The rural-urban divide: health services utilization among older Mexicans in Mexico

Less Is (Often) More: Number of Children and Health Among Older Adults in 24 Countries

OBJECTIVES

Previous evidence about the impact of parenthood on health for older adults is mixed, perhaps due to variation in number of children and context. Higher numbers of children could lead to support or strain, depending on individual and country contexts. Yet, no studies currently exist that examine associations between the number of children and several health indicators among older adults across multiple global regions.

METHODS

We analyze cross-sectional data (1992-2017) of 166,739 adults aged 50+ across 24 countries from the Health and Retirement Study family of surveys to document associations between the number of children, treated as a categorical variable, and 5 health outcomes (self-rated health, activities of daily living limitations, instrumental activities of daily living limitations, chronic conditions, and depression). We perform multivariable analyses by estimating logistic regression models for each country and each outcome.

RESULTS

Multiple comparisons between categories of number of children revealed at least 1 significant difference in each country, and a majority of significant differences indicated those with more children had poorer health. The risk of poorer health for parents of multiple children was observed in 15 countries, but in some countries, fewer children predict poorer health. The greatest number of differences was identified for depression and chronic conditions, and very few for functional limitations.

DISCUSSION

We observe a greater probability that more children are associated with poorer health in later life, especially for chronic conditions and depression. However, a universal global or regional pattern could not be identified. These findings raise new questions about how country contexts shape fertility and health.

The Impact of Education and Insurance Status on Past-Year Dental Visits Among Older Mexican Adults: Results From the 2001 and 2012 Mexican Health and Aging Study

Objective: This study assessed past-year dental visits among older Mexican adults from the Mexican Health and Aging Study (MHAS). MHAS is a nationally representative cohort study of adults 50 years and older from Mexico. Methods: Baseline data from 2001 were compared with 2012 data. Binary logistic regression identified significant predictors of past-year dental visits. Decomposition techniques examined factors that contributed to changes in dental visits between 2001 and 2012. Results: Education and insurance status were positively associated with past-year dental visits, while decomposition results showed that population composition (more adults receiving insurance and higher education over time) contributed to the increased prevalence of dental visits between 2001 and 2012. Discussion: Education and insurance are critical factors that govern access to oral healthcare. After the provision of universal dental coverage by Mexico's Seguro Popular in 2003, our results may reflect promising effects of such programs, which can inform future policies in Mexico and other settings.

Rural and urban differences in lifetime occupation and its influence on mortality among Mexican adults

OBJECTIVE

To determine how primary lifetime occupation type is associated with mortality, and how the relationship varies by rural and urban dwelling.

MATERIALS AND METHODS

Data come from 2001-2018 Mexican Health and Aging Study (adults aged 50+, n=11 094). We created five occupation categories. Cox proportional hazard models predicted mortality using baseline covariates.

RESULTS

In both rural and urban settings, participants with manual jobs, such as agriculture and production/industrial jobs, had an increased risk of mortality compared to those with administrative/professional jobs. In urban settings, participants in the domestic/service and no main job categories had higher risk of mortality than those in the administrative/professional category. For men these differences remained, but not for women.

CONCLUSION

In a context of rural and urban demographic shifts, it is crucial to consider the implications that occupation as a socioeconomic factor can have on health and to identify the most vulnerable groups.

Life Satisfaction and Dental Visits in Adults Aged ≥50 Years and Living with Diabetes Mellitus: A Comparison between Urban and Rural Mexican

OBJECTIVE

To examine the association between low life satisfaction with past-year dental visits in a rural-urban national sample of 50-year-old Mexican adults with diabetes mellitus (DM).

METHODS

Data are drawn from the Mexican Health and Aging Study (MHAS), a cross-sectional study conducted in 2018 involving 3,592 older adults aged 50 years and older and living in urban and rural areas in Mexico. Life satisfaction was measured using the Satisfaction with Life Scale (SWLS) and past-year dental visits dichotomized as none and ≥1 dental visits. The Poisson regression analyses were used to assess the association, adjusting for confounders.

RESULTS

62.9% were women, mean age was 65.5 (±9.6), and 16.5% lived in a rural area, while the female subjects continue to present a higher probability of visiting a dentist (PR = 1.28 (95% CI 1.08-1.51)). In terms of age, the ≥70-year group presented 28% lower possibility of visiting a dentist (PR = 0.72 (95% CI 0.60-0.86)). The interaction showed that adults ≥50 years who reside in a rural area and have low life satisfaction were 40% less likely to have visited a dentist in the last year (PR = 0.60 (95% CI 0.37-0.98)) than adults ≥50 years who reside in an urban area and have high life satisfaction.

CONCLUSIONS

The present study highlights the association between low life satisfaction and past-year dental visits in rural populations. Therefore, rurality should be considered a possible confounder in analysis of life satisfaction in the older adult population.

Factors Associated with Self-Report of Type 2 Diabetes Mellitus in Adults Seeking Dental Care in a Developing Country

The aims of the present study were to identify the prevalence and risk indicators of type 2 diabetes mellitus (T2DM) in urban-based Mexican adults seeking care in a university-based triage/intake dental clinic, and to develop a predictive model. A cross-sectional study was conducted on 3354 medical/dental records of adults who sought care at the triage/intake dental clinics of a public university. The dependent variable was self-report of a previous diagnosis of T2DM made by a physician. Several socio-demographic and socioeconomic covariates were included, as well as others related to oral and general health. A multivariate binary logistic regression model was generated. We subsequently calculated well-known statistical measures employed to evaluate discrimination (classification) using an (adjusted) multivariate logistic regression model (goodness-of-fit test). The average age of patients was 42.5 ± 16.1 years old and the majority were female (64.1%). The prevalence of T2DM was 10.7% (95%CI = 9.7−11.8). In the final multivariate model, the variables associated (p < 0.05) with the presence of T2DM were older age (40 to 59 years old, OR = 2.00; 60 to 95 years old, OR = 2.78), having any type of health insurance (OR = 2.33), having high blood pressure (OR = 1.70), being obese (OR = 1.41), and having a functional dentition (OR = 0.68). Although the global fit of the model and the calibration tests were adequate, the sensitivity (0.0%) and positive predictive (0.0%) values were not. The specificity (100%) and negative predictive (89.3%) values, as well as the correctly classified (89.3%) value, were adequate. The area under the ROC curve, close to 0.70, was modest. In conclusion, a prevalence of T2DM of 10.7% in this sample of Mexican adults seeking dental care was similar to national figures. Clinical (blood pressure, BMI and functional dentition), demographic (age), and socioeconomic (health insurance) variables were found to be associated with T2DM. The dental setting could be appropriate for implementing preventive actions focused on identifying and helping to reduce the burden of T2DM in the population.

A comparison of rural-urban differences in out-of-pocket expenses among older Mexicans with diabetes

Objective

To compare total out-of-pocket expenses for physician visits and medications among older adults living with diabetes in Mexico from urban, semi-urban, and rural areas.

Methods

The sample included 2,398 Mexicans aged 65 years and older with self-reported diabetes from the 2018 Mexican Health and Aging Study. Out-of-pocket expenses for physician visits and medications were regressed on locality, controlling for several factors.

Results

The profile of those with higher out-of-pocket medication expenditures included rural localities, higher education, unmarried, depressive symptoms, participation in Seguro Popular, and lacking insurance. In the multivariate analysis, rural older adults with diabetes paid a higher amount in medication expenditures compared with other localities.

Conclusion

Differences in locality are closely tied to the effective implementation of Seguro Popular. Although this program has improved access to care, participants have higher out-of-pocket expenditures for medications than those on employer-based plans across all localities. Among all groups, the uninsured bare the highest burden of expenditures, highlighting a continued need to address health inequities for the most underserved populations.

Choosing a health behaviour theory or model for related research projects: a narrative review

Background

Theories are integral to a research project, providing the logic underlying what, how, and/or why a particular phenomenon happens. Alternatively, models are used to guide a research project by representing theories and visualising the structural framework of causal pathways by showing the different levels of analysis. With the rise in chronic and behaviour-related diseases, health behaviour theories and models have a particular importance in designing appropriate and research led behavioural intervention strategies. However, there is a dearth of papers that explain the role of behavioural theories and models in research projects.

Aims

The aim of this paper is to synthesise existing evidence on the relevance of health behaviour theories and models in research projects.

Methods

This paper reviews health behaviour theories and models commonly underpinning research projects in public health and clinical practices. The electronic databases, such as MEDLINE, CINAHL, and Scopus, as well as the search engines Google and Google Scholar were searched to identify health behaviour theories and models.

Results

Theories and models are essential in a research project. Theories provide the underlying reason for the occurrence of a phenomenon by explaining what the key drivers and outcomes of the target phenomenon are and why, and what underlying processes are responsible for causing that phenomenon. Models on the other hand provide guidance to a research project and assist in visualising the structural framework of causal pathways by showing the different levels of analysis. Health behaviour theories and models in particular offer valuable insights for designing effective and sustainable research projects for improved public health practice.

Conclusions

By employing appropriate health behaviour theory and/or model as a research framework, researchers will be able to identify relevant variables and translate these into clinical and public health practices.

Rural/urban dwelling across the life-course and late-life cognitive ability in Mexico

BACKGROUND

Urban advantages in older adults' cognitive function have been observed. Less is known about early-life urban dwelling and late-life cognition. We evaluate how rural/urban dwelling throughout life and rural to urban shifts in life relate with cognition in Mexico, a country experiencing aging and urbanization.

METHODS

Data came from the 2003 and 2012 Mexican Health and Aging Study (n = 12,238 adults age 50+). Early-life urban dwelling was self-reported. Late-life urban dwelling was based on population size of respondents' community of residence (community 2500+ people) at the time of survey. Cognitive function was measured across several cognitive tasks. We assess differences in baseline cognitive function and nine-year decline across groups using a latent change score model.

RESULTS

Cross-sectionally, compared to always rural dwellers, rural-urban transitions were associated with cognitive benefits, though individuals residing in urban areas continuously through life exhibited the highest levels of cognitive function (β = 0.89, 95% CI: 0.83, 0.96) even after adjusting for SES, health, and health behaviors (β = 0.28, 95% CI: 0.22, 0.35). Longitudinally, always urban dwellers exhibited slower decline than always rural dwellers when adjusting for baseline cognition (β = 0.11, 95% CI: 0.03, 0.18), though faster decline when baseline cognition was not adjusted (β = -0.11, 95% CI: -0.18, -0.04). No differences were observed for cognitive change across comparison groups after adjusting for potential mechanisms.

CONCLUSIONS

Early- and late-life urban dwelling may result in cognitive advantages for older Mexican adults. Clinicians should consider where individuals resided throughout life to better understand a patient's likelihood of experiencing poor cognitive outcomes.

Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients

OBJECTIVE

To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings.

METHODS

We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities.

RESULTS

Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively).

CONCLUSION

ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

Scaling of mortality in 742 metropolitan areas of the Americas

We explored how mortality scales with city population size using vital registration and population data from 742 cities in 10 Latin American countries and the United States. We found that more populated cities had lower mortality (sublinear scaling), driven by a sublinear pattern in U.S. cities, while Latin American cities had similar mortality across city sizes. Sexually transmitted infections and homicides showed higher rates in larger cities (superlinear scaling). Tuberculosis mortality behaved sublinearly in U.S. and Mexican cities and superlinearly in other Latin American cities. Other communicable, maternal, neonatal, and nutritional deaths, and deaths due to noncommunicable diseases were generally sublinear in the United States and linear or superlinear in Latin America. Our findings reveal distinct patterns across the Americas, suggesting no universal relation between city size and mortality, pointing to the importance of understanding the processes that explain heterogeneity in scaling behavior or mortality to further advance urban health policies.

Health care utilization in very advanced ages: A study on predisposing, enabling and need factors

This study aims to examine the effects of predisposing, enabling, and need factors on healthcare utilization in advanced age. Data from a sample of 270 Portuguese community-dwelling persons aged ≥80 years was used. Face-to-face interviews were conducted and included the application of a research protocol addressing a set of sociodemographic and health-related variables that expressed the Andersen Behavioral model (i.e., predisposing, enabling, and need factors). Predictors of visits to general practitioners (GP) and specialist physicians, as well as emergency department (ED) use and hospitalizations were investigated. Multivariate linear and logistic regression analyzes were used to model the effects of predictor factors specified in the Andersen Behavioral model. Our findings underscore that younger age and having multimorbidity were significantly associated with having GP visits. Specialist physician visits were associated with younger age and a higher number of daily medications. ED use was associated with being male, having formal social support and a higher number of daily medications. Hospitalizations were associated with being younger, being male and having multimorbidity. Our findings revealed that need and predisposing factors determined the most healthcare use.

Assessment of surgical capacity in Chiapas, Mexico: a cross-sectional study of the public and private sector

INTRODUCTION

Surgical, anaesthesia and obstetric (SAO) care are essential, life-saving components of universal healthcare. In Chiapas, Mexico's southernmost state, the capacity of SAO care is unknown. This study aims to assess the surgical capacity in Chiapas, Mexico, as it relates to access, infrastructure, service delivery, surgical volume, quality, workforce and financial risk protection.

METHODS

A cross-sectional study of Ministry of Health public hospitals and private hospitals in Chiapas was performed. The translated Surgical Assessment Tool (SAT) was implemented in sampled hospitals. Surgical volume was collected retrospectively from hospital logbooks. Fisher's exact test and Mann-Whitney U test were used to compare public and private hospitals. Catastrophic expenditure from surgical care was calculated.

RESULTS

Data were collected from 17 public hospitals and 20 private hospitals in Chiapas. Private hospitals were smaller than public hospitals and public hospitals performed more surgeries per operating room. Not all hospitals reported consistent electricity, running water or oxygen, but private hospitals were more likely to have these basic infrastructure components compared with public hospitals (84% vs 95%; 60% vs 100%; 94.1% vs 100%, respectively). Bellwether surgical procedures performed in private hospitals cost significantly more, and posed a higher risk of catastrophic expenditure, than those performed in public hospitals.

CONCLUSION

Capacity limitations are greater in public hospitals compared with private hospitals. However, the cost of care in the private sector is significantly higher than the public sector and may result in catastrophic expenditures. Targeted interventions to improve the infrastructure, workforce availability and data collection are needed.

Hukou-based rural-urban disparities in maternal health service utilization and delivery modes in two Chinese cities in Guangdong Province

BACKGROUND

Most existing research on rural-urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural-urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China.

METHODS

Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015-2019) and 25,849 live births in City B (2018-2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable.

RESULTS

While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively.

CONCLUSIONS

Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services.

Does the Rural Environment Influence Symptomatology and Optimize the Effectiveness of Disease Acceptance? A Study Among Women With Fibromyalgia

The present study aims to explore whether the symptoms associated with fibromyalgia are contextually influenced by the area of residence (rural/urban). Furthermore, it is analyzed whether the effect of the acceptance of the disease on the emotional, cognitive and physical symptoms is moderated by the patients' place of residence. Using a cross-sectional design, a total of 234 women with fibromyalgia (mean age = 56.91 years; SD = 8.94) were surveyed, of which 55.13% resided in rural areas and 44.87% in urban areas. Self-reported questionnaires were used to assess pain severity, anxiety and depression, functional limitation, physical and mental fatigue and acceptance of the disease. The results show significant differences in acceptance (p = 0.040), pain (p < 0.001), and physical and mental fatigue (p = 0.003 and p = 0.004, respectively) between patients from rural and urban areas. The rural area patients presented higher levels of acceptance and pain and lesser levels of physical and mental fatigue compared to the urban area. The moderation analysis add that, only in patients from the rural area, the variables of physical symptoms (pain, functional limitation, and physical fatigue) were significantly and negatively associated with acceptance. This study addresses for the first time the role of the place of residence in suffering from fibromyalgia, suggesting that the rural or urban environment plays a relevant role in the severity and/or management of symptoms in fibromyalgia women. Limitations and practical implications are also discussed.

Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study

OBJECTIVES

Diabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of a novel community-based model of diabetes care in rural Mexico, compared with usual care.

DESIGN

We performed time-driven activity-based costing to estimate annualised costs associated with typical diabetes care in Chiapas, Mexico, as well as a novel diabetes care model known as Compañeros En Salud Programa de Enfermedades Crónicas (CESPEC). We conducted Markov chain analysis to estimate the cost-effectiveness of CESPEC compared with usual care from a societal perspective. We used patient outcomes from CESPEC in 2016, as well as secondary data from existing literature.

SETTING

Rural primary care clinics in Chiapas, Mexico.

PARTICIPANTS

Adults with diabetes.

INTERVENTIONS

CESPEC is a novel, comprehensive, diabetes care model that integrates community health workers, provider education, supply chain management and active case finding.

OUTCOME MEASURE

The primary outcome was the incremental cost-effectiveness of CESPEC compared with care as usual, per quality-adjusted life year (QALY) gained, expressed in 2016 US dollars.

RESULTS

The economic cost of the CESPEC diabetes model was US$144 per patient per year, compared with US$125 for diabetes care as usual. However, CESPEC care was associated with 0.13 additional years of health-adjusted life expectancy compared with usual care and 0.02 additional years in the first 5 years of treatment. This translated to an incremental cost-effectiveness ratio (ICER) of US$2981 per QALY gained over a patient's lifetime and an ICER of US$10 444 over the first 5 years. Findings were robust to multiple sensitivity analyses.

CONCLUSIONS

CESPEC is a cost-effective, community-based model of diabetes care for patients in rural Mexico. Given the high prevalence and significant morbidity associated with diabetes in Mexico and other countries in Central America, this model should be considered for broader scale up and evaluation.

Determinants of health insurance ownership in Jordan: a cross-sectional study of population and family health survey 2017-2018

OBJECTIVES

With about one-third of the population living below the poverty line, Jordan faces major healthcare, social and national development issues. Low insurance coverage among the poor and high out-of-pocket expenditure worsens the financial insecurity especially for the marginalised population. The Government of Jordan aims to achieve universal coverage of health insurance-a bold plan that requires research evidence for successful implementation. In this study, we aimed to assess the proportion of the population covered by any health insurance, and the determinants owing a health insurance.

DESIGN

A population-based prospective cohort study.

SETTING

Jordan.

METHODS

Data for this study were derived from the Jordan Population and Family Health Survey, which was implemented by the Department of Statistics from early October 2017 to January 2018. Sample characteristics were described as percentages with 95% CIs. Binary logistic regression models were used to estimate OR of health insurance ownership. Parsimonious model was employed to assess the sex and geographical differences.

RESULTS

Data revealed that in 2017-2018, 73.13% of the 12 992 men and women had health insurance. There was no indication of age of sex difference in health insurance ownership; however, marital status and socioeconomic factors such as wealth and education as well as internet access and geographical location appeared to be the important predictors of non-use of health insurance. The associations differed by sex and urbanicity for certain variables. Addressing these inequities may help achieve universal coverage in health insurance ownership in the population.

CONCLUSIONS

More than one-quarter of the population in Jordan were not insured. Efforts to decrease disparities in insurance coverage should focus on minimising socioeconomic and geographical disparities to promote equity in terms of healthcare services.

Challenges, inequalities and COVID-19: Examples from indigenous Oaxaca, Mexico

COVID-19 is a challenge for indigenous communities in Mexico. Social inequalities and limited access to services combine with historical patterns of discrimination to amplify its negative impacts. Nevertheless, there are important ways in which indigenous communities organise and respond. Our paper, organised in three parts, summarises these challenges as well as the response. In the first section, we introduce indigenous Oaxaca and the challenges facing indigenous communities. In the second section, we note the ways in which indigenous communities rely on their traditions in response to the pandemic and limitations they face. In the third and concluding section, we argue that the social inequalities that define indigenous life in Oaxaca must be acknowledged in order to create an effective public health response to COVID-19.

Childlessness and Health Among Older Adults: Variation Across Five Outcomes and 20 Countries

OBJECTIVES

No previous study to the best of our knowledge has examined the association between childlessness and health using a wide range of countries and health outcomes. This study improves previous literature by examining the relationship between "childlessness" (1 = childless for any reason, 0 = parent of biological, step, or adopted child) and health across 20 countries and five health outcomes.

METHODS

Drawing on cross-sectional harmonized data from the family of Health and Retirement Surveys across the United States (HRS, Wave 11), Europe (SHARE, Waves 4 and 5), Mexico (MHAS, Wave 3), and China (CHARLS, Wave 2), we use logistic regression models to estimate the association between childlessness and poor health (poor self-rated health, 1 or more ADL limitations, 1 or more IADL limitations, 1 or more chronic conditions, and depression) in a sample of adults aged 50 and older across 20 countries (N = 109,648).

RESULTS

Our results point to an absence of associations between childlessness and health, and suggest that childlessness may be associated with better (e.g., Mexico, Hungary) or worse health (e.g., Austria, Estonia, Netherlands, Poland) in certain contexts and for certain measures.

DISCUSSION

We discuss these findings in light of the meaning of childlessness, as well as cross-national economic, social, and cultural contexts to provide suggestions for aging policy and future research.

The Impact of the COVID-19 Epidemic on Older Adults in Rural and Urban Areas in Mexico

Objectives

Mexico is among the countries in Latin America hit hardest by coronavirus disease 2019 (COVID-19). A large proportion of older adults in Mexico have high prevalence of multimorbidity and live in poverty with limited access to health care services. These statistics are even higher among adults living in rural areas, which suggest that older adults in rural communities may be more susceptible to COVID-19. The objectives of the article were to compare clinical and demographic characteristics for people diagnosed with COVID-19 by age group, and to describe cases and mortality in rural and urban communities.

Method

We linked publicly available data from the Mexican Ministry of Health and the Census. Municipalities were classified based on population as rural (<2,500), semirural (≥2,500 and <15,000), semiurban (≥15,000 and <100,000), and urban (≥100,000). Zero-inflated negative binomial models were performed to calculate the total number of COVID-19 cases, and deaths per 1,000,000 persons using the population of each municipality as a denominator.

Results

Older adults were more likely to be hospitalized and reported severe cases, with higher mortality rates. In addition, rural municipalities reported a higher number of COVID-19 cases and mortality related to COVID-19 per million than urban municipalities. The adjusted absolute difference in COVID-19 cases was 912.7 per million (95% confidence interval [CI]: 79.0–1746.4) and mortality related to COVID-19 was 390.6 per million (95% CI: 204.5–576.7).

Discussion

Urgent policy efforts are needed to mandate the use of face masks, encourage handwashing, and improve specialty care for Mexicans in rural areas.

Assessing geriatric capacity building needs in public hospitals in Mexico

AIMS

To conduct a needs assessment of public hospitals in Mexico to determine workforce specific capacity building needs in the care of older people.

BACKGROUND

The older population in Mexico is growing rapidly. The healthcare system and workforce may not be prepared to handle the needs of older people, especially those with chronic illnesses who are also disadvantaged socioeconomically. Determining workforce and system needs is important to strategically develop capacity.

METHODS

A needs assessment using a pragmatic qualitative approach structured this study. Semi-structured interviews and focus groups were conducted with healthcare professionals at five public hospitals in Mexico. Directed content analysis techniques analysed the data.

RESULTS

Ninety-two healthcare professionals participated in the study. Three themes emerged, including geriatric service delivery, social changes and human resources for health. Participants reported a lack of gerontology knowledge and related clinical skills deficits to provide care for hospitalised elders and expressed emotional distress related to the lack of resources in their institutions. All healthcare professionals expressed strong concern at the social toll the ageing population had on families. The support of government organisations emerged as a facilitator for adoption of geriatric care principles.

CONCLUSIONS

This qualitative study uncovered important data to inform the implementation of quality improvement and capacity building models for older people care in Mexico. There appears to be strong potential for a culturally appropriate translation of high-income country older people care models within the Mexican healthcare context.

IMPLICATIONS FOR PRACTICE

Findings suggests there is a need to increase geriatric capacity building among helathcare professionals in Mexico. This will be an important step in improving care for hospitalised older people.

Age and sex differences in the association between access to medical care and health outcomes among older Chinese

BACKGROUND

Whether the association between access to medical care and health outcomes differs by age and gender among older adults in China is unclear. We aimed to investigate the associations between self-reported inadequate access to care and multiple health outcomes among older men and women in mainland China.

METHODS

Based on four latest waves available so far from a national longitudinal study in mainland China in 2005-2014, we used multilevel random-effect logistic models to estimate the contemporaneous relationships between inadequate access to care and disabilities in instrumental activities of daily living (IADL) and cognitive impairment in men and women at ages 65-74, 75-84, 85-94, and 95+, separately. We also used multilevel hazard models to investigate the relationships between reported access to care and mortality in 2005-2014. Nested models were used to adjust for survey design, sociodemographic background, enrollment in health insurance, and health behaviors.

RESULTS

Approximately 6.5% of older adults in China reported inadequate access to care in the period of 2005-2014; and the percentages increased with age and were higher among women at older ages (≥75 years). Overall, older adults with self-reported inadequate access to care had greater odds of IADL and ADL disabilities and cognitive impairment than those with adequate access to healthcare. The elevated odds ratios (ORs) in men were higher in middle-old (75-84) and old-old (85-94) age groups compared to other age groups; whereas the elevated ORs in women were higher in young-old (65-74) and middle-old (75-84) age groups. The relationship between access to care and the health outcomes was generally weakest at the oldest-old ages (95+). Inadequate access to care was also linked with higher mortality risk, primarily in adults aged 75-84, and it was somewhat more pronounced in women than in men.

CONCLUSIONS

Increased odds of physical disability and cognitive impairment and increased risk of mortality are linked with inadequate access to care. The associations were generally stronger in women than in men and varied across age groups. The findings of the present study have important implications for further improving access to health care and improving health outcomes of older adults in China.

Rural-urban gaps in health care utilization among older Thais: The role of family support

This study examined rural-urban differences in health visits among older Thais utilizing Andersen's model. Data were drawn from the 2011 Survey of Older Persons in Thailand of adults 50 years and older (N = 56,435). Logistic regression models examine individuals' predisposing, enabling, and health need factors for explaining older adults' health care use. Approximately 50% of older adults sought health care but urban dwellers were more likely than rural dwellers to seek health care (54.8% vs. 49.7%). Predisposing factors and health needs narrow the rural-urban gap while enabling factors widened the gap in health visits. The receipt of financial support from children presented a significant moderating effect in the rural-urban divide of health care use. Despite Thailand's universal access to health care, geographic inequity in health care utilization withstands. Findings suggest investments in education, income security, social participation, and healthy lifestyle promotion can improve health care utilization. Furthermore, results suggest a need for continued investigation of the role of family support in bridging the rural-urban divide in the health of older Thais.

Implementation and clinical effectiveness of a community-based non-communicable disease treatment programme in rural Mexico: a difference-in-differences analysis

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P > 0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P < 0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P > 0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.

Social health insurance, healthcare utilization, and costs in middle-aged and elderly community-dwelling adults in China

Background

Although many studies have analyzed health insurance worldwide, most focus on whole populations rather than specific vulnerable groups. There is a lack of studies that compare different schemes. This paper evaluates the impact of different types of social health insurance and other associated factors on healthcare utilization and costs among middle-aged and elderly Chinese adults.

Methods

Data were obtained from a nationally representative middle-aged and elderly household survey, the China Health and Retirement Longitudinal Study, which was conducted in 2015. Middle-aged and elderly are defined as people who are ≥45 years. Descriptive statistics were used to show the prevalence of each variable. Both logistic and multiple linear regression models were used to evaluate the association between healthcare utilization/healthcare costs and health insurance in addition to other related factors.

Results

Although the rapid expansion of social health insurance coverage has significantly improved the healthcare utilization among middle-aged and elderly adults, the difference between three schemes is large. Urban Employee Medical Insurance (UEMI) has had a greater effect in improving healthcare utilization than New Cooperative Medical Insurance (NCMI) or Urban Resident Medical Insurance (URMI). Unification of health insurance programs and optimization of health resource allocations should be a practical way to alleviate healthcare utilization inequality across schemes. People having social health insurance spend more on total and out-of-pocket (OOP) healthcare costs than people not covered by social health insurance, suggesting that enrollment in social health insurance induces significant increases in both total and OOP healthcare expenses. UEMI for the urban employed has relatively higher funding criteria and reimbursement rate, which makes the greatest extent to induce increase in healthcare costs. Some demographic or socioeconomic factors significantly affect healthcare utilization and costs among middle-aged and elderly adults.

Conclusion

Our study demonstrates the differences in healthcare utilization and costs between those with and without social health insurance and between those with different health insurance schemes. Policy efforts should further focus on adjusting social health insurance and optimizing healthcare resource allocation in order to enhance effective utilization of healthcare services and control cost increases among middle-aged and elderly adults.

Knowledge and awareness of and perception towards cardiovascular disease risk in sub-Saharan Africa: A systematic review

INTRODUCTION

Cardiovascular diseases (CVDs) are the most common cause of non-communicable disease mortality in sub-Saharan African (SSA) countries. Gaps in knowledge of CVD conditions and their risk factors are important barriers in effective prevention and treatment. Yet, evidence on the awareness and knowledge level of CVD and associated risk factors among populations of SSA is scarce. This review aimed to synthesize available evidence of the level of knowledge of and perceptions towards CVDs and risk factors in the SSA region.

METHODS

Five databases were searched for publications up to December 2016. Narrative synthesis was conducted for knowledge level of CVDs, knowledge of risk factors and clinical signs, factors influencing knowledge of CVDs and source of health information on CVDs. The review was registered with Prospero (CRD42016049165).

RESULTS

Of 2212 titles and abstracts screened, 45 full-text papers were retrieved and reviewed and 20 were included: eighteen quantitative and two qualitative studies. Levels of knowledge and awareness for CVD and risk factors were generally low, coupled with poor perception. Most studies reported less than half of their study participants having good knowledge of CVDs and/or risk factors. Proportion of participants who were unable to identify a single risk factor and clinical symptom for CVDs ranged from 1.8% in a study among hospital staff in Nigeria to a high of 73% in a population-based survey in Uganda and 7% among University staff in Nigeria to 75.1% in a general population in Uganda respectively. High educational attainment and place of residence had a significant influence on the levels of knowledge for CVDs among SSA populations.

CONCLUSION

Low knowledge of CVDs, risk factors and clinical symptoms is strongly associated with the low levels of educational attainment and rural residency in the region. These findings provide useful information for implementers of interventions targeted at the prevention and control of CVDs, and encourages them to incorporate health promotion and awareness campaigns in order to enhance knowledge and awareness of CVDs in the region.

What sort of medical care is ideal? Differences in thoughts on medical care among residents of urban and rural/remote Japanese communities

Studies of aspirational ideals of medical care generally focus on patients rather than on ordinary people receiving or not receiving medications at the time of interview. The literature has not accurately conveyed the distinct ideals in individual communities or undertaken inter-regional comparisons. This current qualitative study focused on ideal medical care as perceived by residents of distinct Japanese communities in their everyday lives. Between December 2011 and November 2012, one-on-one and group-based semi-structured interviews were conducted with 105 individuals, each of whom had continuously lived for 20 years or more in one of the four types of communities classified as either 'metropolitan area', 'provincial city', 'mountain/fishing village' or 'remote island' in Japan. Interviews were transcribed from digital audio recordings and then analysed (in tandem with non-verbal data including participants' appearances, attitudes and interview atmospheres) using constructivist grounded theory, in which we could get the voice and mind of the participant concerning ideal medical care. The common themes observed among the four community types included 'peace of mind because of the availability of medical care' and 'trust in medical professionals'. Themes that were characteristic of urban communities were the tendency to focus on the content of medical care, including 'high-level medical care', 'elimination of unnecessary medical care' and 'faster, cheaper medical care', whereas those that were characteristic of rural communities were the tendency to focus on lifestyle-oriented medical care such as 'support for local lifestyles', 'locally appropriate standards of medical care' and 'being free from dependence on medical care'. The sense of ideal medical care in urban communities tended to centre around the satisfaction with the content of medical care, whereas that in rural communities tended to centre around the ability to lead a secure life. By considering medical care from the geographical point of view, we found out the significant relationship between communities and perceptions of medical care ideals.

Urban-rural differences in the association between access to healthcare and health outcomes among older adults in China

BACKGROUND

Studies have shown that inadequate access to healthcare is associated with lower levels of health and well-being in older adults. Studies have also shown significant urban-rural differences in access to healthcare in developing countries such as China. However, there is limited evidence of whether the association between access to healthcare and health outcomes differs by urban-rural residence at older ages in China.

METHODS

Four waves of data (2005, 2008/2009, 2011/2012, and 2014) from the largest national longitudinal survey of adults aged 65 and older in mainland China (n = 26,604) were used for analysis. The association between inadequate access to healthcare (y/n) and multiple health outcomes were examined-including instrumental activities of daily living (IADL) disability, ADL disability, cognitive impairment, and all-cause mortality. A series of multivariate models were used to obtain robust estimates and to account for various covariates associated with access to healthcare and/or health outcomes. All models were stratified by urban-rural residence.

RESULTS

Inadequate access to healthcare was significantly higher among older adults in rural areas than in urban areas (9.1% vs. 5.4%; p < 0.01). Results from multivariate models showed that inadequate access to healthcare was associated with significantly higher odds of IADL disability in older adults living in urban areas (odds ratio [OR] = 1.58-1.79) and rural areas (OR = 1.95-2.30) relative to their counterparts with adequate access to healthcare. In terms of ADL disability, we found significant increases in the odds of disability among rural older adults (OR = 1.89-3.05) but not among urban older adults. Inadequate access to healthcare was also associated with substantially higher odds of cognitive impairment in older adults from rural areas (OR = 2.37-3.19) compared with those in rural areas with adequate access to healthcare; however, no significant differences in cognitive impairment were found among older adults in urban areas. Finally, we found that inadequate access to healthcare increased overall mortality risks in older adults by 33-37% in urban areas and 28-29% in rural areas. However, the increased risk of mortality in urban areas was not significant after taking into account health behaviors and baseline health status.

CONCLUSIONS

Inadequate access to healthcare was significantly associated with higher rates of disability, cognitive impairment, and all-cause mortality among older adults in China. The associations between access to healthcare and health outcomes were generally stronger among older adults in rural areas than in urban areas. Our findings underscore the importance of providing adequate access to healthcare for older adults-particularly for those living in rural areas in developing countries such as China.

Socioeconomic determinants of access to health services among older adults: a systematic review

OBJECTIVE

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature. The search has been carried out in the databases PubMed, LILACS and Web of Science, without restriction of dates and languages; however we have included only articles published in Portuguese, English, and Spanish. The inclusion criteria were: observational design, socioeconomic factors as variables of interest in the analysis of the access to or use of health services among older adults, representative sample of the target population, adjustment for confounding factors, and no selection bias.

RESULTS

We have found 5,096 articles after deleting duplicates and 36 of them have been selected for review after the process of reading and evaluating the inclusion criteria. Higher income and education have been associated with the use and access to medical appointments in developing countries and some developed countries. The same association has been observed in dental appointments in all countries. Most studies have shown no association between socioeconomic characteristics and the use of inpatient and emergency services. We have identified greater use of home visits in lower-income individuals, with the exception of the United States.

CONCLUSIONS

We have observed an unequal access to or use of health services in most countries, varying according to the type of service used. The expansion of the health care coverage is necessary to reduce this unequal access generated by social inequities.

Multidimensional social support is associated with healthcare utilization among older Mexican adults

In this study, we aimed to estimate the association between social support and healthcare utilization among older Mexican adults. We conducted a prospective study with 4027 older adults aged 65-74 in rural areas in seven Mexican states. Data were collected at baseline (2007) and 14 months later (2009). Healthcare utilization was defined as number of visits to a physician for preventive or curative purposes in the last 6 months. Multidimensional social support was operationalized into two components: structural (living arrangements, marital status and network size) and functional (perceived availability of support; and perceived support across emotional, instrumental, economic and information domains). Mixed-effects regression models were used to estimate the probability of healthcare use and to examine the association between social support and the number of visits to a physician. Results showed that perceived availability of social support was associated with the probability of visits to a physician (OR 1.44; p < .01). Meanwhile, the following domains of functional component of social support were associated with the probability of visits to a physician: instrumental (OR 1.55; p < .01), economic (OR 1.19; p = .03) and informational (OR 1.39; p < .01); and also with the number of visits to a physician: instrumental (e ^β  = 1.27; p < .01), economic (e ^β  = 1.14; p = .01) and informational (e ^β  = 1.12; p < .10). Our findings suggest that a significant association exists between social support, measured from a multidimensional viewpoint, and healthcare utilization, in which greater social support was related to a greater extent of use of health services.

Cognition and Context: Rural-Urban Differences in Cognitive Aging Among Older Mexican Adults

OBJECTIVE

To describe differences in cognitive functioning across rural and urban areas among older Mexican adults.

METHOD

We include respondents aged 50+ in the 2012 Mexican Health and Aging Study (MHAS). Cognitive functioning by domain is regressed as a function of community size. The role of educational attainment in explaining rural/urban differences in cognitive functioning is examined.

RESULTS

Respondents residing in more rural areas performed worse across five cognitive domains. The majority, but not all, of the association between community size and cognitive functioning was explained by lower education in rural areas.

DISCUSSION

Respondents residing in more rural areas were disadvantaged in terms of cognitive functioning compared with those residing in more urban areas. Poorer cognitive functioning in late life may be the result of historical educational disadvantage in rural areas or selection through migration from rural to urban regions for employment.

Health Insurance and Health Care among the Mid-Aged and Older Chinese: Evidence from the National Baseline Survey of CHARLS

We document the recent profile of health insurance and health care among mid-aged and older Chinese using data from the China Health and Retirement Longitudinal Study conducted in 2011. Overall health insurance coverage is about 93%. Multivariate regressions show that respondents with lower income as measured by per capita expenditure have a lower chance of being insured, as do the less-educated, older, and divorced/widowed women and rural-registered people. Premiums and reimbursement rates of health insurance vary significantly by schemes. Inpatient reimbursement rates for urban people increase with total cost to a plateau of 60%; rural people receive much less. Demographic characteristics such as age, education, marriage status, per capita expenditure, and self-reported health status are not significantly associated with share of out-of-pocket cost after controlling community effects. For health service use, we find large gaps that vary across health insurance plans, especially for inpatient service. People with access to urban health insurance plans are more likely to use health services. In general, Chinese people have easy access to median low-level medical facilities. It is also not difficult to access general hospitals or specialized hospitals, but there exists better access to healthcare facilities in urban areas. Copyright © 2016 John Wiley & Sons, Ltd.

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

BACKGROUND

Previous studies investigating factors associated with healthcare utilization by older Ghanaians lack distinction between public and private health services. The present study examined factors associated with public and private healthcare service use, and the resulting perceived health system responsiveness.

OBJECTIVES

To identify factors associated with public and private healthcare utilization among older adults aged 50 and older in Ghana; and to compare perceived differences in health system responsiveness between the private and public sectors.

METHODS

Cross-sectional data was analyzed from the World Health Organization Study on global AGEing and adult health (SAGE) Wave 1 in Ghana. Using Andersen's conceptual framework, public and private outpatient care utilization was examined using multinomial logistic regression to estimate and identify predictor variables associated with the type of outpatient healthcare facility accessed. Health system responsiveness was compared using chi-square tests.

RESULTS

Of 2517 respondents who used outpatient care in the 12 months preceding interview, 51.7% of respondents used a public facility, 17.8% a private facility, and 30.5% used other facilities. Older age group, higher education and higher wealth were associated with the use of private outpatient healthcare services. Using public outpatient care facilities was associated with having health insurance. Respondents with two or more chronic conditions were more likely to use public and private outpatient care than other facilities. Perceived health system responsiveness was better in private for-profit than in public and private not-for-profit healthcare facilities.

CONCLUSIONS

This study suggested that higher wealth and multimorbidity were significant predictors of public and private outpatient healthcare utilization; however, health insurance was a predictor only for the use of public facilities. Future mixed-method studies could further elucidate factors influencing the choice of public and private outpatient healthcare use.

Trajectories of limitations in activities of daily living among older adults in Mexico, 2001-2012

BACKGROUND

Trajectories of disability are an essential component to understand the burden of disability at the societal level. Longitudinal studies, compared to cross-national studies, enable a better analysis of the progression of physical limitations among the elderly. However, information on disability dynamics in developing countries is limited.

OBJECTIVES

This paper examines the changes in activities of daily living (ADLs) in an 11-yr. period in the Mexican elderly population aged 60 or older and identifies how sociodemographic variables alter these trajectories.

METHODS

The data come from the Mexican Health and Aging Study (MHAS), a national sample of adults born in 1951 or earlier, including a baseline survey in 2001 and follow-ups in 2003 and 2012.

RESULTS

The ADL score increased on average by 0.03 for every year respondents aged after 60. In contrast, the ADL score was reduced by 0.06 for every additional year of education.

CONCLUSIONS

Age, gender, and years of education were confirmed to influence the trajectories of ADL limitations. Understanding the patterns of deterioration of functional limitations will help public health policies to better serve the population.

Medical care ideals among urban and rural residents in Thailand: a qualitative study

BACKGROUND

Health care is generally considered to be more highly valued in urban areas than in rural areas. However, studies have reported that there is no difference in the health care values of urban and rural areas in the Kingdom of Thailand, with some studies even indicating that these values are stronger in rural areas. We, therefore, conducted interviews and implemented a qualitative investigation and analysis aimed at elucidating ideals relating to the medical environment among the Kingdom's urban and rural citizens.

METHODS

The study targeted Thai citizens residing in urban and rural areas. The city of Khon Kaen, located in Khon Kaen Province in northeastern Thailand, was selected as the urban area for the study. We selected Donyang village, located in the same province, as the rural study area. In July 2014, we conducted semi-structured group interviews, applying the Constructivist Grounded Theory (CGT) analytical approach.

RESULTS

We interviewed ten people in Khon Kaen (the urban area) and seven people from Donyang village (the rural area). Five major and distinctive themes emerged from the interviews. These were: locally appropriate standards of medical care, support for local lifestyles, satisfaction with local medical personnel, healthy lifestyles that do not rely on medical services, and desire for regional autonomy/desire to serve the region in terms of medical care. All of these themes were evident in both study areas. Thus, rather than relying on advanced medical services, both urban and rural Thai citizens expressed the desire to continue living within communities (considered as "families"), contributing to them, and tending to all of their health care needs within their communities.

CONCLUSIONS

This study revealed five common themes relating to forms of medical care regarded as ideal among urban and rural citizens of Thailand. Its findings could potentially have important implications for areas characterized by urban-rural inequities relating to the accessibility and utilization of medical services.

Parents' decision making and access to preventive healthcare for young children: applying Andersen's Model

BACKGROUND AND OBJECTIVE

Implementing preventive health care for young children provides the best chance of improving health and changing a child's life course. In Australia, despite government support for preventive health care, uptake of preventive services for young children is low. Using Andersen's behavioural model of health-care utilization, we aimed to understand how parents conceptualized their children's preventive health care and how this impacted on access to preventive health-care services.

DESIGN

Semi-structured telephone interviews conducted between May and July 2011.

SETTING AND PARTICIPANTS

Twenty-eight parents of children aged 3-5 years from three diverse socio-economic areas of Melbourne, Australia.

RESULTS

Thematic analysis showed parents' access to child preventive health care was determined by birth order of their child, cultural health beliefs, personal health practices, relationship with the health provider and the costs associated with health services. Parents with more than one child placed their own experience ahead of professional expertise, and their younger children were less likely to complete routine preventive health checks. Concerns around developmental delays required validation through family, friends and childcare organizations before presentation to health services.

CONCLUSIONS

To improve child preventive health requires increased flexibility of services, strengthening of inter-professional relationships and enhancement of parents' knowledge about the importance of preventive health in early childhood. Policies that encourage continuity of care and remove point of service costs will further reduce barriers to preventive care for young children. Recent reforms in Australia's primary health care and the expansion of child preventive health checks into general practice present a timely opportunity for this to occur.

Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico

OBJECTIVE

The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico.

METHOD

Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012.

RESULTS

After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears.

DISCUSSION

Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.

Effect of User Charges on Secondary Level Surgical Care Utilization and Out-of-Pocket Expenditures in Haryana State, India

BACKGROUND

Generation of resources for providing health care services is an important issue in developing countries. User charges in the form of Surgical Package Program (SPP) were introduced in all district hospitals of Haryana to address this problem. We evaluate the effect of this SPP program on surgical care utilization and out-of-pocket (OOP) expenditures.

METHODS

Data on 25437 surgeries, from July 2006 to June 2013 in 3 districts of Haryana state, was analyzed using interrupted time series analysis to assess the impact of SPP on utilization of services. Adjustment was made for presence of any autocorrelation and seasonality effects. A cross sectional survey was undertaken among 180 patients in District hospital, Panchkula during June 2013 to assess the extent of out of pocket (OOP) expenditure incurred, financial risk protection and methods to cope with OOP expenditure. Catastrophic health expenditure, estimated as any expenditure in excess of 10% of the household consumption expenditure, was used to assess the extent of financial risk protection.

RESULTS

User charges had a negative effect on the number of surgeries in public sector district hospitals in all the 3 districts. The mean out-of-pocket expenditure incurred by the patients was Rs.4564 (USD 74.6). The prevalence of catastrophic expenditure was 5.6%. A higher proportion among the poorest 20% population coped through borrowing money (47.2%), while majority (86.1%) of those belonging to richest quintile paid from their monthly income or savings, or had insurance.

CONCLUSION

There is a need to increase the public financing for curative services and it should be based on the needs of population. Any form of user charge in public sector hospitals should be removed.

Preventive health screening utilization in older Mexicans before and after healthcare reform

OBJECTIVE

To assess changes in preventive screening utilization in older Mexicans, pre- and post-Seguro Popular.

MATERIALS AND METHODS

Data from the Mexican Health and Aging Study (MHAS/Enasem) 2001 and 2012 were used. Logistic and ordinary least squares regression adjusted models were used to predict preventive care in 2012 by insurance status categories in 2001-2012, as the focus explanatory variable.

RESULTS

Participants who were uninsured in 2001 and had Seguro Popular in 2012 were significantly more likely to be tested for diabetes, high blood pressure and receive a tetanus shot than the continually uninsured.

CONCLUSIONS

While disparities in preventive screening between the insured and uninsured continue to exist in Mexico, Seguro Popular seems to have provided better access to health services to prevent chronic and infectious diseases for the otherwise uninsured population.

Universal health coverage in emerging economies: findings on health care utilization by older adults in China, Ghana, India, Mexico, the Russian Federation, and South Africa

BACKGROUND AND OBJECTIVE

The achievement of universal health coverage (UHC) in emerging economies is a high priority within the global community. This timely study uses standardized national population data collected from adults aged 50 and older in China, Ghana, India, Mexico, the Russian Federation, and South Africa. The objective is to describe health care utilization and measure association between inpatient and outpatient service use and patient characteristics in these six low- and middle-income countries.

DESIGN

Secondary analysis of data from the World Health Organization's Study on global AGEing and adult health Wave 1 was undertaken. Country samples are compared by socio-demographic characteristics, type of health care, and reasons for use. Logistic regressions describe association between socio-demographic and health factors and inpatient and outpatient service use.

RESULTS

In the pooled multi-country sample of over 26,000 adults aged 50-plus, who reported getting health care the last time it was needed, almost 80% of men and women received inpatient or outpatient care, or both. Roughly 30% of men and women in the Russian Federation used inpatient services in the previous 3 years and 90% of men and women in India used outpatient services in the past year. In China, public hospitals were the most frequently used service type for 52% of men and 51% of women. Multivariable regression showed that, compared with men, women were less likely to use inpatient services and more likely to use outpatient services. Respondents with two or more chronic conditions were almost three times as likely to use inpatient services and twice as likely to use outpatient services compared with respondents with no reported chronic conditions.

CONCLUSIONS

This study provides a basis for further investigation of country-specific responses to UHC.

The impact of out-of-pocket payments on health care inequity: the case of national health insurance in South Korea

The global financial crisis of 2008 has led to the reinforcement of patient cost sharing in health care policy. This study aimed to explore the impact of direct out-of pocket payments (OOPs) on health care utilization and the resulting financial burden across income groups under the South Korean National Health Insurance (NHI) program with universal population coverage. We used the fourth Korean National Health and Nutrition Examination Survey (KNHNES-IV) and the Korean Household Income and Expenditure Survey (KHIES) of 2007, 2008 and 2009. The Horizontal Inequity Index (HIwv) and the average unit OOPs were used to measure income-related inequity in the quantitative and qualitative aspects of health care utilization, respectively. For financial burden, the incidence rates of catastrophic health expenditure (CHE) were compared across income groups. For outpatient and hospital visits, there was neither pro-poor or pro-rich inequality. The average unit OOPs of the poorest quintile was approximately 75% and 60% of each counterpart in the richest quintile in the outpatient and inpatient services. For the CHE threshold of 40%, the incidence rates were 5.7%, 1.67%, 0.72%, 0.33% and 0.27% in quintiles I (the poorest quintile), II, III, IV and V, respectively. Substantial OOPs under the NHI are disadvantageous, particularly for the lowest income group in terms of health care quality and financial burden.

In hindsight: urban exposure explains the association between prior migration and current health of older adults in Mexico

OBJECTIVE

This study examines sex differences in the association between migration and exposure to an urban environment and overweight, hypertension and diabetes in later life.

METHODS

Interviews were conducted with 3,604 adults aged 50 and older in the Mexican Family Life Survey (MxFLS). Logistic regression analyses were used to examine the association between previous migration, urban exposure, and risk of overweight, hypertension, and diabetes.

RESULTS

Migration itself was not associated with health outcomes after controlling for urban exposure. The risk of overweight and diabetes associated with urban exposure appeared to be greater for men. Sex differences were found in the covariates that helped explain differences in health between those with high and low urban exposure.

DISCUSSION

These findings underscore the need to consider heterogeneity in health by urban exposure and by sex.

Need, enabling, predisposing, and behavioral determinants of access to preventative care in Argentina: analysis of the national survey of risk factors

INTRODUCTION

Health care utilization is an important step to disease management, providing opportunities for prevention and treatment. Anderson's Health Behavior Model has defined utilization by need, predisposing, and enabling determinants. We hypothesize that need, predisposing, and enabling, highlighting behavioral factors are associated with utilization in Argentina.

METHODS

We performed a logistic regression analysis of the 2005 and 2009 Argentinean Survey of Risk Factors, a cohort of 41,392 and 34,732 individuals, to explore the association between need, enabling, predisposing, and behavioral factors to blood pressure measurement in the last year.

RESULTS

In the 2005 cohort, blood pressure measurement was associated with perception of health, insurance coverage, basic needs met, and income. Additionally, female sex, civil state, household type, older age groups, education, and alcohol use were associated with utilization. The 2009 cohort showed similar associations with only minor differences between the models.

CONCLUSIONS

We explored the association between utilization of clinical preventive services with need, enabling, predisposing, and behavioral factors. While predisposing and need determinants are associated with utilization, enabling factors such as insurance coverage provides an area for public intervention. These are important findings where policies should be focused to improve utilization of preventive services in Argentina.

Canadian rural-urban differences in end-of-life care setting transitions

Few studies have focused on the care setting transitions that occur in the last year of life. A three part mixed-methods study was conducted to gain an understanding of the number and implications or impact of care setting transitions in the last year of life for rural Canadians. Provincial health services utilization data, national online survey data, and local qualitative interview data were analyzed to gain general and specific information for consideration. Rural Albertans had significantly more healthcare setting transitions than urbanites in the last year of life (M=4.2 vs 3.3). Online family respondents reported 8 moves on average occurred for family members in the last year of life. These moves were most often identified (65%) on a likert-type scale as “very difficult,” with the free text information revealing these trips were often emotionally painful for themselves and physically painful for their ill family member. Eleven informants were then interviewed until data saturation, with constant-comparative data analysis conducted for a more in-depth understanding of rural transitions. Moving from place to place for needed care in the last year of life was identified as common and concerning for rural people and their families, with three data themes developing: (a) needed care in the last year of life is scattered across many places, (b) travelling is very difficult for terminally-ill persons and their caregivers, and (c) local rural services are minimal. These findings indicate planning is needed to avoid unnecessary end-of-life care setting transitions and to make needed moves for essential services in the last year of life less costly, stressful, and socially disruptive for rural people and their families.

Eye care utilization by older adults in low, middle, and high income countries

Background

The risk of visual impairment increases dramatically with age and therefore older adults should have their eyes examined at least every 1 to 2 years. Using a world-wide, population-based dataset, we sought to determine the frequency that older people had their eyes examined. We also examined factors associated with having a recent eye exam.

Methods

The World Health Surveys were conducted in 70 countries throughout the world in 2002-2003 using a random, multi-stage, stratified, cluster sampling design. Participants 60 years and older from 52 countries (n = 35,839) were asked "When was the last time you had your eyes examined by a medical professional?". The income status of countries was estimated using gross national income per capita data from 2003 from the World Bank website. Prevalence estimates were adjusted to account for the complex sample design.

Results

Overall, only 18% (95% CI 17, 19) of older adults had an eye exam in the last year. The rate of an eye exam in the last year in low, lower middle, upper middle, and high income countries was 10%, 24%, 22%, and 37% respectively. Factors associated with having an eye exam in the last year included older age, female gender, more education, urban residence, greater wealth, worse self-reported health, having diabetes, and wearing glasses or contact lenses (p < 0.05).

Conclusions

Given that older adults often suffer from age-related but treatable conditions, they should be seen on a regular basis to prevent visual impairment and its disabling consequences.

Coexistence of Obesity and Anemia in Older Mexican Adults

INTRODUCTION: Developing countries in Latin America (LA) are experiencing rapid aging as a result of advances in medical interventions. This rapid aging has not occurred with comparable improvements in standards of living. Chronic conditions are becoming highly prevalent while exposure to infectious communicable diseases is very common. This unique situation where communicable and non-communicable diseases coexist in the presence of low socioeconomic status place countries in LA in a unique epidemiological situation. Mexico presents a very good example where the impact of this situation on health warrants further analysis. METHODS: We use data from the Mexican National Health and Nutrition Survey (ENSANut 2006), a cross-sectional study representative of all urban and rural areas of Mexico. A total of 5,605 adults older than 60 years of age with valid values for Body Mass Index and Hemoglobin were analyzed. We first included a descriptive analysis of the coexistence of anemia and obesity by age, gender and characteristics of the living environment. We reported the weighted percentages for each covariate by each of four nutritional condition categories (obese and anemic, only-obese, only-anemic, not obese and not anemic). We used multinomial logit regressions to determine the association of socioeconomic characteristics, health status and the living environment with the presence of the three nutritional condition categories. RESULTS: In the ENSANut cohort 10.3% of older adults are anemic, 25.0% are obese and 2.6% are both anemic and obese. Approximately 62% has neither anemia nor obesity. Within the 38% that fall in the three nutritional condition categories, the co-existence of obesity & anemia appears to be associated with metropolitan area residence, living alone, being male, having relatively high wealth, and reporting two or more chronic health conditions. Analyzing the effect of the covariates to distinguish between outcome categories, living environment, age, gender, wealth, and smoking show a significant effect when comparing across the three nutritional categories. CONCLUSIONS: Older Mexican adults with both obesity & anemia have a different profile compared to that of adults with only one of the conditions. Future studies need to do a careful clinical evaluation of this group and design clinical interventions to avoid complications. Additionally, social support initiatives that target specific groups of older adults according to their health and social needs must be established.