Variations in preventive care utilisation in Europe.
ABSTRACT: Prevention has been identified as an effective strategy to lead healthy, active and independent lives in old age. Developing effective prevention programs requires understanding the influence of both individual and health system level factors on utilisation of specific services. This study examines the variations in utilisation of preventive services by the population aged 50 and over in 14 European countries, pooling data from the two waves of Survey of Health Ageing and Retirement in Europe and the British Household Panel Survey. The models used allow for the impact of individual level demand-side characteristics and supply-side health systems features to be separately identified. The analysis shows significant variations in preventive care utilisation both within and across European countries. In all countries, controlling for individual health status and country-level systemic differences, higher educated and higher income groups use more preventive services. At the health system level, high public health expenditures and high GP density is associated with a high level of preventive care use, but specialist density does not appear to have any effect. Moreover, payment schemes for GPs and specialists appear to significantly affect the incentives to provide preventive health care. In systems where doctors are paid by fee-for-service the utilisation of all health services, including cancer screening, are higher.
Project description:Measles supplementary immunisation activities (SIAs) are an integral component of measles elimination in low-income and middle-income countries (LMICs). Despite their success in increasing vaccination coverage, there are concerns about their negative consequences on routine services. Few studies have conducted quantitative assessments of SIA impact on utilisation of health services.We analysed the impact of SIAs on utilisation of selected maternal and child health services using Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 28 LMICs, where at least one SIA occurred over 2000-2014. Logistic regressions were conducted to investigate the association between SIAs and utilisation of the following services: facility delivery, postnatal care and outpatient sick child care (for fever, diarrhoea, cough).SIAs do not appear to significantly impact utilisation of maternal and child services. We find a reduction in care-seeking for treatment of child cough (OR 0.67; 95%?CI 0.48 to 0.95); and a few significant effects at the country level, suggesting the need for further investigation of the idiosyncratic effects of SIAs in each country.The paper contributes to the debate on vertical versus horizontal programmes to ensure universal access to vaccination. Measles SIAs do not seem to affect care-seeking for critical conditions.
Project description:The objective of this study was to explore how long-term care systems, and in particular the incorporation of needs-based entitlements to care services or benefits, influence formal and informal care utilisation dynamics. We used the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 1 and 2 data, restricting the sample to persons 65+ from 9 European countries (N = 6,293). The effects of changes in health and household composition on formal and informal care transitions were estimated using logistic regression, allowing these effects to vary across countries. The results indicated that, in all countries, formal and informal care were more often complements than substitutes. The likelihood of becoming a formal or informal care user varied significantly between countries. In the Scandinavian countries and in several continental European countries with needs-based entitlements, the transition to formal care was strongly related to informal support being or becoming unavailable. We found little evidence of country differences in the effect of health variables on the transition to formal care. The analysis suggested that, whilst rates of formal care utilisation continue to differ considerably between European countries, formal care allocation practices are not very dissimilar across Northern and continental European welfare states, as we found evidence for all countries of targeting of older persons living alone and of the most care-dependent older people.
Project description:Background:Breast cancer is the most commonly occurring cancer among women in low-resourced countries. Reduction of its impacts is achievable with regular screening and early detection. The main aim of the study was to examine the role of wealth stratified inequality in the utilisation breast cancer screening (BCS) services and identified potential factors contribute to the observed inequalities. Methods:A population-based cross-sectional multi-country analysis was used to study the utilisation of BCS services. Regression-based decomposition analyses were applied to examine the magnitude of the impact of inequalities on the utilisation of BCS services and to identify potential factors contributing to these outcomes. Observations from 140,974 women aged greater than or equal to 40?years were used in the analysis from 14 low-resource countries from the latest available national-level Demographic and Health Surveys (2008-09 to 2016). Results:The population-weighted mean utilisation of BCS services was low at 15.41% (95% CI: 15.22, 15.60), varying from 80.82% in European countries to 25.26% in South American countries, 16.95% in North American countries, 15.06% in Asia and 13.84% in African countries. Women with higher socioeconomic status (SES) had higher utilisation of BCS services (15%) than those with lower SES (9%). A high degree of inequality in accessing and the use of BCS services existed in all study countries across geographical areas. Older women, access to limited mass media communication, being insured, rurality and low wealth score were found to be significantly associated with lower utilisation of BCS services. Together they explained approximately 60% in the total inequality in utilisation of BCS services. Conclusions:The level of wealth relates to the inequality in accessing BCS amongst reproductive women in these 14 low-resource countries. The findings may assist policymakers to develop risk-pooling financial mechanisms and design strategies to increase community awareness of BCS services. These strategies may contribute to reducing inequalities associated with achieving higher rates of the utilisation of BCS services.
Project description:OBJECTIVE:Monitoring inequality in healthcare utilisation is essential to reduce persistent inequalities in health in lower-middle income countries. This study aimed to assess socioeconomic inequalities in the utilisation of primary care, secondary care and preventive care in Indonesia. METHODS:A cross-sectional study was conducted using data from the 2014 Indonesia Family Life Survey with a total of 42 083 adult participants. Socioeconomic status (SES) was measured by educational level and income. Healthcare utilisation was measured in: (1) primary care, (2) outpatient in secondary care, (3) inpatient care and (4) cardiovascular-related preventive care. The magnitude of inequalities was measured using the relative index of inequality (RII). RESULTS:Small educational inequalities were found for primary care utilisation (RII 1.13, 95% CI 1.01 to 1.26). Larger educational inequalities were found for outpatient secondary care (RII 10.35, 95% CI 8.11 to 13.22) and inpatient care (RII 2.78, 95% CI 2.32 to 3.32). The largest educational inequalities were found for preventive care, particularly regarding blood glucose tests (RII 30.31, 95% CI 26.13 to 35.15) and electrocardiography tests (RII 30.90, 95% CI 24.97 to 38.23). Compared with educational inequalities, income inequalities were larger for primary care (RII 1.68, 95% CI 1.52 to 1.85) and inpatient care (RII 3.11, 95% CI 2.63 to 3.66), but not for outpatient secondary care and preventive care. CONCLUSIONS:Socioeconomic inequalities in healthcare utilisation in Indonesia are particularly large in secondary and preventive care. Therefore, it is recommended to prioritise policies focused on improving timely, geographical and financial access to secondary and preventive care for lower SES groups.
Project description:Background:Studies in mental health care for low resource settings indicate that providing services at primary care level would significantly improve provision and utilisation of mental health services. Challenges related to inadequate funding were noted as significant barriers to service provision, with the contribution of low knowledge of mental health conditions and stigma in the community. This study aimed to explore the barriers to the use of mental health services in Zambia, suggesting health systems thinking approaches to solving these challenges. Methods:Primary data were collected through individual interviews from 12 participants; primary caregivers, health workers from public health institutions that treat mental health conditions and policymakers and implementers. The digitally recorded responses were transcribed and analysed using thematic analysis. Results:Key barriers to care included inadequate funding, few human resources, poor infrastructure and stigma. Barriers to care at policy, facility and individual or community level could be alleviated by strengthening the mental health system. Engagement of community health workers and increasing efforts to sensitise the community about mental health would prove beneficial. Conclusions:Strengthening the community health systems for mental health could improve access and increase utilisation of services.
Project description:BACKGROUND: Health services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries. RESULTS: Semi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this. CONCLUSIONS: The needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.
Project description:INTRODUCTION:There is an increasing need for the development of new methods to understand factors affecting delivery of preventive care. This study applies a new measurement approach and assesses clinic-level factors associated with preventive care delivery. METHODS:This retrospective longitudinal cohort study of 94 community health centers used electronic health record data from the OCHIN community health information network, 2014-2015. Clinic-level preventive ratios (time covered by a preventive service/time eligible for a preventive service) were calculated in 2017 for 12 preventive services with A or B recommendations from the U.S. Preventive Services Task Force along with an aggregate preventive index for all services combined. For each service, multivariable negative binomial regression modeling and calculated rate ratios assessed the association between clinic-level variables and delivery of care. RESULTS:Of ambulatory community health center visits, 59.8% were Medicaid-insured and 10.4% were uninsured. Ambulatory community health centers served 16.9% patients who were Hispanic, 13.1% who were nonwhite, and 68.7% who had household incomes <138% of the federal poverty line. Clinic-level preventive ratios ranged from 3% (hepatitis C screening) to 93% (blood pressure screening). The aggregate preventive index including all screening measures was 47% (IQR, 42%-50%). At the clinic level, having a higher percentage of uninsured visits was associated with lower preventive ratios for most (7 of 12) preventive services. CONCLUSIONS:Approaches that use individual preventive ratios and aggregate prevention indices are promising for understanding and improving preventive service delivery over time. Health insurance remains strongly associated with access to needed preventive care, even for safety net clinic populations.
Project description:<h4>Background</h4>Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children.<h4>Methods</h4>A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0-5?years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics).<h4>Results</h4>The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large.<h4>Conclusion</h4>This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.
Project description:BACKGROUND:The objectives of this study were to 1) measure the percentage of women who received SMS-based family planning communication, and 2) its association with modern contraception and maternal healthcare services among mothers. In recent years, there has been a growing interest surrounding mobile phone-based health communication and service delivery methods especially in the areas of family planning and reproductive health. However, little is known regarding the role of SMS-based family planning communication on the utilisation of modern contraception and maternal healthcare services in low-resource settings. METHODS:Cross-sectional data on 94,675 mothers (15-49?years) were collected from the latest Demographic and Health Surveys in 14 low-and-middle-income countries. The outcome variables were self-reported use of modern contraception and basic maternal healthcare services (timely and adequate use of antenatal care, and of facility delivery services). Data were analysed using multivariate regression and random effect meta-analyses. RESULTS:The coverage of SMS-based family planning communication for the pooled sample was 5.4% (95%CI?=?3.71, 7.21), and was slightly higher in Africa (6.04, 95%CI?=?3.38, 8.70) compared with Asia (5.23, 95%CI?=?1.60, 8.86). Among the countries from sub-Saharan Africa, Malawi (11.92, 95%CI?=?11.17, 12.70) had the highest percent of receiving SMS while Senegal (1.24, 95%CI?=?1.00, 1.53) had the lowest. In the multivariate analysis, SMS communication shown significant association with the use of facility delivery only (2.22 (95%CI?=?1.95, 2.83). The strength of the association was highest for Senegal (OR?=?4.70, 95%CI?=?1.14, 7.33) and lowest for Burundi (OR?=?1.5; 95%CI?=?1.01, 2.74). Meta analyses revealed moderate heterogeneity both in the prevalence and the association between SMS communication and the utilisation of facility delivery. CONCLUSION:Although positively associated with using facility delivery services, receiving SMS on family planning does not appear to affect modern contraceptive use and other components of maternal healthcare services such as timely and adequate utilisation of antenatal care.
Project description:<h4>Background</h4>Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use.<h4>Methods</h4>Using data from a nationally representative survey (N?=?649?625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities.<h4>Results</h4>Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR)?=?0.82, 95% confidence interval (CI)?=?0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR?=?1.23, 95% CI?=?1.05-1.43) and with travel times (OR?=?0.72 95% CI?=?0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR?=?1.65, 95% CrI?=?1.59-1.70 decreasing to 1.61, 95% CrI?=?1.56-1.67) or inpatient care utilisation (MOR?=?1.63, 95% CrI?=?1.55-1.69 decreasing to 1.60 95% CrI?=?1.54-1.66).<h4>Conclusions</h4>Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.