Inequalities in Older age and Primary Health Care Utilization in Low- and Middle-Income Countries: A Systematic Review.
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ABSTRACT:
SUBMITTER: Gao Q
PROVIDER: S-EPMC8645300 | biostudies-literature | 2022 Jan
REPOSITORIES: biostudies-literature
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Inequalities in Older age and Primary Health Care Utilization in Low- and Middle-Income Countries: A Systematic Review.
Gao Qian Q Prina A Matthew AM Ma Yuteng Y Aceituno David D Mayston Rosie R
International journal of health services : planning, administration, evaluation 20211021 1
The objective of this research was to systematically review and synthesize quantitative studies that assessed the association between socioeconomic inequalities and primary health care (PHC) utilization among older people living in low- and middle- income countries (LMICs). Six databases were searched, including Embase, Medline, Psych Info, Global Health, Latin American and Caribbean Health Sciences Literature (LILACS), and China National Knowledge Infrastructure, CNKI, to identify eligible stud ...[more]
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Project description:BackgroundEach year, 287,000 women die from complications related to pregnancy or childbirth, and 3.8 million newborns die before reaching 28 days of life. The near totality (99%) of maternal and neonatal deaths occurs in low- and middle-income countries (LMICs). Utilization of essential obstetric care services including postnatal care (PNC) largely contributes to the reduction of maternal and neonatal mortality and morbidity. There is a strong need to evaluate the evidence on the unmet needs in utilization of PNC services to inform health policy planning. Our objective is to assess systematically the socioeconomic, geographic and demographic inequalities in the use of PNC interventions in low- and middle-income countries.Methods/designThe current protocol adopts a strategy informed by the guidelines of The Cochrane Handbook for Systematic Reviews. Our systematic review will identify studies in English, French, Spanish, Portuguese and Chinese - provided inclusion of an English abstract - from 1960 onwards, by searching MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and the gray literature. Study selection criteria include research setting, study design, reported outcomes and determinants of interest. Our primary outcome is the utilization of PNC services, and determinants of concern are: 1) socioeconomic status (for example, income, education); 2) geographic determinants (for example, distance to a health center, rural versus urban residence); and 3) demographic determinants (for example, ethnicity, immigration status). Screening, data abstraction, and scientific quality assessment will be conducted independently by two reviewers using standardized forms. Where feasible, study results will be combined through meta-analyses to obtain a pooled measure of association between utilization of PNC services and key determinants. Results will be stratified by countries' income levels (World Bank classification).DiscussionOur review will inform policy-making with the aim of decreasing inequalities in utilization of PNC services. This research will provide evidence on unmet needs for PNC services in LMICs, knowledge gaps and recommendations to health policy planners. Our research will help promote universal coverage of quality PNC services as an integral part of the continuum of maternal and child health care. This protocol was registered with the Prospero database (registration number: CRD42013004661).
| S-EPMC3717005 | biostudies-literature
Project description:BackgroundThe heavy and ever rising burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) warrants interventions to reduce their underlying risk factors, which are often linked to lifestyles. To effectively supplement nationwide policies with targeted interventions, it is important to know how these risk factors are distributed across socioeconomic segments of populations in LMICs. This study quantifies the prevalence and socioeconomic inequalities in lifestyle risk factors in LMICs, to identify policy priorities conducive to the Sustainable Development Goal of a one third reduction in deaths from NCDs by 2030.MethodsData from 1,278,624 adult respondents to Demographic & Health Surveys across 22 LMICs between 2013 and 2018 are used to estimate crude prevalence rates and socioeconomic inequalities in tobacco use, overweight, harmful alcohol use and the clustering of these three in a household. Inequalities are measured by a concentration index and correlated with the percentage of GDP spent on health. We estimate a multilevel model to examine associations of individual characteristics with the different lifestyle risk factors.ResultsThe prevalence of tobacco use among men ranges from 59.6% (Armenia) to 6.6% (Nigeria). The highest level of overweight among women is 83.7% (Egypt) while this is less than 12% in Burundi, Chad and Timor-Leste. 82.5% of women in Burundi report that their partner is "often or sometimes drunk" compared to 1.3% in Gambia. Tobacco use is concentrated among the poor, except for the low share of men smoking in Nigeria. Overweight, however, is concentrated among the better off, especially in Tanzania and Zimbabwe (Erreygers Index (EI) 0.227 and 0.232). Harmful alcohol use is more concentrated among the better off in Nigeria (EI 0.127), while Chad, Rwanda and Togo show an unequal pro-poor distribution (EI respectively - 0.147, - 0.210, - 0.266). Cambodia exhibits the largest socioeconomic inequality in unhealthy household behaviour (EI - 0.253). The multilevel analyses confirm that in LMICs, tobacco and alcohol use are largely concentrated among the poor, while overweight is concentrated among the better-off. The associations between the share of GDP spent on health and the socioeconomical distribution of lifestyle factors are multidirectional.ConclusionsThis study emphasizes the importance of lifestyle risk factors in LMICs and the socioeconomic variation therein. Given the different socioeconomic patterns in lifestyle risk factors - overweight patters in LMICs differ considerably from those in high income countries- tailored interventions towards specific high-risk populations are warranted to supplement nationwide policies.
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Project description:This study assessed the extent of household catastrophic expenditure in dental health care and its possible determinants in 41 low and middle income countries. Data from 182,007 respondents aged 18 years and over (69,315 in 18 low income countries, 59,645 in 15 lower middle income countries and 53,047 in 8 upper middle income countries) who participated in the WHO World Health Survey (WHS) were analyzed. Expenditure in dental health care was defined as catastrophic if it was equal to or higher than 40% of the household capacity to pay. A number of individual and country-level factors were assessed as potential determinants of catastrophic dental health expenditure (CDHE) in multilevel logistic regression with individuals nested within countries. Up to 7% of households in low and middle income countries faced CDHE in the last 4 weeks. This proportion rose up to 35% among households that incurred some dental health expenditure within the same period. The multilevel model showed that wealthier, urban and larger households and more economically developed countries had higher odds of facing CDHE. The results of this study show that payments for dental health care can be a considerable burden on households, to the extent of preventing expenditure on basic necessities. They also help characterize households more likely to incur catastrophic expenditure on dental health care. Alternative health care financing strategies and policies targeted to improve fairness in financial contribution are urgently required in low and middle income countries.
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Project description:BackgroundGlobal stunting prevalence has been nearly halved between 1990 and 2016, but it remains unclear whether this decline has benefited poor and rural populations within low- and middle-income countries (LMICs).ObjectiveWe assessed time trends in stunting among children <5 y of age (under-5) according to household wealth and place of residence in 67 LMICs.MethodsStunting prevalence was analyzed in 217 nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 67 countries with ≥2 surveys between 1993 and 2014. National estimates were stratified by wealth and area of residence, comparing the poorest 40% with the wealthiest 60%, and those residing in urban and rural areas. Time trends were calculated for LMICs by using multilevel regression models weighted by under-5 population, with stratification by wealth and by residence. Trends in absolute (slope index of inequality; SII) and relative (concentration index; CIX) inequalities were calculated.ResultsMean prevalences in 1993 were 53.7% in low-income and 48.2% in middle-income countries, with annual average linear declines of 0.76 and 0.72 percentage points (pp), respectively. Although similar slopes of declines were observed for the poorest 40% and wealthiest 60% groups in all countries (0.78 and 0.74 pp, respectively), absolute and relative inequalities increased over time in low-income countries (SII increased from -19.3% in 1993 to -23.7% in 2014 and CIX increased from -6.2% to -10.8% in the same period). In middle-income countries, socioeconomic inequalities remained stable. Overall, stunting prevalence decreased more rapidly among rural than for urban children (0.78 and 0.55 pp, respectively).ConclusionsThe prevalence of stunting is decreasing. Poor-rich gaps are stable in middle-income countries and slightly increasing in low-income countries. Rural-urban inequalities are decreasing over time.
| S-EPMC6084584 | biostudies-literature
Project description:Exclusive breastfeeding (EBF)-giving infants only breast-milk for the first 6 months of life-is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization's Global Nutrition Target (WHO GNT) of ≥70% EBF prevalence by 2030. While six LMICs are projected to meet the WHO GNT of ≥70% EBF prevalence at a national scale, only three are predicted to meet the target in all their district-level units by 2030.
| S-EPMC8373614 | biostudies-literature
Project description:BackgroundOral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs.MethodsWe used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000-17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws.FindingsWhile ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000-7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910-68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average.InterpretationTo our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage.FundingBill & Melinda Gates Foundation.
| S-EPMC7388204 | biostudies-literature
Project description:ImportanceVision impairment (VI), including blindness, affects hundreds of millions globally, and 90% of those with VI live in low- and middle-income countries. Cross-national comparisons are important to elucidate the unique and shared factors associated with VI and receipt of eye care in different countries and to target those most in need.ObjectiveTo identify the characteristics associated with VI and receipt of eye care in a sample of low- and middle-income countries.Design, setting, and participantsIn this study of cross-sectional survey data from wave 1 of the World Health Organization Study on Global Aging and Adult Health, data on sociodemographic characteristics and health were collected from nationally representative samples in China, Ghana, India, Mexico, Russia, and South Africa from 2007 to 2010. Probability sampling with multistage, stratified, random-cluster samples was used to identify households and participants. The survey was completed by 34 159 adults 50 years and older. Data were analyzed from December 2017 to February 2018.Main outcomes and measuresWe analyzed associations of individual-level and household-level covariates with 3 primary outcomes: distance VI (visual acuity worse than 6/18 in the better-seeing eye), near VI (visual acuity worse than 6/18 in the better-seeing eye), and receipt of an eye examination within the previous 2 years.ResultsThe study sample in China consisted of 13 350 participants (50.2% female; mean [SD] age, 62.6 [9.0] years); in Ghana, 4725 participants (50.4% female; mean [SD] age, 64.2 [10.8] years); in India, 7150 participants (48.9% female; mean [SD] age, 61.5 [9.0] years); in Mexico, 2103 participants (52.3% female; mean [SD] age, 69.2 [9.2] years); in Russia, 3763 participants (61.1% female; mean [SD] age, 63.9 [10.4] years); and in South Africa, 3838 participants (55.9% female; mean [SD] age 61.6 [9.5]) (all demographic characteristics weighted to reflect respective populations). The weighted proportion of the study sample with distance VI ranged from 9.9% (95% CI, 9.3-10.5) in China to 25.4% (95% CI, 22.0-29.2) in Russia; near VI, from 28.5% (95% CI, 26.9-30.1) in Ghana to 43.1% (95% CI, 41.1-45.1) in India; and receipt of a recent eye examination, from 15.0% (95% CI, 13.8-16.2) in Ghana to 53.1% (95% CI, 49.3-56.8) in Russia. Educational attainment, medical comorbidities, and memory were significantly associated with all outcomes across most low- and middle-income countries. Female sex, low household wealth, food insecurity, no health insurance, rurality, disability, being unmarried, and low social participation were significantly associated with adverse vision-related outcomes, though less consistently.Conclusions and relevanceThere are both common and unique characteristics associated with VI and receipt of eye care across low- and middle-income countries. Our findings suggest that recognizing these factors is important to identify those most at risk and allocate resources optimally. Additional local epidemiological studies are needed.
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Project description:When the Japanese government adopted Western medicine in the late nineteenth century, it left intact the infrastructure of primary care by giving licenses to the existing practitioners and by initially setting the hurdle for entry into medical school low. Public financing of hospitals was kept minimal so that almost all of their revenue came from patient charges. When social health insurance (SHI) was introduced in 1927, benefits were focused on primary care services delivered by physicians in clinics, and not on hospital services. This was reflected in the development and subsequent revisions of the fee schedule. The policy decisions which have helped to retain primary care services might provide lessons for achieving universal health coverage in low- and middle-income countries (LMICs).
| S-EPMC4851997 | biostudies-other
Project description:The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.
| S-EPMC10363957 | biostudies-literature
Project description:ObjectiveEvaluation of the effectiveness of integration of depression and alcohol use disorder care into primary health care in low- and middle-income countries (LMICs) is limited. The authors aimed to quantify the effectiveness of integrating mental health care into primary care by examining depression and alcohol use disorder outcomes. The study updates a previous systematic review summarizing research on care integration in LMICs.MethodsFollowing PRISMA guidelines, the authors included studies from the previous review and studies published from 2017 to 2020 that included adults with alcohol use disorder or depression. Studies were evaluated for type of integration model with the typology developed previously. A meta-analysis using a random-effects model to assess effectiveness of integrated interventions was conducted. Meta-regression analyses to examine the impact of study characteristics on depression and alcohol use disorder outcomes were conducted.ResultsIn total, 49 new articles were identified, and 74 articles from the previous and current studies met inclusion criteria for the meta-analysis. Overall random effect sizes were 0.28 (95% CI=0.22-0.35) and 0.17 (95% CI=0.11-0.24) for studies targeting care integration for depression or for alcohol use disorder, respectively, into primary care in LMICs. High heterogeneity within and among studies was observed. No significant association was found between country income level and depression and alcohol use outcomes. However, differences in effect sizes between types of integration model were statistically significant (p<0.001).ConclusionsIntegration of mental health care into primary health care in LMICs was found to improve depression and alcohol use disorder outcomes. This evidence should be considered when designing interventions to improve mental health screening and treatment in LMICs.
| S-EPMC11910197 | biostudies-literature