Who is bearing the financial burden of non-communicable diseases in Mongolia?

Educational training and nursing professional self-perception in Mongolia: A prospective observational pre-post design study

AIMS

To determine whether professional self-perception of nurses in Mongolia improves following an educational intervention and to identify differences in scores among participant subgroups.

DESIGN

A prospective observational pre-post design.

METHODS

Using a convenience sample of 67 nurses in Mongolia in 2019, the Nursing Professional Values Scale-3 instrument was used pre- and post-intervention. Independent and paired sample t-tests were conducted. Data were analysed using IBM SPSS 28.0.1.1 and Stata/SE 16.1. This study complied with the STROBE checklist.

RESULTS

Of the 67 nurses, 92.0% were female, mean age was 32.15 years (SD 8.96), 70.0% held a bachelor's degree, 58.0% had 5 or more years' nursing experience and 51.0% were members of a professional nursing organization. After participating in the educational training, nurses reported higher overall professional self-perception as well as across subscales: activism, professionalism and caring.

CONCLUSION

Considering the nursing shortage in lower-middle-income countries, it is important to recognise the influence of nurses' professional self-perception on nursing retention. This study highlights the significant role continuing educational opportunities play in increasing nurses' professional self-perception. It is imperative to explore ways of improving this perception and focusing on subgroups of nurses to help guide the use of limited resources. Further research is necessary to include nurses in other areas of Mongolia.

IMPLICATION FOR THE PROFESSION

Accurately assessing nursing professional self-perception and providing educational opportunities could improve nursing professional self-perception, nursing satisfaction, patient safety and nursing retention in lower-middle-income countries.

IMPACT

What problem did the study address? This study meets the need for current study on the nursing professional self-perception of nursing from the perspective of nurses in Mongolia. It addresses the dangerous nursing shortage in Mongolia by determining if an educational intervention could improve nursing professional self-perception and thus improve nursing job satisfaction and retention. What were the main findings? Mongolian nurses in this study scored in the top quartile of the NPVS-3, indicating a baseline high NPSP. Educational intervention (including translated oral education and written clinical pathways) significantly improved the nurses' professional self-perception. Nurses were eager for training in other clinical and leadership topics. Where and on whom will the research have an impact? This research can be impactful for nurses, nurse leaders and policy makers in low- and lower-middle-income countries. Specifically for nurses in Mongolia, with increasing technologies and services such as cardiac catheterization laboratories becoming available, more education in these nursing specialty areas is imperative. Professional Nursing Organizations are poised to foster more educational offerings to their members and to increase membership. Nursing education provided by international volunteer nurses with Non-Governmental Organizations can improve NPSP in nurses in LMICs.

REPORTING METHOD

This study complied with the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Health-related quality of life among adults living with chronic non-communicable diseases in the Ho Municipality of Ghana: a health facility-based cross-sectional study

BACKGROUND

Morbidity and mortality rates from chronic non-communicable diseases (CNCDs) are increasing globally. In Ghana, CNCDs account for 43% of all deaths. We examined the Health-Related Quality of Life (HRQoL) and associated factors among adults living with CNCDs in the Ho Municipality.

METHODS

This was a health facility-based descriptive cross-sectional study among 432 adults living with cancer, diabetes, chronic kidney disease (CKD), stroke, and hypertension in the Ho Municipality of Ghana. The study adopted the EQ-5D-5L instrument and the Ugandan value set to compute respondents' HRQoL index. Quantile regression models were used in analysing the data with STATA v17.0 at 95% Confidence Intervals, and statistical significance set at p < 0.05.

RESULTS

63.7% of our respondents reported having a problem across the five dimensions of the EQ-5D-5L. The most problems were reported in the dimensions "Anxiety/Depression" (94.4%) and "Pain/Discomfort" (91.4%). Divorced/separated respondents (aOR=-0.52, 95% CI=-0.71, -0.33) and those living with comorbidities (aOR=-0.95, 95% CI=-0.15, -0.04,) were less likely to report high index for HRQoL. However, respondents diagnosed with CKD (aOR = 0.26, 95% CI = 0.10, 0.42), diabetes (aOR = 0.28, 95% CI = 0.11, 0.45), hypertension (aOR = 0.35, 95% CI = 0.19, 0.50) and stroke (aOR = 0.26, 95% CI = 0.11, 0.40) were more likely to report higher index than those diagnosed with cancer.

CONCLUSION

Our study revealed elevated proportions of reported problems in the "Anxiety/Depression" and "Pain/Discomfort" dimensions, indicating noteworthy concerns in these areas of HRQoL. The prevalent issues reported across HRQoL dimensions are cause for concern, posing potential exacerbation of health conditions. We advocate for collaborative efforts from the Ministry of Health, Ghana Health Service, and relevant stakeholders to scrutinize and implement interventions targeting social and psychological factors. These efforts should specifically address contributors to diminished health-related quality of life, particularly among less educated, divorced, and comorbid individuals.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

Unrecognized hypertension among a general adult Ghanaian population: An urban community-based cross-sectional study of prevalence and putative risk factors of lifestyle and obesity indices

Hypertension (HTN) is the leading cause of cardiovascular diseases. Nevertheless, most individuals in developing countries are unaware of their blood pressure status. We determined the prevalence of unrecognized hypertension and its association with lifestyle factors and new obesity indices among the adult population. This community-based study was conducted among 1288 apparently healthy adults aged 18-80 years in the Ablekuma North Municipality, Ghana. Sociodemographic, lifestyle characteristics, blood pressure and anthropometric indices were obtained. The prevalence of unrecognized HTN was 18.4% (237 / 1288). The age groups 45-54 years [aOR = 2.29, 95% CI (1.33-3.95), p = 0.003] and 55-79 years [aOR = 3.25, 95% CI (1.61-6.54), p = 0.001], being divorced [aOR = 3.02 95% CI (1.33-6.90), p = 0.008], weekly [aOR = 4.10, 95% CI (1.77-9.51), p = 0.001] and daily alcohol intake [aOR = 5.62, 95% CI (1.26-12.236), p = 0.028] and no exercise or at most once a week [aOR = 2.25, 95% CI (1.56-3.66), p = 0.001] were independently associated with HTN. Among males, the fourth quartile (Q4) of both body roundness index (BRI) and waist to height ratio (WHtR) [aOR = 5.19, 95% CI (1.05-25.50), p = 0.043] were independent determinants of unrecognized HTN. Among females, the third quartile (Q3) [aOR = 7.96, 95% CI (1.51-42.52), p = 0.015] and Q4 [aOR = 9.87 95% CI (1.92-53.31), p = 0.007] of abdominal volume index (AVI), the Q3 of both BRI and WHtR [aOR = 6.07, 95% CI (1.05-34.94), p = 0.044] and Q4 of both BRI and WHtR [aOR = 9.76, 95% CI (1.74-54.96), p = 0.010] were independent risk factors of HTN. Overall, BRI (AUC = 0.724) and WHtR (AUC = 0.724) for males and AVI (AUC = 0.728), WHtR (AUC = 0.703) and BRI (AUC = 0.703) for females yielded a better discriminatory power for predicting unrecognized HTN. Unrecognized hypertension is common among the apparently healthy adults. Increased awareness of its risk factors, screening, and promoting lifestyle modification is needed to prevent the onset of hypertension.

Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption Among Households in Mongolia

BACKGROUND

High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs.

METHODS

This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP.

RESULTS

The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD]=259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI=-8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI=737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI=66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI=-445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI.

CONCLUSION

Our findings suggest that Mongolia's OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest-income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model

Background

While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals.

Methods

This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis.

Results

Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients’ experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs.

Conclusions

A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country’s National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11170-4.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia

Background

High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia.

Methods

This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed.

Results

Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP.

Conclusion

To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

A Review of the Potential Benefits of Increasing Vitamin D Status in Mongolian Adults through Food Fortification and Vitamin D Supplementation

Serum 25-hydroxyvitamin D (25(OH)D) concentrations are low in Mongolia, averaging 22 ng/mL in summer and only 8 ng/mL in winter. Mongolians have high incidence and/or prevalence of several diseases linked to low 25(OH)D concentrations, including ischemic heart disease, malignant neoplasms, cirrhosis of the liver, ischemic stroke, lower respiratory tract infections, preterm birth complications, and diabetes mellitus. Fortifying regularly consumed foods such as flour, milk, and edible oils with vitamin D₃ could raise 25(OH)D concentrations by about 10 ng/mL. However, to achieve 25(OH)D concentrations of 30–40 ng/mL in adults, vitamin D intakes of 1000 to 4000 IU/day would be required, making personal supplement use necessary. On the basis of prospective observational studies and clinical trials of disease incidence or known mortality rates and adverse pregnancy and birth outcomes, raising mean serum 25(OH)D concentrations to 40 ng/mL would likely reduce incidence and mortality rates for those and other diseases, reduce the rate of adverse pregnancy and birth outcomes, and increase mean life expectancy by one year or more.

Public expenditure on Non-Communicable Diseases & Injuries in India: A budget-based analysis

Background

Resource allocation decisions for disease categories can be informed by proper estimates of the magnitude and distribution of total spending. In the backdrop of a high burden of Non-Communicable Diseases and Injuries (NCDI) in India, and a paucity of estimates on government spending on NCDI, this paper attempts to analyse public sector expenditure on NCDI spending in India.

Methods

Various recent budget documents of the Centre and States/Union Territories have been used to extract expenditure on NCDI. The aggregates thus arrived at have been analysed to estimate aggregate and state level per capita spending. State level spending have been compared against disease burden using DALYs. Patterns of spending on NCDI across states were also analysed together with state level poverty to observe possible patterns.

Findings

The total spending on NCDI by the government is low at less than 0.5% of GDP. NCDI spending is little more than one-fourth of total health spending of the country and most spending takes place at the state level (80%). The Ministry of Health and Family Welfare’s share in Central spending on NCDI is around 65%, and currently it spends 20% of its total health spending on NCDI. The gap between spending and DALYs is the most for the economically vulnerable states. Also, the states with high poverty levels also have low per capita expenditure on NCDI

Interpretation

India does not depend on donor funding for health. It will have to step up domestic funding to address the increasing disease burden of NCDIs and to reduce the high out-of-pocket expenditure on NCDI. Policies on NCDI need to focus on UHC, service integration and personnel gaps.

The effect of family doctor-contracted services on noncommunicable disease self-management in Shanghai, China

BACKGROUND

Noncommunicable diseases (NCDs) are a major threat to population health worldwide. In Shanghai, China, a new pattern of NCD management-self-management-has been developed in community health service centres (CHSCs).

OBJECTIVE

To clarify how contracting with CHSC-based family doctors (FDs) influences the engagement in and effectiveness of self-management behaviour among NCD patients.

METHOD

We conducted two waves of a questionnaire survey (in 2013 and 2016) to collect data on patients with NCDs. Separate logistic regression models and longitudinal analysis were performed to examine the effect of contracting with an FD on NCD self-management and the effectiveness of this self-management.

RESULTS

Nearly all contracted patients (80.79%) had implemented NCD self-management, while only 55.57% of non-contracted patients did so. The self-management effectiveness rate was also higher among contracted patients than among non-contracted ones (86.66% vs. 54.79%). In the population-averaged models, contracted patients had 2.25 and 2.91 times greater odds of implementing self-management and reporting that the self-management was effective, respectively, after controlling for all related variables. Additionally, awareness of FD-contracted services, satisfaction with CHSCs, and experiencing first contact at CHSCs had positive impacts on the implementation and effectiveness of self-management.

CONCLUSIONS

FDs were important for ensuring that NCD patients engaged in self-management behaviour, the most common form of which was focus group. Participation in NCD focus groups may be key for attaining the effects of self-management, including improved health knowledge, greater health awareness, more frequent engagement in health behaviour, and, most importantly, greater practice of self-monitoring. Self-management might help to achieve greater NCD control.

When Diabetes Confronts HIV: Biological Sub-citizenship at a Public Hospital in Nairobi, Kenya

This article investigates how international donor policies cultivate a form of biological sub-citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub-citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out-of-pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub-citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.