CI 0·86-0·94; p<0·0001) and higher odds of having a reduced number of disabilities over time (1·17, 1·10-1·25; p<0·0001). Compared with non-beneficiaries, cash transfer beneficiaries were more likely to use rehabilitation services (2·12, 2·11-2·13; p<0·0001) and medical services (1·74, 1·69-1·78; p<0·0001), and less likely to report financial hardship to access rehabilitation services (0·53, 0·52-0·54; p<0·0001) and medical services (0·88, 0·84-0·93; p<0·0001) at the study endpoint.

INTERPRETATION

The receipt of cash transfers was associated with improved disability status and increased access to disability-related services. The findings suggest that cash transfers could be a potential method for promoting universal health coverage among individuals living with disabilities.

FUNDING

China National Natural Science Foundation.

Is there a sexual difference in the relationship between sociodemographic information and the unmet dental care needs of disabled adults? An analysis from a national survey on persons with disabilities

BACKGROUND

Health status and health care utilization in people with disabilities are more likely to be poorer than those without disabilities. Previous studies showed that there were gaps in health-related conditions by sociodemographic information and gender but the association between these factors was not explained. This study aims to analyze the relationship between sociodemographic information and the unmet dental care needs of people with disabilities and explore the effect of sex within this relationship.

METHODS

The 2014 national survey on persons with disabilities was used, which separated unmet healthcare needs into medical and dental services. Unweighted samples included 6,824 people with disabilities in total and 6,555 (96.1% of the total, weighted as 6,583) people aged 20 years or older were selected as the study population. Frequency and chi-square tests were conducted to determine differences in the prevalence of unmet dental needs based on socioeconomic information, chronic diseases, and behavioral factors after applying weights. Logistic regressions were performed using an adjusted model with sociodemographic information, chronic diseases, and behavioral variables. All analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA).

RESULTS

Analysis of the sociodemographic factors related to unmet dental care revealed that they were higher in women and the elderly. In the fully adjusted logistic model, most of the sociodemographic information was significantly associated with unmet dental needs. The lowest group was 4.18 times more likely to have unmet dental care needs than the richest group, and females and middle-school graduates were almost twice as likely to experience unmet dental care needs than males and university graduates. Considering the interaction effect of age on unmet dental needs depending on sex differences, the odds ratio decreased for females with every annual increase in both models. Compared with the younger group, the older group showed a lower risk of having unmet dental needs, especially in females.

CONCLUSIONS

The factor most closely related to the unmet dental care needs of disabled people was socioeconomic problems. Its influence also differed by sex and age. Therefore, economic support measures and sexual differences are needed for long-term policy consideration to reduce the unmet dental care needs of disabled people.

Inequities in Mental Health Care Facing Racialized Immigrant Older Adults With Mental Disorders Despite Universal Coverage: A Population-Based Study in Canada

OBJECTIVES

Contemporary immigration scholarship has typically treated immigrants with diverse racial backgrounds as a monolithic population. Knowledge gaps remain in understanding how racial and nativity inequities in mental health care intersect and unfold in midlife and old age. This study aims to examine the joint impact of race, migration, and old age in shaping mental health treatment.

METHODS

Pooled data were obtained from the Canadian Community Health Survey (2015-2018) and restricted to respondents (aged ≥45 years) with mood or anxiety disorders (n = 9,099). Multivariable logistic regression was performed to estimate associations between race-migration nexus and past-year mental health consultations (MHC). Classification and regression tree (CART) analysis was applied to identify intersecting determinants of MHC.

RESULTS

Compared to Canadian-born Whites, racialized immigrants had greater mental health needs: poor/fair self-rated mental health (odds ratio [OR] = 2.23, 99% confidence interval [CI]: 1.67-2.99), perceived life stressful (OR = 1.49, 99% CI: 1.14-1.95), psychiatric comorbidity (OR = 1.42, 99% CI: 1.06-1.89), and unmet needs for care (OR = 2.02, 99% CI: 1.36-3.02); in sharp contrast, they were less likely to access mental health services across most indicators: overall past-year MHC (OR = 0.54, 99% CI: 0.41-0.71) and consultations with family doctors (OR = 0.67, 99% CI: 0.50-0.89), psychologists (OR = 0.54, 99% CI: 0.33-0.87), and social workers (OR = 0.37, 99% CI: 0.21-0.65), with the exception of psychiatrist visits (p = .324). The CART algorithm identifies three groups at risk of MHC service underuse: racialized immigrants aged ≥55 years, immigrants without high school diplomas, and linguistic minorities who were home renters.

DISCUSSION

To safeguard health care equity for medically underserved communities in Canada, multisectoral efforts need to guarantee culturally responsive mental health care, multilingual services, and affordable housing for racialized immigrant older adults with mental disorders.

Association of blood pressure trajectories with coronary heart disease among the disabled population in Shanghai, China: a cohort study of 7 years following up

BACKGROUND

Much less is known about the importance of blood pressure (BP) trajectories concerning the incidence of coronary heart disease (CHD) in people with disabilities. Our aim was to evaluate this association.

METHODS

This cohort study surveyed 5711 adults from the Shanghai Disability Health Survey from June 2012 to June 2019. The latent class growth mixture model was used to examine distinct BP trajectories. We evaluated the association of BP trajectories with the risk of CHD by Cox proportional hazard models. The model for CHD risk fitted to BP trajectories was compared with models fitted to other BP-related indicators by goodness-of-fit, discrimination, and calibration.

RESULTS

During a median follow-up of 71.74 months, 686 cases (median age was 49.03 (54.49, 58.55) years, 51.90% female) with CHD were identified, with a cumulative incidence of 12.01%. Systolic BP (SBP) and diastolic BP (DBP) were categorized into three classes, respectively. A statistically significant association was only observed between SBP trajectories and CHD. Compared with the normotensive stable SBP group (n = 1956), the prehypertension-stable group (n = 3268) had a higher risk (adjust hazards ratio (aHR) = 1.266, 95% confidence interval (CI) 1.014-1.581), and the stage 1 hypertension-decreasing group (n = 487) had the highest risk (aHR = 1.609, 95%CI 1.157-2.238). Among the BP-related indicators, the SBP trajectory was the strongest predictor of new-onset CHD. Findings were similar when sensitivity analyses were conducted.

CONCLUSIONS

SBP trajectory was a more important risk factor for CHD than other BP-related indicators and stringent BP control strategies may be effective for primary CHD prevention in the disabled population.

Violence in rural areas against disabled people from the perspective of their families

OBJECTIVES

to know the violence spoken and felt by disabled people, living in rural areas, from the perspective of their families.

METHODS

a descriptive-exploratory and qualitative study, carried out in four municipalities in Rio Grande do Sul, Brazil. Twelve family members who lived with disabled people in rural areas participated. Data were collected through semi-structured interviews and analyzed using thematic content analysis.

RESULTS

disabled people, living in rural areas, experienced physical, psychological and sexual violence, perpetrated by family members, colleagues, community members and health professionals. Adaptations were mentioned in family dynamics for the care of disabled people, social, financial and leisure impacts, and challenges in access and accessibility to education and health services.

FINAL CONSIDERATIONS

violence against this population manifests itself in a reality with socioeconomic and family particularities, marked by exclusion, disrespect and denial of rights and access to fundamental goods and services.

Development of a Three-Stage Strength-Based Meaning Intervention to Promote Mental Health Among Individuals with Physical Disabilities in Disadvantaged Communities: A Randomized Controlled Trial

A three-stage strength-based meaning intervention (SMI) was developed in the present study, and its utility in facilitating the mental health of individuals with physical disabilities in low-income communities was tested. A randomized controlled and single-blind trial was adopted. A total of 50 qualified participants (mean age = 42.12, standard deviation = 8.68; 48% males; 26 for the intervention group, 24 for the control group) completed the pre-intervention test, post-intervention test, and three-month follow-up test. No significant difference was observed between the two groups at pre-intervention assessment . After intervention, the results in terms of strength knowledge, strength use, sense of meaning in life and mental health showed a significant improvement in the intervention group, with the changes maintained over three months except mental health. The differences in mental health between the post-intervention test and the three-month follow-up test were not significant in the intervention group. The results imply that the SMI model is a promising approach in promoting the mental health of individuals with physical disabilities in low-income communities as it promotes improved knowledge and use of strength and sense of meaning in life.

Medical expenditure and its inequity for people with disabilities: Evidence from the CHARLS 2018 data

Introduction

Disabilities may raise heavy medical expenses and rich-poor inequalities. However, data is lacking for the Chinese older populations. This study aimed to measure socioeconomic inequalities in medical expenses amongst the Chinese adult 45 years or older, and explored the main determinants among different disability categories.

Method

Data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) were used. Disabilities were divided into five categories: physical disabilities, intellectual disability, vision problems, hearing problems, and multiple disabilities. The two-part model was employed to identify the factors that are associated with medical expenditures. Socioeconomic inequalities were measured by the concentration index (CI), and the horizontal inequity index (HI) which adjusts for health needs. Decomposition analysis was further applied to evaluate the contribution of each determinant.

Results

Two thousand four hundred nineteen people were included in this study. The CIs and HIs of the expenditure were both positive. Amongst the varied types of medical expenses, the highest CIs were found for self-treatment expenses (0.0262). Amongst the five categories of disabilities, the group with vision problem disability reported the highest CIs and HIs for outpatient expenses (CI = 0.0843, HI = 0.0751), self-treatment expenses (CI = 0.0958, HI = 0.1119), and total expenses (CI = 0.0622, HI = 0.0541). The group of intellectual disability reported the highest CI and HI (CI = 0.0707, HI = 0.0625). The decomposition analysis showed that income (80.32%), education (25.14%) and living in the rural areas (13.96%) were the main determinants of medical expenses for HI amongst all types of disabilities.

Conclusion

For five types of disabilities, our data shows that medical expenses concentrated in the richer groups in China. Income, education, and rural areas factors were the main contributors to the economic-related inequalities. Health policies to improve the affordability of medical care are needed to decrease inequity of medical expenditures for people with disabilities.