Digital and Economic Determinants of Healthcare in the Crisis-Affected Population in Afghanistan: Access to Mobile Phone and Socioeconomic Barriers

Patterns and determinants of healthcare utilization and medication use before and during the COVID-19 crisis in Afghanistan, Bangladesh, and India

BACKGROUND

COVID-19 rapidly spread through South Asian countries and overwhelmed the health systems that were unprepared for such an outbreak. Evidence from high-income countries showed that COVID-19 impacted healthcare utilization, including medication use, but empirical evidence is lacking in South Asia. This study aimed to investigate the effect of COVID-19 on healthcare utilization and medication use in South Asia.

METHOD

The current study used longitudinal data from the 'Premise Health Service Disruption Survey' 2020 and 2021. The countries of interest were limited to Afghanistan, Bangladesh, and India. In these surveys, data related to healthcare utilization and medication use were collected for three-time points; 'Pre-COVID phase', 'Initial phase of COVID-19 outbreak', and 'One year of COVID-19 outbreak'. Generalized estimating equation (GEE) along with McNemar's test, Kruskal-Wallis test and χ2 test were applied in this study following the conceptualization of Andersen's healthcare utilization model.

RESULT

The use of healthcare and medication was unevenly impacted by the COVID-19 epidemic in Afghanistan, Bangladesh, and India. Immediately after the COVID-19 outbreak, respondents in Bangladesh reported around four times higher incomplete healthcare utilization compared to pre-COVID phase. In contrast, respondents in Afghanistan reported lower incomplete utilization of healthcare in a similar context. In the post COVID-19 outbreak, non-adherence to medication use was significantly higher in Afghanistan (OR:1.7; 95%CI:1.6,1.9) and India (OR:1.3; 95%CI:1.1,1.7) compared to pre-COVID phase. Respondents of all three countries who sought assistance to manage non-communicable diseases (NCDs) had higher odds (Afghanistan: OR:1.5; 95%CI:1.3,1.8; Bangladesh: OR: 3.7; 95%CI:1.9,7.3; India: OR: 2.3; 95% CI: 1.4,3.6) of non-adherence to medication use after the COVID-19 outbreak compared to pre-COVID phase.

CONCLUSION

The present study documented important evidence of the influence of COVID-19 epidemic on healthcare utilization and medication use in three countries of South Asia. Lessons learned from this study can feed into policy responses to the crisis and preparedness for future pandemics.

Factors Associated With People's Accessibility to Mental Healthcare Services in Ukraine: Focusing on Household Head Vulnerability

Objectives: This study examines the factors associated with access to mental healthcare services among people living in the government-controlled areas (GCAs) of Donetsk and Luhansk oblasts in Ukraine. Methods: The 2020 Ukraine Multi-Sector Needs Assessment conducted by REACH was subjected to frequency analysis, percentage analysis, and binary logistic regression to confirm the factors associated with accessibility to mental healthcare services among Ukrainian household heads. Results: Older household heads, heads with high accessibility to healthcare facilities, and those with low health expenditures were highly likely to have low access to mental healthcare services. Household heads' awareness of household members' medical assistance eligibility was significantly and positively associated with the former's mental healthcare accessibility. Conclusion: This study revealed the mental health vulnerability of people living in GCAs in Ukraine, in which the situation progresses from conflict to war. The need for mental healthcare, which is adversely affected by armed conflict, is expected to increase. Accordingly, further studies should clarify the demand for and methods to enhance mental healthcare services to ensure the timely provision of these services in the future.

Disability types, determinants and healthcare utilisation amongst Afghan adults: a secondary analysis of the Model Disability Survey of Afghanistan

OBJECTIVES

The needs of people with disability in Afghanistan are not well understood. We describe the characteristics, healthcare utilisation patterns, and experience of care among Afghan adults with moderate or severe disability (MSD) by disability type.

DESIGN

We mapped 47 questions related to functional disability in the cross-sectional Model Disability Survey of Afghanistan (MDSA) 2019 into 7 disability domains based on the WHO Disability Assessment Schedule 2.0. We conducted multivariable hierarchical logistic regression to identify drivers of high disability burden.

SETTING

The MDSA primary sampling unit were villages in rural areas and neighbourhoods in urban areas, and the secondary sample units were the settlements within districts.

PARTICIPANTS

The MDSA collected data for 14 520 households across all 34 provinces. The adult tool of the survey was administered to a randomly selected household member aged 18 years or older.

MAIN OUTCOME MEASURES

The main outcome measured was moderate or severe disability (MSD), which was estimated using a Rasch composite score.

RESULTS

MSD prevalence was upwards of 35% in 6/7 domains. Across most disability types, being a woman, older age, residing in rural areas, being uneducated, non-Pashtun ethnicity, being unmarried, living in a household in the low-income tertiles and a non-working household had the highest levels of MSD (p<0.05). Determinants of MSD varied by domain; however, variables including better access to health facilities and better experience of care (higher satisfaction with time spent and respect during visits) were generally protective. People with MSD in the self-care and life activities domains had the highest and lowest healthcare utilisation, respectively.

CONCLUSIONS

Disability in Afghanistan is at public health crisis levels, with vulnerable populations being impacted most severely. To ensure progress towards Afghanistan's 2030 Sustainable Development Goals, targeted interventions for disability types based on population risk factors should be implemented.

Challenges of COVID-19 prevention during protracted conflicts: differential adherence to preventive measures in "contact line" regions in eastern Ukraine

Objectives

Despite the epidemiological importance of social vulnerabilities in compliance with preventive measures, little is known about the disproportional nature of preventive behaviors in crisis-affected populations. We examined adherence to COVID-19 preventive behaviors, focusing on social distancing measures in the conflict-affected regions in eastern Ukraine.

Methods

From a multisectoral needs assessment conducted in 2020 using a household interview of a stratified simple random sample, we included 1,617 rural and urban households located in the government-controlled area. We performed multivariable binary logistic regression analysis with latent class analysis (LCA) to identify unmeasured patterns of classification of preventive measures using data from a cross-sectional survey.

Results

The conflict-affected populations showed difficulty in complying with COVID-19 preventive measures due to losses of housing, partners, and access to food resources due to conflicts. Among the various preventive measures, wearing a face mask (88.1%) and washing hands more regularly (71.4%) were the most frequently reported. Compliance with social distancing was significantly lower in those who experienced the direct impacts of conflicts indicated by damaged accommodation or being widowed. Three different groups who showed distinctive patterns of employing COVID-19 preventive measures were identified via the LCA model, which were "highly complying group", "moderately complying group", and "face masks only group". The group membership was associated with a respondent's poverty status.

Conclusion

The findings show the difficulty in compliance with COVID-19 preventive measures among conflict-affected populations indicating secondary impacts of the conflicts on preventive health behaviors. To mitigate the health impacts of conflicts, immediate attention is needed to address barriers to COVID-19 preventive measures among conflict-affected populations in Ukraine. This study suggests the need for public health strategies to improve preventive health behaviors in conflict-affected populations under pandemics or large-scale outbreaks.

The Impact of Information and Communication Technologies (ICTs) on Health Outcomes: A Mediating Effect Analysis Based on Cross-National Panel Data

When ICTs (Information and Communications Technologies) are combined with healthcare, they can make a key contribution to gradually improve national health outcomes. The global outbreak of COVID-19 in 2020 further highlighted the important role of e-Health and m-Health service modes. This research structures a mediated effect model to explore dynamic relationships between ICT factors, ICT impacts, and national health outcomes, among which ICT factors are independent variables; ICT impacts are mediating variables, and national health outcome indicators selected from United Nations Millennium Development Goals (MDGs) and World Development Indicators are dependent variables. The fixed effect model is used to process a set of 141 countries’ panel data from 2012 to 2016 from World Bank and World Economic Forum, while the classical three-step test method and Sobel test combined with fixed effects are used to test the mediated effects of the panel data. The results show that there are significant associations between ICT factors and national health outcome indicators, while only some of the partial mediated effects are proved. ICT environment and ICT usage can influence both the under-five mortality rate and adolescent fertility rate via ICT social impact. However, the mediated effect of ICT social impact on maternal mortality ratio and life expectancy at birth has not been confirmed. Meanwhile, the mediated effect of ICT economic impact has not been proven. This research is an interdisciplinary research in the field of information and communication technology and public health and reveals the path and mechanism whereby ICT factors improve national health outcomes, which can help global policymakers drive the next phase of the implementation of the Sustainable Development Goals (SDGs) and continue to improve the overall health at the national level.

The Influence of Socioeconomic Status on the Prognosis and Profile of Patients Admitted for Acute Heart Failure during COVID-19 Pandemic: Overestimated Aspects or a Multifaceted Hydra of Cardiovascular Risk Factors?

Background: Heart failure (HF) is a complex clinical syndrome that represents a great burden on public health systems due to its increased prevalence, disability and mortality rates. There are multiple triggers that can induce or aggravate a preexisting HF, socioeconomic status (SES) emerging as one of the most common modifiable risk factors. Our study aimed to analyze the influence of certain SES indicators on the outcome, clinical aspects and laboratory parameters of patients with HF in North-Eastern Romania, as well as their relationship with other traditional cardiovascular risk factors. Methods: We conducted a prospective, single-center study comprising 120 consecutively enrolled patients admitted for acute HF. The evaluation of individual SES was based upon a standard questionnaire and evidence from official documents. Results: the patients’ age ranged between 18 and 94 years; Out of 120 patients, 49 (40.8%) were women and 71 (59.2%) were men, residing in rural 59 (49.2%) or urban 61 (50.8%) areas. 14.2% were university graduates, while 15.8% had only attended primary school. The majority of the patients are or were employed in the service sector (54.5%), followed by industry (29.2%) and agriculture (20%). The mean monthly income was 306.1 ± 177.4 euro, while the mean hospitalization cost was 2471.8 ± 2073.8 euro per patient. The individual income level was positively correlated with urban area of residence, adequate household sanitation facilities and healthcare access, and negatively associated with advanced age and previous hospitalizations due to HF. However, the individual financial situation was also positively correlated with the increased prevalence of certain cardiovascular risk factors, such as arterial hypertension, anemia or obesity, but not with total cholesterol or male gender. Concerning the direct impact of a poor economic status upon prognosis in the setting of acute HF, our results showed no statistically significant differences concerning the in-hospital or at 1-month follow-up mortality rates. Rather than inducing a direct impact on the short-term outcome, these findings concerning SES indicators are meant to enhance the implementation of policies aimed to provide adequate healthcare for people from all social layers, with a primary focus on modifiable cardiovascular risk factors.