Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal

Gerontology in Public Health: A Scoping Review of Current Perspectives and Interventions

The intersection of gerontology and public health is increasingly vital due to the global aging population and its implications for health systems. This scoping review aims to map existing literature on gerontology within public health, identify current perspectives, and evaluate interventions tailored to the needs of older adults. A systematic search was performed using predefined keywords across multiple databases, including PubMed, Google Scholar, Scopus, and Web of Science. The review included 42 studies that employed various designs, all focusing on public health interventions targeting the aging population.  Key findings indicate a pressing need to integrate gerontological principles into public health practice, recognizing the heterogeneous nature of older adults and the significance of social determinants of health. Interventions ranged from preventive health measures and chronic disease management programs to health promotion activities and caregiver support, including the application of technology to improve health outcomes. However, there was a notable lack of research on diverse populations and mental health interventions. The review also uncovered critical gaps in the literature, such as economic barriers to care access and the necessity for comprehensive policies addressing the aging population's diverse needs. In conclusion, this review emphasizes the importance of a multidimensional approach to effectively addressing older adults' health needs. While several effective interventions exist, there is an urgent need to tackle identified gaps, particularly concerning diverse populations and mental health, to enhance overall health strategies for the aging demographic.

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Barriers and facilitators to health technology adoption by older adults with chronic diseases: an integrative systematic review

BACKGROUND

In recent years, healthcare systems have progressively adopted several technologies enhancing access to healthcare for older adults and support the delivery of efficient and effective care for this specific population. These technologies include both assistive technologies designed to maintain or improve the independence, social participation and functionality of older people at home, as well as health information technology developed to manage long-term conditions. Examples of such technologies include telehealth, wearable devices and mobile health. However, despite the great promise that health technology holds for promoting independent living among older people, its actual implementation remains challenging.

METHODS

This study aimed to conduct an integrative systematic review of the research evidence on the factors that facilitate or hinder the adoption of different types of technology by older individuals with chronic diseases. For this purpose, four electronic databases (PsycArticles, Scopus, Web of Science and PubMed) were queried to search for indexed published studies. The methodological quality of the selected papers has been assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Twenty-nine articles were selected, including 6.213 adults aged 60 or older. The studies have been synthesised considering the types of technological interventions and chronic diseases, as well as the main barriers and facilitators in technology acceptance. The results revealed that the majority of the selected articles focused on comorbid conditions and the utilisation of telemedicine tools. With regard to hindering and facilitating factors, five main domains were identified: demographic and socioeconomic, health-related, dispositional, technology-related and social factors.

CONCLUSION

The study results have practical implications not only for technology developers but also for all the social actors involved in the design and implementation of healthcare technologies, including formal and informal caregivers and policy stakeholders. These actors could use this work to enhance their understanding of the utilisation of technology by the ageing population. This review emphasises the factors that facilitate technology adoption and identifies barriers that impede it, with the ultimate goal of promoting health and independent living.

Integrating health intervention into existing program structure of the neglected tropical diseases: lessons learned from Yobe and Ebonyi states

Background

Nigeria has a national policy on neglected tropical diseases (NTD) which is coordinated by the Federal Ministry of Health and integrated into the health system at all government levels. A network of grassroots mobilizers, named community drug distributors (CDDs), deliver NTD drugs and commodities to rural and hard-to-reach communities throughout Nigeria.

Methods

Interviews with state and local government coordinators of Nigerian NTD programs and focus group discussions with CDDs in Yobe and Ebonyi states were conducted to understand the working modalities of NTD programs in Nigeria to identify the potential of leveraging the NTD structure for additional health interventions such as COVID-19 vaccine rollouts. Collected data was coded and managed on NVivo version 12 using content analysis.

Results and discussion

The study found that the NTD committee had the following: a structured planning and coordination process, a community mobilization approach for the effective delivery of routine Mass Administration of Medication (MAM) activities. Challenges encountered included little or no incentives for the CDDs, insecurity, transportation and logistics, and lack of equipment and drug commodities. Nigerian NTD health structures have a wide reach, with a presence in all states and local government areas (LGAs), and this has previously been leveraged to deliver commodities and interventions to rural and hard-to-reach communities for non-NTD health programs and could thus be used similarly for COVID-19 vaccination programs. The enablers of integrating health interventions into the NTD structure are increased availability of finances and manpower, while lack of financial incentives and partners' buy-in were identified as possible. challenges.

Conclusion

The study suggests that integrating COVID-19 interventions into the NTD program in Nigeria would be a significant accomplishment, as the existing structure can support future interventions. The study also highlights the efficiency of the NTD program's modalities and processes, indicating that an organized structural system for public health interventions can. increase the services of existing interventions while allowing for the integration of future interventions.

Particulate matters (PM2.5, PM10) and the risk of depression among middle-aged and older population: analysis of the Korean Longitudinal Study of Aging (KLoSA), 2016-2020 in South Korea

BACKGROUND

There is a growing concern that particulate matter (PM) such as PM2.5 and PM10 has contributed to exacerbating psychological disorders, particularly depression. However, little is known about the roles of these air pollutants on depression in elderly. Therefore, this study aimed to examine the association between PM2.5 and PM10, and depression in the elderly population in South Korea.

METHODS

We used panel survey data, the Korean Longitudinal Study of Aging (KLoSA), administered by the Labor Institute during the study period of 2016, 2018, and 2020 covering 217 districts in South Korea (n = 7674). Annual district-specific PM2.5 and PM10 concentrations were calculated for the study period from the monthly prediction concentrations produced by a machine-learning-based ensemble model (cross-validated R2: 0.87), then linked to the people matching with year and their residential district. We constructed a generalized estimating equation (GEE) model with a logit link to identify the associations between each of the long-term PM2.5 and PM10 exposures and depression (CES-D 10) after adjusting for individual and regional factors as confounders.

RESULTS

In single-pollutant models, we found that long-term 10 [Formula: see text] increments in PM2.5 (OR 1.36, 95% CI 1.20-1.56) and PM10 (OR 1.19, 95% CI 1.10-1.29) were associated with an increased risk of depression in the elderly. Associations were consistent after adjusting for other air pollutants (NO2 and O3) in two-pollutant models. In addition, the impacts substantially differed by regions grouped by the tertile of the population density, for which the risks of particulate matters on depression were substantial in the middle- or high-population-density areas in contrast to the low-population-density areas.

CONCLUSIONS

Long-term exposure to PM2.5 and PM10 was associated with a higher risk of developing depression in elderly people. The impact was modified by the population density level of the region where they reside.

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

The Longitudinal Association between Co-Residential Care Provision and Healthcare Use among the Portuguese Population Aged 50 and Over: A SHARE Study

Co-residential care is associated with poor caregiver health and a high burden. Although Portugal relies heavily on co-residential care by individuals aged 50 and over, studies on the impact of co-residential care provision on Portuguese caregivers' healthcare use are lacking. This study aims to analyze the impact of co-residential care (spousal and non-spousal care) on healthcare use of the Portuguese population aged 50 plus. Data from waves 4 (n = 1697) and 6 (n = 1460) of the Survey of Health, Ageing and Retirement in Europe (SHARE) were used. Negative Binomial Generalized Linear Mixed Models with random (individual level) and fixed (covariates) effects were performed. The results show that the number of visits to the doctor decrease significantly over time for the co-residential spousal caregivers as compared to the non-co-residential caregivers. This result highlights the fact that the Portuguese co-residential spousal caregiver group is at a higher risk of not using healthcare, thus jeopardizing their own health and continuity of care. Promoting more accessible healthcare services and implementing public policies adjusted to the needs of informal caregivers are important to improve the health and healthcare use of Portuguese spousal co-residential caregivers.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

INTRODUCTION

The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups.

OBJECTIVE

To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain.

METHODS

Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models.

RESULTS

IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018.

CONCLUSION

Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

A scoping review on the impact of austerity on healthcare access in the European Union: rethinking austerity for the most vulnerable

BACKGROUND

There is consensus that the 2008 financial and economic crisis and related austerity measures adversely impacted access to healthcare. In light of the growing debt caused by the COVID-19 crisis, it is uncertain whether a period of austerity will return.

OBJECTIVE

This study aims to provide a structured overview of the impact of austerity policies in the EU-28 zone, applied in response to the Great Recession, on access to health care for the adult population, using the five access dimensions by Levesque et al. (2013).

METHODS

This study followed the PRISMA extension for Scoping Reviews guideline. Medline (PubMed) and Web of Science were searched between February 2021 and June 2021. Primary studies in the English language published after the 1st of January 2008 reporting on the possible change in access to the healthcare system for the adult population induced by austerity in an EU28 country were included.

RESULTS

The final search strategy resulted in 525 articles, of which 75 studies were reviewed for full-text analysis, and a total of 21 studies were included. Results revealed that austerity policy has been primarily associated with a reduction in access to healthcare, described through four main categories: i) Increase in rates of reported unmet needs (86%); ii) Affordability (38%); iii) Appropriateness (38%); iv) and Availability and Accommodation (19%). Vulnerable populations were more affected by austerity measures than the general population when specific safeguards were not in place. The main affected adult vulnerable population groups were: patients with chronic diseases, elderly people, (undocumented) migrants, unemployed, economically inactive people and individuals with lower levels of education or socioeconomic status.

CONCLUSION

Austerity measures have led to a deterioration in access to healthcare in the vast majority of the countries studied in the EU-28 zone. Findings should prompt policymakers to rethink the fiscal agenda across all policies in times of economic crisis and focus on the needs of the most vulnerable populations from the health perspective.

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience - A Realist Review

BACKGROUND

The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks.

METHODS

A realist review identified legacies associated with austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007-May 2021), resulting in 1081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of context-mechanism-outcome configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience.

RESULTS

Five CMOCs demonstrated how austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks.

CONCLUSION

This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.

Visual impairment and falls among older adults and elderly: evidence from longitudinal study of ageing in India

BACKGROUND

The present study determines the prevalence and correlates of falls, multiple falls, and injuries, focusing on visual impairment among the older adult and elderly population in India. Additionally, owing to the higher prevalence of falls and visual impairment among women, a sex-stratified analysis has also been done in the present study.

METHODS

The study utilized the data from the first wave of the Longitudinal Ageing Study in India (LASI wave-1), conducted during 2017-2018. Bivariate with chi-square and multivariate analyses were performed to fulfill the objective.

RESULTS

Around 34% of population had low vision (male:30% and female: 38%), while blindness prevalence was 1.63% (males: 1.88% and females: 1.41%). The fall was higher among females and increased across the gender with increasing visual impairment and blindness levels. The unadjusted odds of falls were 16% higher among individuals with low vision and 40% higher among individuals with blindness than with normal vision, and comparatively higher odds among females than males.

CONCLUSION

In summary, falls and visual impairment is public health challenge and needs to be addressed. Visual impairment is preventable in most cases, so it may be a modifiable target for reducing the risk of falls.

Access to healthcare for people aged 50+ in Europe during the COVID-19 outbreak

This paper combines SHARE Corona Survey and SHARE Wave 7 data for 25 European countries and Israel (N = 40,919) with institutional and epidemic-related country characteristics to investigate healthcare access for Europeans aged 50+ during the outbreak of COVID-19. We use a micro-macro approach to examine whether and to what extent barriers to accessing healthcare measured by reported unmet healthcare needs vary within and between countries. We consider various aspects of barriers and distinguish among: (1) respondents who forewent medical treatment because they were afraid of becoming infected with the Coronavirus; (2) respondents who had pre-scheduled medical appointments postponed by health providers due to the outbreak; and (3) respondents who tried to arrange a medical appointment but were denied one. Limited access to healthcare during the initial outbreak was more common for the occupationally active, women, the more educated and those living in urban areas. A bad economic situation, poor overall health and higher healthcare utilisation were robust predictors of unmet healthcare. People aged 50+ in countries of 'Old' Europe, countries with higher universal health coverage and stricter containment and closure policies were more likely to have medical services postponed. Policymakers should address the healthcare needs of older people with chronic health conditions and a poor socio-economic status who were made more vulnerable by this pandemic. In the aftermath of the health crisis, public health systems might experience a great revival in healthcare demand, a challenge that should be mitigated by careful planning and provision of healthcare services.

The COVID-19 Pandemic in Care Homes: An Exploration of Its Impact across Regions in Spain

This article provides an updated picture of the enormous consequences that the first wave of the COVID-19 pandemic (March–June 2020) had for older adults living in Spanish care homes. It aims to describe the regional variation in deaths among home care residents through a methodological triangulation of descriptive quantitative, ecological and documentary analysis. Figures of five different indicators of care home mortality are provided and some factors related to higher mortality rates are presented and analysed in the descriptive ecological analysis in order to depict trends and, in a linear regression, to determine their statistical significance. The clearest trend reflected by the data is that the higher the cumulative incidence and the number of care home beds in the surrounding area, the higher the COVID-19 care home mortality. We argue that the pandemic has brought to light the historical fragility and underdevelopment of the Spanish LTC sector, and that these factors have exacerbated the consequences of the pandemic. Finally, we conclude that publicly available and disaggregated data would allow a deeper and more accurate analysis of potentially explanatory factors such as the type of care home ownership and management, and that further qualitative research would shed more light on people’s experiences.

Implications for health system reform, workforce recovery and rebuilding in the context of the Great Recession and COVID-19: a case study of workforce trends in Ireland 2008-2021

BACKGROUND

Workforce is a fundamental health systems building block, with unprecedented measures taken to meet extra demand and facilitate surge capacity during the COVID-19 pandemic, following a prolonged period of austerity. This case study examines trends in Ireland's publicly funded health service workforce, from the global financial crisis, through the Recovery period and into the COVID-19 pandemic, to understand resource allocation across community and acute settings. Specifically, this paper aims to uncover whether skill-mix and staff capacity are aligned with policy intent and the broader reform agenda to achieve universal access to integrated healthcare, in part, by shifting free care into primary and community settings.

METHODS

Secondary analysis of anonymised aggregated national human resources data was conducted over a period of almost 14 years, from December 31st 2008 to August 31st 2021. Comparative analysis was conducted, by professional cadre, across three keys periods: 'Recession period' December 31st 2008-December 31st 2014; 'Recovery period' December 31st 2014-December 31st 2019; and the 'COVID-19 period' December 31st 2019-August 31st 2021.

RESULTS

During the Recession period there was an overall decrease of 8.1% (n = 9333) between December 31st 2008 and December 31st 2014, while the Recovery period saw the overall staff levels rebound and increase by 15.2% (n = 16,789) between December 31st 2014 and December 31st 2019. These figures continued to grow, at an accelerated rate during the most recent COVID-19 period, increasing by a further 8.9% (n = 10,716) in under 2 years. However, a notable shift occurred in 2013, when the number of staff in acute services surpassed those employed in community services (n = 50,038 and 49,857, respectively). This gap accelerated during the Recovery and COVID-19 phase. By August 2021, there were 13,645 more whole-time equivalents in acute settings compared to community, a complete reverse of the 2008 situation. This was consistent across all cadres. Workforce absence trends indicate short-term spikes resulting from shocks while COVID-19 redeployment disproportionately impacted negatively on primary care and community services.

CONCLUSIONS

This paper clearly demonstrates the prioritisation of staff recruitment within acute services-increasing needed capacity, without the same commitment to support government policy to shift care into primary and community settings. Concerted action including the permanent redistribution of personnel is required to ensure progressive and sustainable responses are learned from recent shocks.

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Transcendence, the Most Important Spiritual Need of Muslim Older Adults: A Content Analysis Study

Healthcare providers agree that promoting spirituality among older adults while caring for them increases their quality of life. However, there is little knowledge about the spiritual needs of the elderly, especially in the Muslim community. This qualitative study attempted to explore the spiritual needs of Muslim older adults. Fifteen non-hospitalized Muslim older adults from Hamadan City, Iran, were interviewed. The semi-structured interviews were analyzed using conventional content analysis. After identifying semantic units from the text, related codes were extracted and placed in subcategories and categories based on their similarities. Once the data were analyzed, one theme was formed. The study's findings showed that the spiritual needs of older adults fell into three main categories: religious needs, the need for transcendence, and the need for connection. Religious needs included subcategories of religious practices and beliefs, and the need for transcendence included the search for meaning and purpose in life, and the need for peace and stability and balance. Also, the need for connection included the need to connect with nature and connect with others. Healthcare professionals and family caregivers should be trained in the specific competence of recognizing older people's unmet spiritual needs and fulfilling them.

Willingness, perceived barriers and motivators in adopting mobile applications for health-related interventions among older adults: a scoping review

OBJECTIVES

This scoping review aims to identify the level of willingness, the existing barriers, and motivators among older adults in using mobile applications to monitor and manage their health conditions. The secondary aim of this paper is to categorise these willingness, barriers and motivators using the Theoretical Domains Framework (TDF).

DESIGN

Scoping review.

DATA SOURCE

PubMed, Embase, CINAHL, Cochrane Library, Google Scholar and Science Direct (January 2009-December 2020).

STUDY SELECTION

Studies that describe older adults' perspectives with regard to their willingness, barriers or motivators towards the use of mobile applications in monitoring and managing their health condition were included.

DATA EXTRACTION

Titles and abstracts were initially screened by two reviewers. Articles agreed by both reviewers were proceeded to full-text screening. One reviewer extracted the data, which were verified by a second reviewer. Findings were further classified according to the 14 TDF domains by two researchers.

RESULTS

Six studies were included in the final scoping review. Barriers to adopting mobile applications for health-related interventions among older adults were the most common topic identified in the included studies. Barriers included being unaware of the existence of mobile health applications, lack of technological skills, lack of perceived ability and time, absence of professional involvements, and violation of trust and privacy. With regard to willingness, older adults are willing to use mobile applications if the apps incorporated features from a trusted source and have valid credentials. Motivators included continuous improvements of mobile applications' design interface and personalised features tailored to older adults' needs.

CONCLUSIONS

With the constant research for more diversified technology, the development of mobile applications to help older adults to manage and monitor health is seen as feasible, but barriers have to be addressed. The most prominent barriers linked to TDF domains were: (1) technological skills, (2) belief about consequences, and (3) memory, attention and decision process. Future interventions should use behaviour change techniques that target these three TDF domains in order to improve the ability to engage older adults with mobile technology.

The Sustainable Care Model for an Ageing Population in Vietnam: Evidence from a Systematic Review

Social demographic studies in Vietnam have shown a growing trend of an ageing population. Demographic trends project that one third of the Vietnamese population will be aged 65 years and older by 2050. Vietnam is a country where the majority of the elderly live with their children, with little savings and pension. The purpose of this review was to explore existing literature on models of care for an ageing population and provide evidence to develop a care model that is suitable for the ageing community in Vietnam. A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was carried out. An extensive literature search was performed, with a focus on articles and other materials with relevance to elderly care in Vietnam in terms of socio-economic, demographic, and associated factors based on comprehensive data sources. The review found that there is a lack of evidence of professional practice for caring for the aged in Vietnam. There also is a lack of evidence of government support for the limited community initiatives to support the ageing. There exist no community models of care for the ageing population in Vietnam. From a global perspective, there exist alternative models of care options to support the elderly through various care models, such as living in assisted-care facilities, home care, and other assistance. Inter-professional practice care models and health services were found to be essential for an ageing population. There is limited literature specifically for the care of an ageing population in Vietnam. Most of the available literature on care models for the aged is drawn from developed countries. The review offers insights into the development of care models for the elderly in Vietnam, with the need for inter-professional efforts in practice settings to support the ageing Vietnamese population. The reviewed literature agrees on the developing global challenges due to ageing. Despite the existing literature on care models for the ageing, there is a lack evidence-based care models concerning the current and future needs of elderly care in middle- and lower-income economies like Vietnam. More evidence is required to establish evidence for best care models for the elderly in developing economies.

Morbidities and health-seeking behavior of elderly patients attending primary health care in the Kingdom of Bahrain

Background:

Understanding the health-seeking behaviors help in increasing the effectiveness and efficiency of the health-care system; however, there is lack of knowledge regarding the health-seeking behavior of the elderly population in the Kingdom of Bahrain.

Objective:

The objective of this study was to identify the morbidity profile and determine the health-seeking behavior of the elderly population.

Methods:

This cross-sectional study included all elderly patients (≥60 years) who attended four primary health-care centers that represent four governorates with the largest catchment area in the Kingdom of Bahrain between June 19 and August 31, 2021. Information concerning their sociodemographic data, morbidity profile and health-seeking behavior were collected through direct interviewing using a structured, predesigned and pretested questionnaire.

Results:

A total of 414 elderly patients were included, with the majority being Bahraini (89.1%) and male (55%). The most prevalent morbidity was hypertension (67.6%), followed by hyperlipidemia (54.7%), diabetes (52.6%), and arthritis (32.1%); arthritis was significantly more common among females than males (P < 0.001). The majority reported the reason for their visit being “repeat prescription” (32.1%). Almost one-third (28.2%) attempted self-management prior to their visit, and almost half (46.7%) reported seeking non-professional medical advice. The majority rated their health as good (39.4%) and moderate (38.2%). Less than one-third (28%) reported having had a health problem for which they did not attend to a health care facility.

Conclusion:

The study highlighted the morbidity profile and the health-seeking behavior among elderly population in Bahrain, which may serve as a point from which further efforts may be directed to improve the services.

Trends of amenable deaths due to healthcare within the European Union countries. Exploring the association with the economic crisis and education

The study of premature deaths from causes that are generally preventable given the current availability of healthcare - called amenable deaths due to healthcare - provides information on the quality of services. However, they are not only impacted by healthcare characteristics: other factors are also likely to influence. Therefore, identifying the association between amenable deaths due to healthcare and health determinants, such as education, might be the key to preventing these deaths in the future. Still unclear however, is how this works and how amenable deaths due to healthcare are distributed and evolve within the European Union (EU) below the national level. We therefore studied the geographical and temporal patterns of amenable deaths due to healthcare in the 259 EU regions from 1999 to 2016, including the 2007-2008 financial crisis and the post-2008 economic downturn, and identified whether any association with education exists. A cross-sectional ecological study was carried out. Using a hierarchical Bayesian model, we estimated the average smoothed Standardized Mortality Ratios (sSMR). A regression model was also applied to measure the relative risks (RR) at 95% credible intervals for cause-specific mortality association with education. Results show that amenable deaths due to healthcare decreased globally. Nevertheless, the decrease is not the same across all regions, and inequalities within countries do persist, with lower mortality ratios seen in regions from Central European countries and higher mortality ratios in regions from Eastern European countries. Also, the evolution trend reveals that after the financial crisis, the number of these deaths increased in regions across almost all EU countries. Moreover, educational disparities in mortality emerged, and a statistical association was found between amenable deaths due to healthcare and early exit from education and training. These results confirm that identifying and understanding the background of regional differences may lead to a better understanding of the amenable deaths due to healthcare and allow for the application of more effective policies.

Factors influencing access and utilization of health services among older people during the COVID - 19 pandemic: a scoping review

BACKGROUND

Access to healthcare and service utilization are both considered essential factors for improving the general health and wellbeing of older people, especially at the time of COVID-19 pandemic. The aim of the study is to explore factors affecting healthcare access and health service utilization for older people during the pandemic.

METHODS

PubMed, Web of Science, Scopus and Embase were systematically searched for relevant articles. Access, utilization, health, elderly and COVID-19 were used as keywords in the search strategy. A total of 4308 articles were identified through the initial database search; 50 articles were included in the review as passing the eligibility criteria. The searches were conducted up to August 2021. Data extraction was performed, and evidence was descriptively illustrated. Thematic analysis was used to explore factors influencing the elderly's access and utilization of healthcare services, using Max QDA10, a qualitative analysis software.

RESULTS

Among articles included in the review (n = 50), a majority of the studies were from the United States (36%), followed by India (8%). According to the main healthcare services, a large number of articles (18%) were related to mental health services, followed by digital health services (16%). Factors were identified at an individual, provider and systems level. Seven main themes emerged from the thematic analysis, as determinants of elderly's access and utilization of healthcare services during COVID-19 pandemic. These included: access to non-COVID related services, access to COVID-related services, literacy and education, accommodation challenges, perceived attitudes of aging, and policies and structures, and social determinants.

CONCLUSION

Mental health and digital health services were identified as major issues influencing or contributing to or influencing older people's health during the COVID-19 pandemic. We also argue on the importance of a rounded view, as attention to a range of factors is vital for policy decisions towards sustainable care and equitable interventions for improving the health of older people.

Assessing healthcare access using the Levesque's conceptual framework- a scoping review

INTRODUCTION

Countries are working hard to improve access to healthcare through Universal Healthcare Coverage. To genuinely address the problems of healthcare access, we need to recognize all the dimensions and complexities of healthcare access. Levesque's Conceptual Framework of Access to Health introduced in 2013 provides an interesting and comprehensive perspective through the five dimensions of access and the five abilities of the population to access healthcare. The objectives of this paper are to identify and analyze all empirical studies that applied Levesque's conceptual framework for access to healthcare and to explore the experiences and challenges of researchers who used this framework in developing tools for assessing access.

METHODS

A scoping review was conducted by searching through four databases, for studies citing Levesque et al. 2013 to select all empirical studies focusing on healthcare access that applied the framework. An initial 1838 documents underwent title screening, followed by abstract screening, and finally full text screening by two independent reviewers. Authors of studies identified from the scoping review were also interviewed.

RESULTS

There were 31 studies identified on healthcare access using the Levesque framework either a priori, to develop assessment tool/s (11 studies), or a posteriori, to organize and analyze collected data (20 studies). From the tools used, 147 unique questions on healthcare access were collected, 91 of these explored dimensions of access while 56 were about abilities to access. Those that were designed from the patient's perspective were 73%, while 20% were for health providers, and 7% were addressed to both. Interviews from seven out of the 26 authors, showed that while there were some challenges such as instances of categorization difficulty and unequal representation of dimensions and abilities, the overall experience was positive.

CONCLUSION

Levesque's framework has been successfully used in research that explored, assessed, and measured access in various healthcare services and settings. The framework allowed researchers to comprehensively assess the complex and dynamic process of access both in the health systems and the population contexts. There is still potential room for improvement of the framework, particularly the incorporation of time-related elements of access.

Spatial Access Matters: An Analysis of Policy Change and Its Effects on Avoidable Infant Mortality in Portugal

In 2006, a policy reform restructured the maternal and perinatal healthcare system, including closing smaller maternity units, to further improve care in Portugal. This study aimed to investigate the effects of the 2006 National Program of Maternal and Neonatal Health policy on spatial inequalities in access to care and consequently avoidable infant mortality. A thematic analysis of qualitative data including interviews and surveys and a quantitative spatial analysis using Geographic Information Systems was applied. Spatial inequalities were found which may lead to avoidable infant mortality. Inequalities exist in freedom of choice and autonomy in care, within a medicalized system. Changes in approach to and organization of care would further enhance equitable spatial access to care in maternal health and reduce avoidable infant mortality.

Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

BACKGROUND

The WHO identified the importance of macro-socioeconomic determinants and political context as interlinked key factors affecting healthcare quality and health equity. As a response to the recent economic and financial crisis, Portugal approved in 2011 the Economic Adjustment Programme (EAP) to obtain financial assistance from the Troika in order to reduce public debt. This study aims to analyse the impact of the economic crisis and the EAP on perinatal healthcare quality for very preterm (VPT) and/or very low birth weight (VLBW) infants, as perceived by healthcare professionals and experts, within the health administrative regions of the two major metropolitan areas in Portugal.

METHODS

A qualitative approach was applied to receive an in-depth understanding and accomplish perspective variability. A purposive sampling technique was used. Semi-structured interviews were conducted with twenty-one healthcare professionals and experts between October 2018-July 2019. Inductive thematic analysis was performed which encompassed a five-step categorization procedure. Data analysis was undertaken by utilizing Nvivo2011 software. Evolved themes were then associated with WHO's Quality Standards on Maternal and New-born Care. A framework on the impact of macro-socioeconomic determinants on perinatal health care quality was developed.

RESULTS

Although participants did not perceive the quality of perinatal care had deteriorated, the analysis of their accounts on work experience revealed that it was indeed adversely modified in all WHO Quality Standards. Health care provision was perceived as detrimental in five main areas: 1) Availability of human resources; 2) Functional referral systems; 3) Competent and motivated human resources; 4) Emotional support; and 5) Essential physical resources available. Policy reforms by the EAP resulted in reduced timeliness of care, increased waiting times, cuts in sequence and duration of consultations, and deficiencies in follow-up care for VPT/VLBW infants and their mothers. The EAP directly influenced working environment of healthcare professionals by causing stress, burnout, work absence, and brain drain.

CONCLUSION

An interrelation between macro-socioeconomic determinants and perinatal health care quality was disclosed. The economic crisis and EAP have adversely modified equitable perinatal health care quality for VPT/VLBW infants and their mothers. Our findings underlined the negative impact of austerity policies on vulnerable populations.

Factors of Never Screened with Faecal Occult Blood Test in Public Primary Care Facilities

BACKGROUND

Colorectal cancer (CRC) is still a major public health threat. In the effort to reduce CRC incidence and mortality, faecal occult blood test (FOBT) is currently the screening tools used for early detection of CRC. However, the uptake of FOBT screening is less than promising. This study aims to identify the prevalence and predictors of Never Screened with FOBT (NS-FOBT).

METHODS

A cross sectional study was conducted in five health clinics under Kota Kinabalu district, Sabah, Malaysia Borneo involving 162 attendees with age of 50 years old and above. A validated self-administered questionnaire was used to collect the data. Multiple logistic regression analysis was used to determine the predictors of NS-FOBT.

RESULTS

The prevalence of NS-FOBT was 85.8% (n=139). Important predictors of NS-FOBT were age (aOR: 0.922; 95% CI: 0.855, 0.995; p=0.035), Bumiputera ethnicity (vs Non Bumiputera; aOR: 4.285; 95% CI: 1.384, 13.263; p=0.012), knowledge score (aOR: 0.921; 95% CI: 0.856, 0.99; p=0.027), and attitude score (aOR: 0.801; 95% CI: 0.702, 0.913; p=0.001).

CONCLUSION

There is high prevalence of NS-FOBT. Age, ethnicity, knowledge, and attitude were important predictors of NS-FOBT. Strategies are needed to improve FOBT screening rate among the public. Socio-culturally tailored health promotion strategies as well as strengthening the communication, collaboration, and education to enhance the role of family physician is vital in improving the CRC prevention and care.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Differences in the Potential Accessibility of Home-Based Healthcare Services among Different Groups of Older Adults: A Case from Shaanxi Province, China

With the increase of the aging population and the lack of family care, home-based healthcare services have gradually become the main model to cope with aging, so local governments have invested heavily in the construction of home-based healthcare services. However, healthcare services still have problems such as low resource utilization and imbalanced development. The reason is that the supply and demand of healthcare services are not matched and the potential accessibility is low. Therefore, based on the supply and demand of healthcare services, this article pulls out the spatial and social factors that affect the potential accessibility, and tests the influence of individual factors on the potential accessibility among different groups of older adults. It is found that the perceived vulnerability of the older adults will reduce the potential accessibility of healthcare services. The psychosocial status, income and education level with the willingness to use healthcare services of the older adults are directly proportional, while residence has a negative impact on the potential accessibility. Finally, based on this finding, this article puts forward feasible suggestions from the perspective of policy content, publicity, and implementation.

Disparities in Geographical Access to Hospitals in Portugal

Geographical accessibility to health care services is widely accepted as relevant to improve population health. However, measuring it is very complex, mainly when applied at administrative levels that go beyond the small-area level. This is the case in Portugal, where the municipality is the administrative level that is most appropriate for implementing policies to improve the access to those services. The aim of this paper is to assess whether inequalities in terms of access to a hospital in Portugal have improved over the last 20 years. A population-weighted driving time was applied using the census tract population, the roads network, the reference hospitals’ catchment area and the municipality boundaries. The results show that municipalities are 25 min away from the hospital—3 min less than in 1991—and that there is an association with premature mortality, elderly population and population density. However, disparities between municipalities are still huge. Municipalities with higher rates of older populations, isolated communities or those located closer to the border with Spain face harder challenges and require greater attention from local administration. Since municipalities now have responsibilities for health, it is important they implement interventions at the local level to tackle disparities impacting access to healthcare.

Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging

The rapid growth of the global aging population has raised attention to the health and healthcare needs of older adults. The purpose of this mini-review is to: (1) elucidate the complex factors affecting the relationship between chronological age, socio-economic status (SES), access to care, and healthy aging using a SES-focused framework; (2) present examples of interventions from across the globe; and (3) offer recommendations for research-guided action to remediate the trend of older age being associated with lower SES, lack of access to care, and poorer health outcomes. Evidence supports a relationship between SES and healthcare access as well as healthcare access and health outcomes for older adults. Because financial resources are proportional to health status, efforts are needed to support older adults and the burdened healthcare system with financial resources. This can be most effective with grassroots approaches and interventions to improve SES among older adults and through data-driven policy and systems change.

Willingness, perceived barriers and motivators in adopting mobile applications for health-related interventions among older adults: a scoping review protocol

INTRODUCTION

The world's older population continues to grow at an unprecedented rate. An ageing population poses a great challenge to our healthcare system that requires new tool to tackle the complexity of health services as well as the increasing expenses. Mobile health applications (mHealth app) is seen to have the potential to address these challenges, alleviating burdens on the healthcare system and enhance the quality of life for older adults. Despite the numerous benefits of mHealth apps, relatively little is known about whether older adults perceive that these apps confer such benefits. Their perspectives towards the use of mobile applications for health-related purposes have also been little studied. Therefore, in this paper, we outline our scoping review protocol to systematically review literature specific to older adults' willingness, perceived barriers and motivators towards the use of mobile applications to monitor and manage their health.

METHODS AND ANALYSIS

Arksey and O'Malley's scoping review methodology framework will guide the conduct of this scoping review. The search strategy will involve electronic databases including PubMed, Excerpta Medica Database, Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Google Scholar and ScienceDirect, in addition to grey literature sources and hand-searching of reference lists. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Data will be charted and sorted through an iterative process by the research team. The extracted data will undergo a descriptive analysis and simple quantitative analysis will be conducted using descriptive statistics. Engagement with relevant stakeholders will be carried out to gain more insights into our data from different perspectives.

ETHICS AND DISSEMINATION

Since the data used are from publicly available sources, this study does not require ethical approval. Results will be disseminated through academic journals, conferences and seminars. We anticipate that our findings will aid technology developers and health professionals working in the area of ageing and rehabilitation.

[Access to healthcare in Portugal in the wake of the crisis. Not everything is money?]

Unmet healthcare needs have been used to assess access to healthcare. In scenarios of recession and financial constraints on public policies, it is important to identify which factors besides income can be used to mitigate barriers to access. This was the focus of our study on Portugal's case in the wake of the crisis. We used 17,698 observations from the 5th National Health Survey (2014). We analyzed self-reported unmet needs for medical appointments and treatments, dental healthcare, and prescribed medications. We used a bivariate selection model, considering the fact that unmet needs could only be observed in the subsample of individuals that felt the need for healthcare. The risk of unmet needs for healthcare decreased in individuals with higher income and schooling levels and in the elderly and men. Exclusive coverage by the National Health Service increased the risk of unmet dental healthcare needs. The absence of a circle of close friends to whom one can ask for help and lack of trust in others increased the likelihood of unmet healthcare needs. Better health decreased the risk of unmet needs. While income is an important predictor of unmet needs, we found the impact of other factors such as gender, age, and education. Participation in informal groups reduced the likelihood of unmet needs. Individuals with more healthcare needs end up suffering additional risk.

“Geografias” do acesso dos idosos aos cuidados de saúde primários na Área Metropolitana de Lisboa, Portugal - um território de diferenças

Resumo Vários autores têm refletido sobre a questão do acesso aos serviços de saúde, considerando a existência de várias dimensões, nas quais se inclui a disponibilidade e a acessibilidade. No contexto de envelhecimento que caracteriza as sociedades, a população idosa precisa de mais cuidados de saúde, e a acessibilidade a essas unidades assume importância acrescida. O objetivo do estudo é caracterizar o acesso da população idosa aos serviços de saúde, confrontando as possibilidades decorrentes da oferta de serviços com os padrões de procura. Do confronto entre oferta e procura resulta a possibilidade de identificar as dinâmicas intrarregionais e associá-las às diferentes condições socioeconômicas dos idosos, ao seu enquadramento familiar, modo de transporte e tipo de serviço. Esta abordagem considera duas fases metodológicas: o cálculo do potencial de cobertura populacional das unidades de cuidados primários, considerando a acessibilidade física recorrendo aos modos pedonal e rodoviário; e o confronto desses valores com a procura dos serviços, determinada a partir de inquéritos realizados aos residentes. Concluiu-se que, apesar dos equipamentos de saúde prestadores de cuidados primários terem sido programados como serviço de proximidade, a forma de prestação do serviço, as características socioeconômicas da população idosa e o modelo de urbanização apontam para diferenças relevantes no contexto da Área Metropolitana de Lisboa.

Measuring Health Vulnerability: An Interdisciplinary Indicator Applied to Mainland Portugal

Health promotion and inequality reduction are specific goals of the United Nations 2030 Agenda, which are interconnected with several dimensions of life. This work proposes a composite index SEHVI-socioeconomic health vulnerability index-to address Portuguese population socioeconomic determinants that affect health outcomes. Variables composing SEHVI are aligned with the sustainable development goals considering data and times series availability to enable progress monitoring, and variables adequacy to translate populations' life conditions affecting health outcomes. Data for 35 variables and three periods were collected from official national databases. All variables are part of one of the groups: Health determinants (social, economic, cultural, and environmental factors) and health outcomes (mortality indicators). Variables were standardized and normalized by "Distance to a reference" method and then aggregated into the SEHVI formula. Several statistical procedures for validation of SEHVI revealed the internal consistency of the index. For all municipalities, SEHVI was calculated and cartographically represented. Results were analyzed by statistical tests and compared for three years and territory typologies. SEHVI differences were found as a function of population density, suggesting inequalities of communities' life conditions and in vulnerability to health.

Motivations Influencing the Surgeon's Healthcare Unit Choice to Perform Surgery: A Confirmatory Study in Portugal

Quality surgical practice is a fundamental subject in health institutions, and it is important to understand the structural and organizational conditions of the operating room (OR). The present exploratory study sought to understand the motivations that underlie the choice of surgeons for the best healthcare unit to perform surgery, as well as the characteristics of those professionals regarding age, years of work experience, and sex. A questionnaire survey was administered to a convenience sample of 99 surgeons, 67.3% male and 32.7% female, aged 37 to 66 (M = 23.7; Std = 8.92). The results show that at the top of the surgeons' motivations to perform surgery is the 77.8% attributed to the human resources and equipment available and at the other extreme the 3% to the previous online visit to facilities. This study opens important clues to the development of more in-depth and comparative approaches, necessary for the continuous improvement of the healthcare provided in the context of surgical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Individual and Neighborhood Characteristics on Mental Health after a Period of Economic Crisis in the Lisbon Region (Portugal): A Multilevel Analysis

Mental health is an intrinsic dimension of health influenced by individual and contextual factors. This cross-sectional study analyzes the association between the individual, neighborhood characteristics, and one’s self-assessed mental health status in the Lisbon region after an economic crisis. Via the application of multilevel regression models, the study assesses the link between one’s neighborhood environment—deprivation, low self-assessed social capital, and low self-assessed satisfaction with the area of residence—and mental health regardless of one’s individual characteristics. Constraints related to the economic crisis play an important role in the explanation of poor mental health.

Excess winter mortality and morbidity before, during, and after the Great Recession: the Portuguese case

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual's vulnerability to winter conditions. The impact of poor socioeconomic conditions may be of such magnitude that an economic recession may aggravate the seasonal mortality pattern. This paper aims to measure the seasonal winter mortality, morbidity, and their related costs during the Great Recession (2009-2012) in mainland Portugal and its Regional Health Administrations (RHAs) and to compare it with the periods preceding and following it. Monthly mortality and morbidity data were collected and clustered into three periods: Great Recession (2009-2012), Pre-Recession (2005-2008), and Post-Recession (2013-2016). The impact of seasonal winter mortality and morbidity during the Great Recession in Portugal and its Regional Health Administrations was measured through the assessment of age-standardized excess winter (EW) death and hospital admissions rate and index, expected life expectancy gains without EW deaths, EW rate of potential years of life lost, and EW rate of emergency hospital admission costs. Important increases of winter deaths and hospital admissions were identified, resulting in an important number of potential years of life lost (87 years of life lost per 100,000 inhabitants in 2009-2012), life expectancy loss (1 year in 2009-2012), and National Health Service costs with explicit temporal and spatial variations. These human and economic costs have decreased consistently during the analyzed periods, while no significant increase was found during the Great Recession. Despite its reduction, the winter excess morbidity and mortality highlight that Portugal still faces substantial challenges related to a highly vulnerable population, calling for investments in better social and health protection.

Regional differences in morbidity profiles and health care use in the oldest old: Findings from two Centenarian Studies in Portugal

BACKGROUND

The worldwide increase of human life expectancy and the rapid aging of the population will contribute to an increasing prevalence of chronic illness. Even so, individuals who reach very advanced ages often postpone or escape age-related diseases that are common causes of death.

OBJECTIVE

This article aims to examine health-related characteristics of two distinct samples of Portuguese centenarians (one predominantly rural - PR vs. one predominantly urban - PU), and explore potential dissimilarities in their morbidity profiles and use of health care services.

METHODS

A total of 241 centenarians were considered. Sociodemographic characteristics, health status, and use of health care services were assessed by semi-structured interviews with the centenarians and their proxies (family or formal caregiver).

RESULTS

A higher average of 4.80 self-reported illnesses (sd = 2.01) were found in the PU sample (vs. 2.96; sd = 1.77 in the PR sample); in overall the PR sample presented a better health condition with lower levels of physical and mental impairments, and a greater number of centenarians who did not succumb to the three most common lethal diseases (heart disease, non-skin cancer and stroke) in the elderly population (85.4% vs. 60% in the PU sample).

CONCLUSIONS

Portuguese centenarians experienced a substantial number of illnesses, but an overall better health status was found in centenarians from the PR area. By providing distinctive health-related profiles, our findings suggest the importance of contextual factors in shaping how very advanced ages may be achieved.

Financial Crisis in Portugal: Effects in the Health Care Sector

Portugal has faced an economic and financial crisis that began circa FY2009 and whose effects are still ongoing. In FY2011, the Portuguese state and the European triumvirate - composed of the European Commission, the International Monetary Fund, and the European Central Bank - signed the Memoranda of Understanding. This troika agreement aimed to improve the operational efficiency of public services. This crisis had a considerable impact on the Portuguese citizens' life and productivity, as well as on the public health care system. Cuts over public expenditures have been made to reduce the risk of noncompliance with budgetary targets, despite their potential impact on quality and access to health care services. We analyzed the main policies and measures undertaken by the Portuguese Ministry of Health with respect to the bailout program associated with the troika agreement. Then, we focused on the budgetary cuts-related risks over the social performance of the care system. Evidence suggests that structural reforms in the health care sector in the troika period had positive effects in terms of drugs administration and consumption, on the one hand, and secondary care expenditures reduction, on the other hand. Nonetheless, we observed some divestitures on infrastructures and the worsening of access to health care services.