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PubMed2006

Our farmers at risk: behaviour and belief system in pesticide safety.

BACKGROUND: The study was done in three villages in Nueva Ecija, Philippines. It surveys farmers' belief system and pesticide practices relative to health and safety. METHODS: Initially it used a simulated market study on willingness to pay for personal protective equipment in the form of gloves and masks. Then a combination of semi-structured, formal, informal, and key-informant interviews, as well as focus groups, and field observations was done intermittently in a span of approximately 12 years. RESULTS: The farmers perceive illness in terms of inability to function. Pesticide to them may not be a threat because (i) they are immune, (ii) it is regarded as a medicine that is needed by the plants rather than poison, and (iii) exposure is only through inhalation and ingestion not through dermal contact. Added to that, they put value on pasma, and try to prevent it at the cost of exposure to pesticides. These perceptions lead to their practices showing inadequate protection. CONCLUSION: There is the need for more health education programs that tap farmers' belief system and cognitive categories to stress the need for precautions.

Agricultural Workers' Diseases↗
PubMed2004

Care arrangements for people with dementia in developing countries.

BACKGROUND: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. METHODS: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. RESULTS: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. CONCLUSIONS: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world.

Aged↗
PubMed2006

Alternative therapy use in liver transplant recipients.

BACKGROUND: The extent of use of alternative therapies and the psychosocial variables predictive of their use have not been well defined in liver transplant recipients. OBJECTIVE: To determine types of alternative therapies used by liver transplant recipients and to assess psychosocial, behavioral, and quality of life variables associated with the use of alternative therapies in these patients. METHODS: Assessment of types of alternative therapies used, demographic characteristics, satisfaction with social support, coping styles, sense of personal control (mastery), quality of life, and health beliefs in 32 liver transplant recipients. RESULTS: Overall, 34.4% of the liver transplant recipients used a form of alternative therapy. Herbal products were used by 45% of the alternative therapy users and included milk thistle (silymarin), eclipta, and green beet leaf-all considered "hepatic tonics". Alternative therapy users tended to have greater problem-focused coping skills than nonusers (P = .08). Nineteen percent of the patients incurred annual out-of-pocket expense of at least dollars 100 for alternative therapies. Patients incurring out-of-pocket expenses reported better overall health (P = .02), were more likely to be employed (P = .025), and had higher mastery scores (P = .01). CONCLUSIONS: Use of alternative therapies is common after liver transplantation. Herbal products used by liver transplant recipients are disease specific; that is, they claim to promote liver health.

Adaptation, Psychological↗
PubMed2005

The Richard Cory phenomenon: suicide and wealth in Kansas City, Missouri.

This case-control study investigates the relationship between suicide and wealth in Kansas City, Missouri. House and personal property appraisal data on all victims of suicide from 1998 and 2002 and victims from a control population of deaths reported to the Jackson County Medical Examiner during the same time interval were obtained from the Jackson County Government website. The controls were matched to suicide cases by race, gender, year of death, and age at death (+/- 1 year). Data from the 426 members of each group of suicides and controls indicate that suicide victims were: 1) 77% more likely than controls to have lived in houses rather than in apartments or trailers, 2) more likely than controls to have lived in more expensive houses (mean values dollar 70,143 versus dolllar 61,513 respectively, p = 0.04) and 3) more likely to have killed themselves because of factors other than financial strain (8.0% of suicides showed financial strain).

Adolescent↗
PubMed2001

An age-embedding effect: time sensitivity and time insensitivity when pricing health benefits.

Benefits are often extended over time. One determinant of this benefit duration is how long a person will live to enjoy them. In four studies, we investigated whether people are sensitive to age when pricing benefits that will last for the remainder of one's life. In Study 1 drivers gave their willingness-to-pay (WTP) to cure a medical condition which would stop them from driving. Results showed an age-embedding effect: WTP was unrelated to the estimated number of driving years left. Study 2 tested whether age-embedding arose because people have a lot of information about themselves which dilutes the impact of age on their valuations. In Studies 3 and 4 we investigated whether people believed that age was an important consideration, or if they failed to properly incorporate it into their judgment. Results indicate that little weight is given to age when making individual pricing decisions, although people did not believe it was normatively irrelevant.

Adult↗
PubMed2000

Uninsured status and out-of-pocket costs at midlife.

OBJECTIVE: To investigate how baseline health insurance coverage affects subsequent out-of-pocket costs and utilization of health services over a two-year period. DATA SOURCE: The first two waves of the Health and Retirement Study, a nationally representative survey of the noninstitutionalized population, ages 51 to 61 at baseline. Interviews were conducted in 1992 and 1994. Our sample consisted of 7,018 respondents who did not report public insurance as their sole source of coverage at baseline. STUDY DESIGN: We compared self-reports of physician visits, hospitalizations, and out-of-pocket health care costs, measured as payments to physicians, hospitals, and nursing homes, by type of insurance coverage at the beginning of the period. We estimated multivariate models of costs and service use to control for individual health, demographic, and economic characteristics and employed instrumental variable techniques to account for the endogeneity of insurance coverage. PRINCIPAL FINDINGS: Controlling for personal characteristics and accounting for the endogeneity of insurance coverage, persons at midlife with job-related health benefits went on to spend only about $50 per year less in out-of-pocket payments for health services than persons who lacked health insurance at the beginning of the period. However, they spent about $650 more per year in insurance premiums than the uninsured. The uninsured used relatively few health services, except when they were seriously ill, in which case they were likely to acquire public insurance. CONCLUSIONS: The medically uninsured appear to avoid substantial out-of-pocket health care costs by using relatively few health services when they are not seriously ill, and then relying upon health care safety nets when they experience medical problems. These results suggest that the main impact of non-insurance at midlife is not to place the locus of responsibility for costly health care upon individuals. Instead, it discourages routine care and transfers the costs of care for severe health events to other payers. Our findings on the high cost of employment-based coverage are consistent with evidence that the proportion of workers accepting health benefits from employers has been declining in recent years.

Age Factors↗
PubMed2002

Self-rated economic condition and the health of elderly persons in Hong Kong.

Studies have documented that health and income are important variables affecting the quality of life in old age. However, there is little knowledge about whether perceived financial sufficiency affects the health of elderly persons. Recent research has documented that in addition to material and behavioural determinants, psychosocial pathways also have an influence on health inequalities. This is the first paper to examine the relation between self-rated economic condition (measured with a single item question) and reported health conditions (i.e., somatic complaints, diagnosed physical diseases, functional health (Activities of Daily Living), self-rated health, and mental health status (General Health Questionnaire-30 [GHQ-30]) among elderly persons in Hong Kong. The respondents of the study were persons aged 65 and over residing in public housing estates in the Southern District of Hong Kong Island. Four hundred and fifty respondents were interviewed in 1995 by means of a structured questionnaire. The study found that although it did not record the actual income levels of the respondents, the subjective measure vividly demonstrated the health differentials among the elderly respondents. Multiple regression analyses suggested that self-rated economic condition was a significant predictor of the number of somatic complaints and physical illnesses reported, as well as of functional health, self-rated health, and mental health status (controlling for socio-demographic variables). However, the measure explained a higher proportion of variance in models related to psychological health than those related to physical health. The findings substantiated the role of psychosocial processes in understanding perceived health and illness and health inequalities in particular.

Activities of Daily Living↗
PubMed2004

Antiretroviral therapy and health care utilization: a study of privately insured men and women with HIV disease.

OBJECTIVE: To compare the use of antiretroviral therapy and other health care resources by women and men with HIV disease who are privately insured. DATA SOURCES: Data were obtained from the MarketScan Commercial Claims and Encounter Database produced by the Medstat Group, Inc., of Ann Arbor, Michigan. This database includes eligibility files as well as claims data for inpatient care, outpatient care, physician services, and prescription drugs for enrollees in employer-sponsored benefit plans for 24 large employers around the nation. STUDY DESIGN: Examine utilization by 2,026 privately insured persons (1,494 men and 532 women) with HIV disease in calendar year 2000 under the age of 65. PRINCIPAL FINDINGS: Using a simple comparison, we found that 71 percent of men (68.7 to 73.3 percent is 95 percent confidence interval) and 39 percent of women (35.1 to 43.5 percent is 95 percent confidence interval) with HIV disease received antiretroviral therapy. We also found that the average annual drug cost was $9,037 for a man ($8,372 to $9,702 is 95 percent confidence interval) and $3,893 for a woman ($3,476 to $4,490 is 95 percent confidence interval). Furthermore, we found that the out-of-pocket expenses comprised 10 percent of total expenses for men ($1,617 out of $16,405) and 4 percent for women ($405 out of $10,397). CONCLUSION: There are major differences in the utilization and cost of health care between privately insured men and women with HIV disease.

Adult↗
PubMed1999

The personal costs of diabetes: a significant barrier to care in South Auckland.

AIM: To estimate the out-of-pocket expenses associated with diabetes care and their impact on self-care activities in inner urban South Auckland. METHODS: Follow-up, cross-sectional household survey among 1629 residents with known diabetes. A brief questionnaire was completed during either two consecutive mail surveys or a subsequent household visit to diabetic patients identified in a previous household survey. RESULTS: Responses were obtained from 802 (75%) of the 1075 subjects remaining resident in the area. Median annual costs of scripts, shoes, clinic and general practice visits ranged between $191-$329 depending on ethnic group. Costs were higher among males, those requiring insulin therapy and those aged under 60 years. A significant proportion of subjects reported that these costs prevented regular self-blood-glucose monitoring (18-49%), self-medication (11-47%) and regular insulin therapy among insulin-treated patients (8-52%). CONCLUSIONS: The out-of-pocket expenses associated with diabetes remain a substantial portion of disposable income and a barrier to the prevention of diabetes-related complications. These data support the provision of preventive diabetes care at no cost to the patient at the point of care.

Adult↗
PubMed2003

Aggregating the benefits of environmental improvements: distance-decay functions for use and non-use values.

One of the main problems in using environmental cost-benefit analysis is deciding on the relevant population: whose benefits should we count? This is important since aggregate benefits depend on both per-person benefit and the number of beneficiaries. Yet this latter term is often hard to evaluate. Distance-decay functions are one way of addressing this problem. In this paper, we present estimates of distance-decay functions for a particular environmental improvement, namely a reduction in low flow problems on the River Mimram in Southern England. We do this both for users and non-users, in the context of a contingent valuation study of the benefits of improving low flow conditions. We test whether distance-decay effects for mean Willingness to Pay are stronger for a single environmental good (the River Mimram, in this case) than for a more inclusive set (here, all rivers in Thames region which suffer from low flow problems). Finally, we explore the impact on part-whole bias, in terms of the relationship between WTP for an individual site and WTP for a more inclusive group of sites, of allowing for distance-decay effects.

Attitude↗
PubMed2002

Private demand for a HIV/AIDS vaccine: evidence from Guadalajara, Mexico.

The private demand for a hypothetical vaccine that would provide lifetime protection against HIV/AIDS to an uninfected adult was measured in Guadalajara, Mexico, using the concept of willingness to pay (WTP). A 91-question survey instrument was administered by trained enumerators employing contingent valuation techniques to 234 adults, aged 18-60. Our estimates of private demand indicate that individuals anticipate sizable personal benefits from such a vaccine, and that they would be willing to allocate a substantial portion of their income to be protected in this way from HIV infection. A conservative estimate of the mean WTP of adults in the Guadalajara sample is 6358 pesos (669 US dollars) and the median is 3000 pesos (316 US dollars). A multivariate statistical analysis of the determinants of individuals' WTP shows that individuals with higher incomes, with spouses or partners, and with higher perceived risks of becoming infected with HIV are willing to pay more for the vaccine. Older respondents are willing to pay less. These results suggest that there is likely to be a potentially large private market for a HIV/AIDS vaccine in the middle-income developing countries such as Mexico. These findings have important implications both for the level of R&D effort that is devoted to a vaccine and, assuming these efforts are successful, for future policies to make the vaccine available to the public.

AIDS Vaccines↗
PubMed2005

Visiting adult patients in intensive care: the importance of relatives' travel and time costs.

UNLABELLED: Families of critically ill patients consistently rate visiting and being near their relative as very important. However, the costs incurred by families whilst visiting have received little attention. This study investigated the personal costs to informal caregivers (families, relatives and friends) visiting critically ill patients in an intensive care unit (ICU). The purpose of the study was (1) to test the feasibility of collecting data from informal caregivers visiting critically ill relatives and (2) to estimate the personal costs incurred by them. Data were collected by self-completed questionnaires over a 2-week period on out-of-pocket expenses and time foregone. RESULTS: One hundred and seven informal caregivers were invited to participate in the study. Fifty-four completed the questionnaire (response 50%). Forty-eight percent of respondents were male and 52% female. Fifty-nine percent of participants were in paid employment, and of these 16% lost wages as a result of the visit. The mean cost of time foregone was 46.21 pounds sterlings /visit (66.92 US dollars) and mean out-of-pocket expenses 29.30 pounds sterlings (42.43 US dollars). CONCLUSION: It is feasible to collect data on expenses and time foregone from informal caregivers visiting the ICU. The main out-of-pocket expense was that related to travel. More empirical work is needed across different settings to obtain more generalisable estimates of out-of-pocket expenses and time foregone.

Adolescent↗
PubMed2005

Financial capacity in persons with schizophrenia and serious mental illness: clinical and research ethics aspects.

In contrast with issues of consent capacity, financial capacity has received surprisingly little clinical or ethical attention in the psychiatric literature. Issues of financial capacity emerge frequently regarding clients with serious mental illness (SMI), and their resolution has practical and ethical significance for clients, their families, and mental health professionals. These issues include whether a client has sufficient financial skills and judgment to live independently, whether a client requires a representative payee, and what goals for community reintegration should be established with a client. Similar to informed consent, issues of financial capacity raise ethical challenges for clinicians, caseworkers, and agencies. The present article addresses clinical and research ethics questions related to financial capacity in clients with schizophrenia and SMI. Clinical questions concern evaluation of financial capacity in clients with SMI, whether to seek assignment of a mandatory representative payee, whether to leverage treatment compliance through a representative payee arrangement, and whether a mental health professional should also serve as a client's representative payee. The research ethics question addresses implications of providing financial compensation for research participation to individuals with SMI and limited financial capacity and means. The ultimate goal of this article is to focus clinical and ethical attention on a neglected decisional capacity in SMI that is of fundamental importance for clients, families, clinicians, and researchers.

Biomedical Research↗
PubMed2001

Being uninsured in 1996 compared to 1987: how has the experience of the uninsured changed over time?

OBJECTIVE: To explore trends in the nonelderly uninsured population between 1987 and 1996 and examine whether the broad disparities in medical care utilization and out-of -pocket spending between the privately insured and uninsured populations that existed in 1987 continued over the following decade. DATA SOURCES/STUDY DESIGN: Data are from the 1996 Medical Expenditure Panel Survey and the 1987 National Medical Expenditure Survey. We used survey data to create descriptive tables examining the characteristics of the uninsured population and the use of medical services, total and out-of -pocket expenditures, and the burden of out-of -pocket spending for the uninsured and the privately insured in 1987 and 1996. Tabulations are presented by demographic and socioeconomic characteristics. PRINCIPAL FINDINGS: The composition of the uninsured population changed somewhat between 1987 and 1996, with adults over age 18 and employed persons making up larger proportions of the uninsured in 1996, and the poor and those in fair or poor health making up smaller proportions. There were few changes in utilization of services by the uninsured over this period and no change in mean expenses, but there was an increase in receipt of at least one preventive service (mammograms) and a decline in the proportion of families with high out-of-pocket burden. Disparities in use and expenses that existed between the uninsured and the privately insured in 1987, however, remained in 1996. CONCLUSIONS: Despite the fundamental changes in the health care system that took place between 1987 and 1996, health care utilization and expenses for the uninsured changed very little. The uninsured are still much less likely to use services than are the privately insured, and they pay for a larger proportion of their medical care expenses out of pocket. There was some improvement in the burden of out-of -pocket spending between 1987 and 1996, but a significant number of the uninsured still have high financial burden.

Adolescent↗
PubMed2006

Health insurance take-up by the near-elderly.

OBJECTIVE: To examine the effect of price on the demand for health insurance by early retirees between the ages of 55 and 64. DATA SOURCE: Administrative health plan enrollment data from a medium-sized U.S. employer. STUDY DESIGN: The analysis takes advantage of a natural experiment created by the firm's health insurance contribution policy. The amount the firm contributes toward retiree health insurance coverage depends on when a person retired and her years of service at that date. As a result of this policy, there is considerable variation in out-of-pocket premiums faced by individuals in the data. This variation is independent of the nonprice attributes of the health insurance plans offered and is plausibly exogenous to individual characteristics that are likely to affect the demand for insurance. A probit model is used to estimate the decision to take-up employer-sponsored health insurance by early retirees between the ages of 55 and 64. Demand for insurance is measured as a function of out-of-pocket premiums and a set of individual characteristics. PRINCIPAL FINDINGS: We find that price has a small but statistically significant effect on the decision to take up coverage. Estimated price elasticities range from -0.10 to -0.16, depending on the sample. CONCLUSIONS: The implied elasticities are comparable with results found in previous studies using very different data. Our estimates indicate that policy proposals for a Medicare buy-in or a nongroup tax credit will have a modest impact on take-up rates of near-elderly retirees.

Choice Behavior↗
PubMed2004

Senior citizens and the burden of prescription drug outlays: what lessons for the Medicare prescription drug benefit?

This article uses data from a cohort of elderly and retired persons over the 1996-2001 period in the US to (i) determine the extent to which changes in socioeconomic or demographic characteristics, particularly age, income and education, impact the total amount that is spent on prescription drugs and (ii) to analyse the predictors of individual out-of-pocket (OOP) prescription drug outlays among the same cohort and determine whether age, race, sex, income, education, marital status and health status have an influence on these. The analysis considers the implications for elderly individuals who choose to participate in the new Medicare Part D drug benefit, labelled the Medicare Prescription Drug, Improvement, and Modernisation Act of 2003. The results highlight the necessity for the Medicare prescription drug benefit to carefully target the eldest among the elderly, who are most in need and are in danger of becoming trapped in the so-called Medicare 'doughnut hole', i.e. incur high prescription drug outlays, without adequate coverage. The study also finds evidence that women, those who are not married, middle income elderly and those in poor health, who purchase drugs more intensively, are at risk of incurring significant prescription OOP drug outlays.

Age Factors↗
PubMed2001

Dental caries and dental health behavior of patients with primary Sjögren syndrome.

This comprehensive study was carried out to describe and analyze the oral health status, perceived oral health problems, patients' costs, and oral health behavior in a group of patients with primary Sjögren syndrome (PSS). In particular, the objective of this report was to assess whether Sjögren syndrome patients had more dental caries experience than a control group. Data were collected by means of interviews and clinical oral examinations. The study comprised 53 patients with PSS and a control group of 53 persons matched by age. Among the younger patients the number of decayed, missing, or filled teeth (DMFT) was 22.3, compared with 18.8 among controls (P< 0.05). In parallel, the DMFT in the old-age PSS patients was 26.2, against a DMFT of 22.1 for controls (P< 0.001). On average, the young patients had seven teeth missing, whereas two missing teeth were found among controls (P < 0.01). PSS patients had more frequent dental visits--every 3-4 months (40%)--than controls (19%). In parallel, 78% of the PSS patients brushed their teeth more than twice daily, compared with 28% of the control group. The PSS patient group reported having had more teeth extracted, more trouble with their teeth during lifetime, and higher expenses for dental treatment than controls. In spite of the more regular oral health care practices than the general population, PSS patients had experienced more dental caries and more radical dental treatment. It is suggested that the National Health Insurance should give emphasis to preventive care to patients with PSS.

Adult↗
PubMed1999

'In an important way, I did die': uncertainty and revival in persons living with HIV or AIDS.

This study reports the revival experiences of persons who once were reconciled to their death from HIV/AIDS but who, as a result of dramatic treatment responses, now believe they may survive (popularly known as the Lazarus Syndrome). A purposive sample of men and women living with HIV infection or AIDS were interviewed in six focus groups. As part of a larger study of uncertainty in HIV illness, participants described their uncertainty accompanying renewed health and a return to the joys and problems of continued life. While new discoveries about the disease and exciting antiretroviral therapies hold the promise of improved survival, ambiguity about the durability of treatment response and ultimate survival contribute to the level of uncertainty with which a patient must cope. The experience of uncertainty in the narratives about revival involved renegotiation. Participants described physical renewal as an unexpected new stressor forcing them to renegotiate: (a) feelings of hope and future orientation, (b) social roles and identities, (c) interpersonal relations, and (d) the quality of their lives. Implications for prevention, practice, research and theory are presented and suggestions for education and assistance are offered.

Acquired Immunodeficiency Syndrome↗