Social and Structural Determinants of Health Inequities: Socioeconomic, Transportation-Related, and Provincial-Level Indicators of Cost-Related Forgone Hospital Care in China

Effects of multimorbidity patterns and socioeconomic status on catastrophic health expenditure of widowed older adults in China

Background

The high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults' households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults.

Methods

Data was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively.

Results

About 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns (cardiovascular class, multisystem class, and minimal disease class). Among SES-related indicators (education, occupation and household per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70-79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity.

Conclusion

Widowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults.

Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a global health concern, that can leave lasting physical, cognitive, and/or behavioral changes for many who sustain this type of injury. Because of the heterogeneity of this population, development of appropriate intervention tools can be difficult. Social determinants of health (SDoH) are factors that may impact TBI incidence, recovery, and outcome. The purpose of this study is to describe and analyze the existing literature regarding the prevailing SDoH and health disparities (HDs) associated with TBI in adults. A scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to explore three electronic databases-PubMed, Medline, and CINAHL. Searches identified peer-reviewed empirical literature addressing aspects of SDoH and HDs related to TBI. A total of 123 records were identified and reduced to 27 studies based on inclusion criteria. Results revealed race/ethnicity was the most commonly reported SDoH impacting TBI, followed by an individual's insurance status. Health disparities were noted to occur across the continuum of TBI, including TBI risk, acute hospitalization, rehabilitation, and recovery. The most frequently reported HD was that Whites are more likely to be discharged to inpatient rehabilitation compared to racial/ethnic minorities. Health disparities associated with TBI are most commonly associated with the race/ethnicity SDoH, though insurance status and socioeconomic status commonly influence health inequities as well. The additional need for evidence related to the impact of other, lesser researched, SDoH is discussed, as well as clinical implications that can be used to target intervention for at-risk groups using an individual's known SDoH.

Are Social Determinants of Health Associated With Onset of Rehabilitation Services in Patients Hospitalized for Traumatic Brain Injury?

OBJECTIVE

To examine the impact of community-level social determinants of health (SDoH) on the onset of occupational therapy (OT) and physical therapy (PT) services among individuals hospitalized for traumatic brain injury (TBI).

SETTING

14 acute care hospitals in the state of Colorado.

PARTICIPANTS

We studied 5825 adults with TBI.

DESIGN

In a secondary analysis of de-identified electronic health record data, we performed multivariable logistic and linear regressions to calculate odds ratios (ORs) and 95% CIs for the likelihood of receiving services and duration to initiation of services among those who received them.

MAIN MEASURES

Community-level SDoH, receipt of rehabilitation services, and onset of rehabilitation services.

RESULTS

Multivariable logistic and linear regressions revealed that those in top quartiles for community income were associated with duration to OT services, ranging from OR = 0.33 [05% CI, 0.07, 0.60] for quartile 2 to 0.76 [0.44, 1.08] for quartile 4 compared with those with the lowest quartile. Only the top quartile differed significantly for duration to PT services (0.63 [0.28, 0.98]). Relative to those with below the median community percentage of high school degree, those with above the median were associated with duration to PT services only (-0.32 [-0.60, -0.04]). Neither community percentage with bachelor's degree nor rural-urban designation was associated with duration to either therapy service.

CONCLUSION

Further research is needed to determine whether our SDoH variables were too diffuse to capture individual experiences and impacts on care or whether community-level education and income, and rurality, truly do not influence time to therapy for patients hospitalized with TBI. Other, individual-level variables, such as age, comorbidity burden, and TBI severity, demonstrated clear relationships with therapy onset. These findings may help therapists evaluate and standardize equitable access to timely rehabilitation services.

Socioeconomic factors and autism among 16- to 30-month-old children: Evidence from a national survey of China

We examined the association of socioeconomic status with the diagnosis of autism during 16–30 months of age. Using data from a national survey in China, we included 6049 children (55.6% male) in the final analysis, among which 71 of them were clinically diagnosed with autism. Adjusted for covariates, the odds ratios for having the diagnosis of autism (2.46, 95% confidence interval: [1.32, 4.59]) among children whose mother’s level is “junior middle school or below” were significantly higher than children whose mother’s level is “college or above.” Among children of lower educated mothers, there is a higher risk of being diagnosed with autism at a young age. We recommend more support for families with a low socioeconomic status to early detect, diagnose, and manage autism.

Lay abstract

Does being born in a family of high socioeconomic status mean a higher risk of being diagnosed with autism? The evidence from the Asian area is lacking. This research was conducted among 6049 toddlers who went through an evaluation–diagnose procedure of autism and whose parents were surveyed during the national survey of China, 2016–2017. Parents reported their education levels, occupations, family income, and ethnic background. We recruited the toddlers and parents from kindergartens, communities, and hospitals in five geographically representative areas of China. On average, these toddlers were 23 months of age. We found toddlers whose mothers had less than 9 years of education (junior middle school or below) had 2.46 times the chance to get a diagnosis of autism, compared with toddlers whose mothers had more than 15 years of education (college or above). We also found that 1.17 toddlers could be diagnosed with autism in each 100 Chinese toddlers. These findings have important implications for providing support to families that have low socioeconomic status, especially families with a mother who did not complete 9 years of education. Early detection programs focused on children from low socioeconomic backgrounds should be promoted.

Multimorbidity and catastrophic health expenditure: Evidence from the China Health and Retirement Longitudinal Study

Background

Population aging accompanied by multimorbidity imposes a great burden on households and the healthcare system. This study aimed to determine the incidence and determinants of catastrophic health expenditure (CHE) in the households of old people with multimorbidity in China.

Methods

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2018, with 3,511 old people (≥60 years) with multimorbidity responding to the survey on behalf of their households. CHE was identified using two thresholds: ≥10% of out-of-pocket (OOP) health spending in total household expenditure (THE) and ≥40% of OOP health spending in household capacity to pay (CTP) measured by non-food household expenditure. Logistic regression models were established to identify the individual and household characteristics associated with CHE incidence.

Results

The median values of THE, OOP health spending, and CTP reached 19,900, 1,500, and 10,520 Yuan, respectively. The CHE incidence reached 31.5% using the ≥40% CTP threshold and 45.6% using the ≥10% THE threshold. It increased by the number of chronic conditions reported by the respondents (aOR = 1.293-1.855, p < 0.05) and decreased with increasing household economic status (aOR = 1.622-4.595 relative the highest quartile, p < 0.001). Hospital admissions over the past year (aOR = 6.707, 95% CI: 5.186 to 8.674) and outpatient visits over the past month (aOR = 4.891, 95% CI: 3.822 to 6.259) of the respondents were the strongest predictors of CHE incidence. The respondents who were male (aOR = 1.266, 95% CI: 1.054 to 1.521), married (OR = 1.502, 95% CI: 1.211 to 1.862), older than 70 years (aOR = 1.288-1.458 relative to 60-69 years, p < 0.05), completed primary (aOR = 1.328 relative to illiterate, 95% CI: 1.079 to 1.635) or secondary school education (aOR = 1.305 relative to illiterate, 95% CI: 1.002 to 1.701), lived in a small (≤2 members) household (aOR = 2.207, 95% CI: 1.825 to 2.669), and resided in the northeast region (aOR = 1.935 relative to eastern, 95% CI: 1.396 to 2.682) were more likely to incur CHE.

Conclusion

Multimorbidity is a significant risk of CHE. Household CHE incidence increases with the number of reported chronic conditions. Socioeconomic and regional disparities in CHE incidence persist in China.

The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China

Poor health and poverty interact and restrict each other. While this relationship is acknowledged, little is known about the extent of its impact. By integrating multisource data, this study used spatial econometric models to quantitatively reveal the relationship between health and rural poverty and explore its intrinsic mechanisms. The results indicated that health-care system input, individual health status, and individual health-seeking behavior have a significantly positive effect on the eradication of rural poverty. The health-care system input is characterized by spatial spillover, significantly contributing to rural poverty alleviation in the region and neighboring regions, as well. However, the effect of health-care system services’ capability was negative. Thus, it is necessary to increase investment in the health-care system and pay attention to both the health status and healthy behaviors of rural residents. Moreover, further effort should be given to the supply-side reform of health services as a breakthrough point.