Association of Neighborhood Deprivation Index With Success in Cancer Care Crowdfunding

Importance

Financial toxicity resulting from cancer care poses a substantial public health concern, leading some patients to turn to online crowdfunding. However, the practice may exacerbate existing socioeconomic cancer disparities by privileging those with access to interpersonal wealth and digital media literacy.

Objective

To test the hypotheses that higher county-level socioeconomic status and the presence (vs absence) of text indicators of beneficiary worth in campaign descriptions are associated with amount raised from cancer crowdfunding.

Design, Setting, and Participants

This cross-sectional analysis examined US cancer crowdfunding campaigns conducted between 2010 and 2019 and data from the American Community Survey (2013-2017). Data analysis was performed from December 2019 to March 2020.

Exposures

Neighborhood deprivation index of campaign location and campaign text features indicating the beneficiary's worth.

Main Outcomes and Measures

Amount of money raised.

Results

This study analyzed 144 061 US cancer crowdfunding campaigns. Campaigns in counties with higher neighborhood deprivation raised less (-26.07%; 95% CI, -27.46% to -24.65%; P < .001) than those in counties with less neighborhood deprivation. Campaigns raised more funds when legitimizing details were provided, including clinical details about the cancer type (9.58%; 95% CI, 8.00% to 11.18%; P < .001) and treatment type (6.58%; 95% CI, 5.44% to 7.79%; P < .001) and financial details, such as insurance status (1.39%; 95% CI, 0.20% to 2.63%; P = .02) and out-of-pocket costs (7.36%; 95% CI, 6.18% to 8.55%; P < .001). Campaigns raised more money when beneficiaries were described as warm (13.80%; 95% CI, 12.30% to 15.26%; P < .001), brave (15.40%; 95% CI, 14.11% to 16.65%; P < .001), or self-reliant (5.23%; 95% CI, 3.77% to 6.72%; P < .001).

Conclusions and Relevance

These findings suggest that cancer crowdfunding success ay disproportionately benefit those in high-socioeconomic status areas and those with the internet literacy necessary to portray beneficiaries as worthy. By rewarding those with existing socioeconomic advantage, cancer crowdfunding may perpetuate socioeconomic disparities in cancer care access. The findings also underscore the widespread nature of financial toxicity resulting from cancer care.

A Contingent Valuation Study for Eliciting a Monetary Value of a Quality-Adjusted Life-Year in the General Greek Population

OBJECTIVES

To elicit a willingness-to-pay (WTP) per quality-adjusted life-year (QALY) estimate for the general Greek population and assess the impact of individuals' socio-demographic characteristics and motives on this estimate.

METHODS

A telephone-based survey was carried out employing a representative sample of the general Greek population (n = 1342). A computer-assisted telephone-interview method was adopted to ensure random sampling. A total of 528 participants reported a WTP value for a utility improvement from their current health to perfect health. Those individuals' motives were assessed through predefined statements. Test-retest reliability was assessed using intraclass correlation coefficient (ICC). Multiple linear regression (MLR) and one-way analysis of variance (ANOVA) tests were conducted to assess the effect of socioeconomic/demographic determinants and motive statements, respectively, on WTP/QALY. MLR was re-estimated considering as dependent variable the WTP/QALY estimate calculated for participants: (1) stating a WTP value ≤ their household income and (2) presenting higher certainty regarding stated WTP value (sensitivity analysis).

RESULTS

Analysis revealed good reliability for WTP/QALY estimates and motive statements (ICC values > 0.8). Mean WTP/QALY was €26 280. The respective 5% trimmed value was €14 862. Being a student and household income affected WTP/QALY. Sensitivity analysis did not produce markedly different WTP/QALY predictors, implying the robustness of results, irrespective of the participant group considered. Individuals who indicated the inability to cover basic family needs or pay tax claims as motives reported lower WTP/QALY values compared with those not viewing these aspects as motives.

CONCLUSIONS

Findings confirm that the World Health Organization's criterion used currently in Greek cost-effectiveness studies is not unreasonable. Additional research is essential to further explore WTP/QALY estimates in the Greek setting and facilitate informed decision making.

Developing a Financial Literacy Program with Survivors of Intimate Partner Violence: The Voices of Survivors

As the social work field increasingly recognizes economic abuse within intimate partner relationships, the field has developed financial empowerment programs to empower survivors for their financial future. Although research has demonstrated the effectiveness of financial literacy programs, there are barriers to their implementation in the field. Studies have explored, from the perspective of advocates, best practices in incorporating financial literacy into services; however, no studies have explored implementation approaches from the perspective of survivors. This study explores, from the perspective of 34 survivors, approaches for implementing financial literacy programming. Participants described their understanding of financial empowerment as being in charge of finances, having financial power, and not having to endure the struggle. To counter financial disempowerment, participants identified the need for financial confidence, knowledge, and tools. Participants shared their strategies for saving money, though many participants reported barriers to using banks as savings tools. Almost all participants stressed the importance of financial literacy services for survivors, especially around banking, credit, and debt. Finally, participants shared recommendations for job readiness and training programming. Findings have implications for domestic violence and broader social work organizations implementing financial empowerment services. Social workers can support financial empowerment efforts through program development and research efforts.

Microfinance Interventions and HIV Treatment Outcomes: A Synthesizing Conceptual Framework and Systematic Review

BACKGROUND

Microfinance interventions have the potential to improve HIV treatment outcomes, but the mechanisms through which they operate are not entirely clear.

OBJECTIVES

To construct a synthesizing conceptual framework for the impact of microfinance interventions on HIV treatment outcomes using evidence from our systematic review.

METHODS

We conducted a systematic review by searching electronic databases and journals from 1996 to 2018 to assess the effects of microfinance interventions on HIV treatment outcomes, including adherence, retention, viral suppression, and CD4 cell count.

RESULTS

All studies in the review showed improved adherence, retention, and viral suppression, but varied in CD4 cell count following participation in microfinance interventions-overall supporting microfinance's positive role in improving HIV treatment outcomes. Our synthesizing conceptual framework identifies potential mechanisms through which microfinance impacts HIV treatment outcomes through hypothesized intermediate outcomes.

CONCLUSION

Greater emphasis should be placed on assessing the effect mechanisms and intermediate behaviors to generate a sound theoretical basis for microfinance interventions.

Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis

BACKGROUND

Microfinance is the provision of savings and small loans services, with no physical collateral. Most recipients are disadvantaged women. The social and health impacts of microfinance have not been comprehensively evaluated.

OBJECTIVE

To explore the impact of microfinance on contraceptive use, female empowerment and children's nutrition in South Asia, Sub-Saharan Africa and Latin America and the Caribbean.

DESIGN

We conducted a systematic search of published and grey literature (1990-2018), with no language restrictions. We conducted meta-analysis, where possible, to calculate pooled ORs. Where studies could not be combined, we described these qualitatively.

DATA SOURCES

EMBASE, MEDLINE, LILACS, CENTRAL and ECONLIT were searched (1990-June 2018).

ELIGIBILITY CRITERIA

We included controlled trials, observational studies and panel data analyses investigating microfinance involving women and children.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. The methodological quality of included studies was assessed using the Cochrane risk-of-bias tool for controlled trials and quasi-experimental studies and a modified Newcastle Ottawa Scale for cross-sectional surveys and analyses of panel data. Meta-analyses were conducted using STATA V.15 (StataCorp).

RESULTS

We included 27 studies. Microfinance was associated with a 64% increase in the number of women using contraceptives (OR 1.64, 95% CI 1.45 to 1.86). We found mixed results for the association between microfinance and intimate partner violence. Some positive changes were noted in female empowerment. Improvements in children's nutrition were noted in three studies.

CONCLUSION

Microfinance has the potential to generate changes in contraceptive use, female empowerment and children's nutrition. It was not possible to compare microfinance models due to the small numbers of studies. More rigorous evidence is needed to evaluate the association between microfinance and social and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42015026018.

Demand for Long-Term Care Insurance in China

The aim of this study was to estimate willingness to pay (WTP) for long-term care insurance (LTCI) and to explore the determinants of demand for LTCI in China. We collected data from a household survey conducted in Qinghai and Zhejiang on a sample of 1842 households. We relied on contingent valuation methods to elicit the demand for LTCI and random effects logistic regression to analyze the factors associated with the demand for LTCI. Complementarily, we used document analysis to compare the LTCI designed in this study and the current LTCI policies in the pilot cities. More than 90% of the respondents expressed their willingness to buy LTCI. The median WTP for LTCI was estimated at 370.14 RMB/year, accounting for 2.29% of average annual per capita disposable income. Price, age, education status, and income were significantly associated with demand for LTCI. Most pilot cities were found to mainly rely on Urban Employees Basic Medical Insurance funds as the financing source for LTCI. Considering that financing is one of the greatest challenges in the development of China's LTCI, we suggest that policy makers consider individual contribution as an important and possible option as a source of financing for LTCI.

A decision support model for investment on P2P lending platform

Peer-to-peer (P2P) lending, as a novel economic lending model, has triggered new challenges on making effective investment decisions. In a P2P lending platform, one lender can invest N loans and a loan may be accepted by M investors, thus forming a bipartite graph. Basing on the bipartite graph model, we built an iteration computation model to evaluate the unknown loans. To validate the proposed model, we perform extensive experiments on real-world data from the largest American P2P lending marketplace—Prosper. By comparing our experimental results with those obtained by Bayes and Logistic Regression, we show that our computation model can help borrowers select good loans and help lenders make good investment decisions. Experimental results also show that the Logistic classification model is a good complement to our iterative computation model, which motivates us to integrate the two classification models. The experimental results of the hybrid classification model demonstrate that the logistic classification model and our iteration computation model are complementary to each other. We conclude that the hybrid model (i.e., the integration of iterative computation model and Logistic classification model) is more efficient and stable than the individual model alone.

Improved Financial Capability Can Reduce Material Hardship among Mothers

This study draws on the theoretical framework of financial capability in investigating whether financial access (that is, availability of financial products and services) and financial knowledge (that is, understanding of basic financial concepts) can influence the risk of material hardship. Authors examine the possibility of direct associations as well as of indirect ones in which financial management (that is, individual financial behaviors) serves as a mediator. The probability sample of mothers with young children born in Oklahoma during 2007 (N = 2,529) was selected from Oklahoma birth certificates. Results from structural equation modeling analyses show that financial access is positively associated with financial management (p < 0.001) but that financial knowledge is not; both financial access (p < 0.001) and financial management (p < 0.001) are negatively correlated with material hardship. Similar results are obtained from analyses with a subsample of low-income mothers. Findings suggest that financial capability, particularly the financial access component, is critical for improving financial management and reducing the risk of material hardship among mothers with young children, including low-income mothers. Efforts to promote financial capability offer social workers an important strategy for improving their clients’ economic well-being.

Coming of Age on a Shoestring Budget: Financial Capability and Financial Behaviors of Lower-Income Millennials

Lower-income millennials make important financial decisions that may affect their future financial well-being. With limited resources, this population is at risk for acquiring too much debt or being unprepared for a financial emergency that can send them further into poverty and constrain their ability to leverage resources for future economic mobility. A financial capability approach, an intervention that combines financial education with financial inclusion through the use of a savings account, may correlate with millennials’ healthy financial behaviors. This study used data from the 2012 National Financial Capability Study to examine the relationship between financial capability and the financial behaviors of lower-income millennials between the ages of 18 and 34 years (N = 2,578). Compared with those lower-income millennials who were financially excluded, those who were financially capable were also 171 percent more likely to afford an unexpected expense, 182 percent more likely to save for emergencies, and 34 percent less likely to carry too much debt, relating to their greater overall financial satisfaction. The findings of this study indicate that interventions that develop lower-income millennials’ financial capability may be effective for promoting healthy financial behaviors.

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments

BACKGROUND

Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.

METHODS

The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.

RESULTS

OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.

CONCLUSIONS

Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

Investigating the affordability of key health services in South Africa

This paper considers the affordability of using public sector health services for three tracer conditions (obstetric care, tuberculosis treatment and antiretroviral treatment for HIV-positive people), based on research undertaken in two urban and two rural sites in South Africa. We understand affordability as the 'degree of fit' between the costs of seeking health care and a household's ability-to-pay. Exit interviews were conducted with over 300 patients for each of the three tracer conditions in each of the four sites (i.e. a total sample of over 3600). Total direct costs for the service used at the time of the interview, as well as other health related costs incurred during the preceding month either for self-care or the use of plural providers were assessed, as were a range of indicators of ability-to-pay. The percentage of households incurring direct costs exceeding 10% of household consumption expenditure and those borrowing money or selling assets as a mechanism for coping with the burden of direct costs were calculated. Logistic regressions were also conducted to identify factors that were significantly associated with these indicators of affordability. There were significant differences in affordability between rural and urban sites; costs were higher, ability-to-pay was lower and there was a greater proportion of households selling assets or borrowing money in rural areas. There were also significant differences across tracers, with a higher percentage of households receiving tuberculosis and antiretroviral treatment borrowing money or selling assets than those using obstetric services. As these conditions require expenses to be incurred on an ongoing basis, the sustainability of such coping strategies is questionable. Policy makers need to explore how to reduce direct costs for users of these key health services in the context of the particular characteristics of different treatment types. Affordability needs to be considered in relation to the dynamic aspects of the costs of treating different conditions and the timing of treatment in relation to diagnosis. The frequently high transport costs associated with treatments involving multiple consultations can be addressed by initiatives that provide close-to-client services and subsidised patient transport for referrals.

Paying informally in the Albanian health care sector: a two-tiered stochastic frontier model

Informal payments are deeply ingrained in the health care sector of most Central, Eastern and Southern European countries. Evidence suggests that the price paid informally to medical staff is negotiated either directly or indirectly between patients and medical staff. The aim of this paper is to measure the imperfect information that exists on the amount that has to be paid informally to medical staff. We measure the extent to which patients pay more than the amount medical staff expect informally and the extent to which medical staff request less than patients are willing to pay informally. A two-tiered stochastic frontier model is developed to estimate indicators of patients' and medical staff's imperfect information on informal payments and the effects on the amount the other party is minimally expecting or maximally willing to pay informally. The estimates are based on informal payments to medical staff in the inpatient health care sector in Albania. We use data from the Albania Living Standards Measurement Survey 2002 and 2005. The pooled samples include 707 individuals who have visited inpatient health care services in these 2 years. Our results show that medical staff has less information on the patients' maximum willingness to pay informally than patients have on medical staff's minimum expected amount. These estimates do not depend on categories of illnesses but on certain socio-demographic characteristics.

Strategies for coping with the costs of inpatient care: a mixed methods study of urban and rural poor in Vadodara District, Gujarat, India

BACKGROUND

In India, coping mechanisms for inpatient care costs have been explored in rural areas, but seldom among urbanites. This study aims to explore and compare mechanisms employed by the urban and rural poor for coping with inpatient expenditures, in order to help identify formal mechanisms and policies to provide improved social protection for health care.

METHODS

A three-step methodology was used: (1) six focus-group discussions; (2) 800 exit survey interviews with users of public and private facilities in both urban and rural areas; and (3) 18 in-depth interviews with poor (below 30th percentile of socio-economic status) hospital users, to explore coping mechanisms in greater depth.

RESULTS

Users of public hospitals, in both urban and rural areas, were poor relative to users of private hospitals. Median expenditures per day were much higher at private than at public facilities. Most respondents using public facilities (in both urban and rural areas) were able to pay out of their savings or income; or by borrowing from friends, family or employer. Those using private facilities were more likely to report selling land or other assets as the primary source of coping (particularly in rural areas) and they were more likely to have to borrow money at interest (particularly in urban areas). Poor individuals who used private facilities cited as reasons their closer proximity and higher perceived quality of care.

CONCLUSIONS

In India, national and state governments should invest in improving the quality and access of public first-referral hospitals. This should be done selectively-with a focus, for example, on rural areas and urban slum areas-in order to promote a more equitable distribution of resources. Policy makers should continue to explore and support efforts to provide financial protection through insurance mechanisms. Past experience suggests that these efforts must be carefully monitored to ensure that the poorer among the insured are able to access scheme benefits, and the quality and quantity of health care provided must be monitored and regulated.

A history of medical student debt: observations and implications for the future of medical education

Over the last 50 years, medical student debt has become a problem of national importance, and obtaining medical education in the United States has become a loan-dependent, individual investment. Although this phenomenon must be understood in the general context of U.S. higher education as well as economic and social trends in late-20th-century America, the historical problem of medical student debt requires specific attention for several reasons. First, current mechanisms for students' educational financing may not withstand debt levels above a certain ceiling which is rapidly approaching. Second, there are no standards for costs of medical school attendance, and these can vary dramatically between different schools even within a single city. Third, there is no consensus on the true cost of educating a medical student, which limits accountability to students and society for these costs. Fourth, policy efforts to improve physician workforce diversity and mitigate shortages in the primary care workforce are inhibited by rising levels of medical student indebtedness. Fortunately, the current effort to expand the U.S. physician workforce presents a unique opportunity to confront the unsustainable growth of medical student debt and explore new approaches to the financing of medical students' education.

Financing physical therapy doctoral education: methods used by entry-level students and the financial impact after graduation

With the move to the doctor of physical therapy (DPT) degree and increasing tuition costs, there is concern about financing entry-level education. The purposes of this study were to identify how students finance their DPT education and to describe the financial impact after graduation.

METHODS

A written survey was used to collect data on financing DPT education, student debt, and the financial impact on graduates. There were 92 subjects who had graduated from one program. Frequencies as well as nonparametric statistics using cross-tabulations and chi-squared statistics were calculated.

RESULTS

The response rate was 55%. Of the respondents, 86% had student loans, 66% worked during school, 57% received some family assistance, and 21% had some scholarship support. The amount of monthly loan repayment was not statistically related to the ability to save for a house, the ability to obtain a loan for a house or car, or the decision to have children. Saving for the future (p = 0.016) and lifestyle choices (p = 0.035) were related to the amount of monthly loan repayment.

DISCUSSION

Major sources of funding were student loans, employment income, and/or family assistance. Respondent's ability to save for the future and lifestyle choices were negatively impacted when loan debt increased. Physical therapist education programs should consider offering debt planning and counseling.

A survey of clergy practices associated with premarital financial counseling

The purpose of this exploratory study was to gain an understanding of the state of clergy-led premarital financial counseling. Clergy respondents (n = 223) indicated that they often include a financial component in their formal premarital counseling. The most frequently discussed financial topics are budgeting, managing debt and credit, and saving. The most frequently cited obstacles to providing premarital financial counseling are lack of time and lack of subject matter expertise.

Personal and contextual factors that contribute to a higher out-of-pocket to total income ratio

INTRODUCTION

This analysis sought to define the out-of-pocket healthcare spending to total income ratio for rural residents, as well as to explore the impact of county-level factors that may contribute to urban-rural differences.

METHODS

Three years of pooled data were utilized from the Medical Expenditure Panel Survey (2003-2005). The dependent variable was the ratio of total out-of-pocket healthcare spending to total income, at the household level. Unadjusted and adjusted analyses estimated the factors associated with this ratio, including rurality, socio-demographics, and county-level factors.

RESULTS

The unadjusted analysis indicated that small adjacent and remote rural residents had higher out-of-pocket to total income ratios than urban residents. The adjusted multivariate analysis indicated that when other factors are held equal, rurality is no longer a significant factor. Other factors such as insurance type, healthcare utilization, and income, which differ significantly by rurality, are better predictors of the ratio.

CONCLUSIONS

The identification of factors that contribute to a higher ratio among some rural residents is necessary in order to better target interventions that will reduce this financial burden.

Do microfinance programs help families insure consumption against illness?

Families in developing countries face enormous financial risks from major illness both in terms of the cost of medical care and the loss in income associated with reduced labor supply and productivity. We test whether access to microfinancial savings and lending institutions helps Indonesian families smooth consumption after declines in adult health. In general, results support the importance of these institutions in helping families to self-insure consumption against health shocks.

Small individual loans and mental health: a randomized controlled trial among South African adults

BACKGROUND

In the developing world, access to small, individual loans has been variously hailed as a poverty-alleviation tool - in the context of "microcredit" - but has also been criticized as "usury" and harmful to vulnerable borrowers. Prior studies have assessed effects of access to credit on traditional economic outcomes for poor borrowers, but effects on mental health have been largely ignored.

METHODS

Applicants who had previously been rejected (n = 257) for a loan (200% annual percentage rate - APR) from a lender in South Africa were randomly assigned to a "second-look" that encouraged loan officers to approve their applications. This randomized encouragement resulted in 53% of applicants receiving a loan they otherwise would not have received. All subjects were assessed 6-12 months later with questions about demographics, socio-economic status, and two indicators of mental health: the Center for Epidemiologic Studies - Depression Scale (CES-D) and Cohen's Perceived Stress scale. Intent-to-treat analyses were calculated using multinomial probit regressions.

RESULTS

Randomization into receiving a "second look" for access to credit increased perceived stress in the combined sample of women and men; the findings were stronger among men. Credit access was associated with reduced depressive symptoms in men, but not women.

CONCLUSION

Our findings suggest that a mechanism used to reduce the economic stress of extremely poor individuals can have mixed effects on their experiences of psychological stress and depressive symptomatology. Our data support the notion that mental health should be included as a measure of success (or failure) when examining potential tools for poverty alleviation. Further longitudinal research is needed in South Africa and other settings to understand how borrowing at high interest rates affects gender roles and daily life activities. CCT: ISRCTN 10734925.

The financial pressures of having a baby

Having a baby can bring money problems that can put a strain on the family budget and cause difficulties in a couple's relationship. Health professionals, especially those working in the community, often encounter families with money worries who may confide these during a home or clinic visit. This article provides some insight into the type of problems that occur and some possible solutions. It suggests appropriate sources of information and advice on, for example, state benefits, budgeting and dealing with debt.

Making choices between prepayment and user charges in Zambia. What are the results for equity?

In many low-income countries, user charges were introduced in the 1990s. As problems emerged of equity of access, interest grew in developing prepayment mechanisms to protect users from risk of out-of-pocket payments. In Zambia, a prepayment scheme did not generate sufficient revenue, due to abuses of its terms. An alternative scheme using discount cards (a set of coupons to cover episodes of care at discount) was devised. We aimed to understand the equity implications of prepayment and discount cards relative to user charges. We proposed models predicting roles of income, perceived health status, perceived quality of care and time preference in choice of payment mechanism and use of health services. We tested these models using three data sets that could be accessed or collected. It is concluded that relative to user charges, prepayment may facilitate access without incurring income-related equity losses. Evidence concerning discount cards was weaker. We concluded that they facilitate access to a lesser extent. Discount cards offer a credible intermediate solution between user charges and prepayment that avoid some problems associated with prepayment. However, since prepayment seems to be associated with the most positive outcomes, finding other solutions to their problems would be preferred.

Beliefs about informal payments in Albania

Informal payments for health care are a growing concern in Albania and other transitional economy countries. Recent international studies have shown that informal payments can have negative effects on health care access, equity and health status by causing people to forgo or delay seeking care, or sell assets to pay for care. Many countries are putting in place reforms meant to reduce informal payments. In order to be successful, such policies need to consider people's attitudes and beliefs about the practice. This study collected data from 222 citizens in Albania regarding intentions, past behaviours, attitudes and beliefs about informal payments. Comparing people who intend to make informal payments with people who do not intend to make payments, the study found differences in attitudes as well as beliefs about the consequences of making informal payments, in perceptions about what others think and in control beliefs, but no difference in moral beliefs or demographic characteristics. People who intend to make informal payments the next time they seek care are more likely to believe they will get faster and better quality care than non-intenders, but also think they must pay to receive any care at all. People who do not intend to make informal payments are more likely to report that they have connections with medical personnel, which may be substituting for informal payments. The study has implications for educational campaigns accompanying policy reforms. Campaigns which focus on anti-corruption messages are unlikely to be effective, as moral beliefs do not appear to influence intention.

Gifts, bribes and solicitions: print media and the social construction of informal payments to doctors in Taiwan

The Taiwanese practice of patients giving informal payments to physicians to secure services is deeply rooted in social and cultural factors. This study examines the portrayal of informal payments by Taiwanese print news media over a period of 12 years-from prior to until after the implementation of national health insurance (NHI) in Taiwan in 1995. The goal of the study was to examine how the advent of NHI changed the rationale for and use of informal payments. Both before and after the introduction of NHI, Taiwanese newspapers portrayed informal payments as appropriate means to secure access to better health care. Newspaper accounts established that, although NHI reduced patients' financial barriers to care, it did not change deeply held cultural beliefs that good care depended on the development of a reciprocal sense of obligation between patients and physicians. Physicians may have also encouraged the ongoing use of informal payments to make up revenue lost when NHI standardized fees and limited income from dispensing medications. In 2002, seven years after the implementation of NHI, the use of informal payments, though illegal, was still being justified in the print media through allusions to its role in traditional Taiwanese culture.

Informal payments for health care: definitions, distinctions, and dilemmas

There is increasing interest in the issue of informal payments for health care in low- and middle-income countries. Emerging evidence suggests that the phenomenon is both diverse, including many variants from cash payments to in-kind contributions and from gift giving to informal charging, and widespread, reported from countries in at least three continents. However, cross-national research is hampered by the lack of consensus among researchers on the definition of informal payments, and the definitions that have been proposed are unable to incorporate all forms of the phenomenon that have been described so far. This article aims to overcome this limitation by proposing a new definition based on the concept of entitlement for services. First, the various forms of informal payment observed in practice are reviewed briefly. Then, some of the proposed definitions are discussed, pointing out that none of the distinctive characteristics implied by these definitions, including illegality, informality, and corruption, is adequate to capture all varieties of the phenomenon. Next, an alternative definition is formulated, which identifies the distinctive feature common to all forms of informal payments as something that is contributed in addition to the terms of entitlement. Then, the boundaries implied by this definition are explored and, finally, the implications for research and policy making are discussed with reference to the lessons developed countries can learn from the experiences of transitional countries.

One question: credit or debit? As health savings accounts gain in popularity, insurers and the financial services industry want to bank the cash

The Blue Cross and Blue Shield Association has a new sideline-banking. By chartering its own bank, the Blues is joining other insurers that have moved into financial services to adapt to the changes being wrought by health savings accounts. And other insurers have been faster to make the move. The Blues "is certainly late to the game" of banking, says analyst Katy Henrickson, left.

Reverse mortgages: a novel tool for financing long-term health care needs

There is growing agreement among policymakers, health care professionals, and the aging industry in general that reverse mortgages can play an important role in financing our nation's long-term health care system, addressing many of our seniors' unmet needs.

Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India?

The study investigates the association between tobacco and alcohol use, and the potential risk of impoverishment from borrowing and distress selling of assets for meeting costs of hospitalization in India. Data from the fifty-second round of the National Sample Survey, a representative survey of 120,942 households across India, were used to investigate the likelihood and the levels of borrowing and distress selling of assets to cover hospitalization expenditures among regular users of tobacco and/or alcohol, non-users from households where there was use, and non-users from households with no use. The data were analyzed by bivariate comparisons and multivariate logistic and ordinary least square regression. The study found a higher risk of borrowing/distress selling during hospitalization for individuals who use tobacco (OR 1.35, p<0.05), who were non-users but belong to households that use tobacco (OR 1.38, p<0.05), and non-users from households that use both tobacco and alcohol (OR 1.51, p<0.05), even after controlling for socio-economic and demographic factors. The same groups also met a higher percentage of hospitalization expenditures through borrowing/distress selling of assets. The adjusted population-attributable risk proportion of borrowing/distress selling to meet hospital expenditures for tobacco and alcohol use was 16%. The study suggests that there is an association between use of tobacco and alcohol, and impoverishment through borrowing and distress selling of assets due to costs of hospitalization. While reduction of poverty is the overarching goal of developing countries and multilateral development organizations, very little is mentioned about control of tobacco and alcohol in the framework of development. It might be necessary to include strategies for control of tobacco and alcohol in the larger framework of poverty reduction.