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PubMed2005

Do divergences between stated and actual willingness to pay signify the existence of bias in contingent valuation surveys?

This study's objective is to determine the factors that cause divergences over time (differences) between stated willingness to pay (WTP) and actual WTP (purchase behaviour), and consider whether any divergence signifies the presence of bias in contingent valuation studies. Stated WTP for insecticide-treated bed-nets (ITNs) was elicited from a random sample of respondents using three question formats in Nigeria. The question formats were the bidding game (BG), binary with follow-up (BWFU) and a novel structured haggling (SH) technique. The sales of the nets and a second survey were conducted 1 month after the first survey. In the second survey, factors that might explain the divergences were built into the questionnaire and these together with socio-economic variables were examined for causes of divergences in WTP. Data were analysed using non-parametric tests, testing of means and cross-tabulations. There were divergences in WTP in all three question formats: 69.4% in the BG, 78.7% in the BWFU and 48.8% in the SH. The higher the stated WTP, the more likely the divergence between stated and actual WTP. The attitude of the community leaders to the ITNs in the BG (p<0.05), the time respondents had to think about their WTP (p<0.05) and the external information they received about the ITNs in the BWFU (p<0.05) all led to divergences in WTP. We conclude that there are genuine causes of divergences between stated and actual WTP across the three question formats, and that the lesser the criterion validity score, the more the level of divergence in WTP. Studies that compare stated and actual WTP should explicitly determine the causes of divergences in order to assess the role of bias in the divergences.

Bedding and Linens↗
PubMed2005

Fee-for-service or donation? Hungarian perspectives on informal payment for health care.

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious with the debate characterized by much polemic. This paper aims to make sense of this debate by reviewing and summarizing the main arguments of the theoretical debate in Hungary. The review examines the possible causes of informal payment, the motivation of the actors involved and the impact of informal payment on system performance, focusing on efficiency and equity. The lines of arguments are summarized in two contrasting hypotheses, which envisage informal payment as either a donation or a fee-for-service. Evidence pertaining to the scale of informal payments and the motivation of patients are reviewed, but found to be inconclusive to verify the hypotheses. Although focused on Hungary, accounts from other countries facing informal payments show similar threads of discussion and dilemmas. These theories should be tested further using evidence from existing studies and new empirical research, since the validity of the gratitude payment concept is a central dilemma of effective policy making in the area. To orient future research, a possible agenda is outlined, which links evidence to be obtained to the defining features of gratitude payments.

Coercion↗
PubMed2005

Comparison or consumption? Distinguishing between different effects of income on health in Nordic welfare states.

In the relation between income and health it has been suggested that individual level mechanisms are related either to absolute or to relative income. Both absolute income level and the individual's own income in relation to that of others are likely to affect health, but to distinguish between these effects in analyses has been difficult. The aim of this study is to distinguish between the effect on health of one's own position in the income distribution and the effect on health of the individual's ability to consume. Combining data from Sweden, Finland and Norway provides a setting where individuals with the same absolute income level may occupy different positions within their national income distribution. The data come from Swedish, Finnish and Norwegian surveys of living conditions from the mid 1990s. Both the position in the income distribution and the ability to consume is measured by household disposable equivalent income. In order to eliminate differences in price levels, household income is adjusted for purchasing power parities. The outcome measure used is limiting long-standing illness. There was a clear income gradient in health over the individual's relative position in their national income distribution. Stratifying for groups of household income adjusted for purchasing power parities, we still find a significant effect of the individual's relative position. In Nordic welfare states the relative position in the income distribution is related to limiting long-standing illness independently of the ability to consume among individuals with high ability to consume.

Female↗
PubMed2005

A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures.

Prescription medications enhance the well-being of most chronically ill patients. Many individuals, however, struggle with how to pay for their treatments and as a result experience problems with self-care and health maintenance. Although studies have documented that high out-of-pocket costs are associated with medication non-adherence, little research on prescription cost sharing has been theoretically grounded in knowledge of the more general determinants of patients' self-management behaviors and chronic disease outcomes. We present a conceptual framework for understanding the influence of patient, medication, clinician, and health system factors on individuals' responses to medication costs. We review what is known about how these factors influence medication adherence, identify possible strategies through which clinicians, health systems, and policy-makers may assist patients burdened by their medication costs, and highlight areas in need of further research. Although medication costs represent a burden to chronically ill patients worldwide, most patients report using their medication as prescribed despite the costs, and others report cost-related underuse despite an apparent ability to afford those treatments. The cost-adherence relationship is modified by contextual factors, including patients' characteristics (e.g., age, ethnicity, and attitudes toward medications), the type of medications they are using (e.g., the complexity of dosing and the drug's clinical target), clinician factors (e.g., choice of first-line agent and communication about medication costs), and health system factors (e.g., efforts to influence clinicians' prescribing and to help patients apply for financial assistance programs). Understanding these relationships will enable clinicians and policy-makers to better design pharmacy benefits and assist patients in taking their medication as prescribed. The next generation of studies examining the consequences of prescription drug costs should expand our knowledge of the ways in which these co-factors influence patients' responses to medication cost pressures.

Chronic Disease↗
PubMed2005

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.

Cost of Illness↗
PubMed2005

Informal payments in government health facilities in Albania: results of a qualitative study.

As governments seek to expand access to quality health care services, policy makers in many countries are confronting the problem of informal payments to medical personnel. The aim of this study was to help health planners in Albania understand informal payments occurring in government health facilities. Researchers used in-depth interviews and focus groups with 131 general public and provider informants in three districts. The results suggest that factors promoting informal payments in Albania include perceived low salaries of health staff; a belief that good health is worth any price; the desire to get better service; the fear of being denied treatment; and the tradition of giving a gift to express gratitude. Members of the general public also believe informal payments create uncertainties and anxiety during the care-seeking process, while providers perceive that informal payments harm their professional reputation, induce unnecessary medical interventions, and create discontinuity of care. The study showed that focusing on the most harmful effects and targeting the most vulnerable populations may be one way to gain consensus for policy reform. Understanding citizens' and caregivers' viewpoints is an important step in designing regulatory and bureaucratic interventions.

Albania↗
PubMed2006

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.

Financing, Personal↗
PubMed2006

Using focus groups to develop contingent valuation scenarios--a case study of women's groups in rural Nepal.

The construction of a contingent valuation (CV) scenario forms a critical component of willingness-to-pay (WTP) survey design, especially when working across diverse cultural and socio-economic settings. However, the methods used to develop CV scenarios have not been well reported in the health economics literature. This paper begins by describing how qualitative methods can be used to develop CV surveys. It then presents a case study illustrating how focus groups were used to develop a CV survey to value a women's group intervention in rural Nepal. A series of focus group discussions were conducted with three stakeholder groups. These were used to determine the most appropriate description of the good to be valued and the means by which payment would be elicited. These methods were very helpful in designing the survey tool and choosing the key attributes to describe the intervention. They also familiarised field workers with the concept of WTP. Further work of this kind will help to highlight additional advantages and limitations of qualitative approaches to survey design.

Data Collection↗
PubMed1987

Money management. Steps to financial independence.

Lack of knowledge about money leads to the seven money mistakes. To become financially independent, one must become educated about money, avoid those mistakes, and pay yourself first. This formula is simple. Some people insist that it is too simple to work and will ignore it. Those people will probably be no better off in the future than they are today. However, those who follow it can make their financial future secure.

Economics, Nursing↗
PubMed2004

Willingness-to-pay for reducing fatal accident risk in urban areas: an Internet-based Web page stated preference survey.

Contemporary transport project evaluation requires the ability to value reductions in the number of estimated fatal and non-fatal accidents after project implementation. In this quest, we designed a stated preference (SP) experiment to estimate willingness-to-pay (WTP) for reducing fatal accident risk in urban areas. The survey was implemented in a Web page allowing rapid turnover and a complete customisation of the interview. The sample was presented with a series of route choice situations based on travel time, cost and number of car fatal accidents per year. With this data we estimated Multinomial Logit (MNL) and Mixed Logit (ML) models based on a consistent microeconomic framework; the former with linear and non-linear utility specifications and allowing for various stratifications of the data. The more flexible ML models also allow to treat the repeated observations problem common to SP data and, as expected, gave a better fit to the data in all cases. Based on these models, we estimated subjective values of time, that were consistent with previous values obtained in the country, and also sensible values for the WTP for reductions in fatal accident risk. Thus, the Internet appears as a potentially very interesting medium to carry out complex stated choice surveys.

Accidents, Traffic↗
PubMed1987

Stress in residency: proposals for solution.

Current problems leading to excessive stress in residency are presented and are compared with those of a generation ago. Solutions are proposed that can be summarized as follows: (1) commitment by the program director and chairman to resolving stress in residency and (2) flexibility by the American Board of Obstetrics and Gynecology and the Residency Review Committee. A general discussion is presented.

Adaptation, Psychological↗
PubMed2000

A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites.

BACKGROUND: Interest in complementary therapies in the United States is rising. We sought to characterize the use of complementary therapies among our cancer patients in our community and analyze differences in use between patients with breast versus those with other primary tumor sites. METHODS: A survey of 1,935 randomly selected patients from the tumor registry was performed. A questionnaire was mailed to 935 breast cancer patients and 1,000 patients with other primary site diagnoses. RESULTS: There were 617 responses (288 breast, 329 other). Seventy-five patients (75%) reported use of a complementary modality. Top therapies used were nutrition (63%), massage (53%), and healing herbs (44%). The most common reason for use, immune modulation (73%), was similar in both groups. Therapy was used consistently by 84% of breast patients versus 66% of others (P = 0.003). CONCLUSION: A significant number of cancer patients are using complementary therapies. Breast cancer patients are far more likely to be consistent users compared with other tumor sites.

Adolescent↗
PubMed1995

Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations.

OBJECTIVE: To determine, from the societal perspective, the most cost efficient of the three methods commonly used to repair pediatric facial lacerations: nondissolving sutures, dissolving sutures, or a tissue adhesive (Histoacryl blue). DESIGN: Cost-minimization analysis and willingness-to-pay survey. SETTING: Tertiary-care pediatric emergency department. METHODS: All differential costs relevant to equipment utilization, pharmaceutical use, health care worker time, and parental loss of income for follow-up visits were calculated for each method. On the basis of previous research, our model assumes equal cosmetic outcome for the three methods. In addition, a convenience sample of 30 parents were surveyed in the emergency department to rank their preferences and willingness to pay for the three methods of wound closure. RESULTS: The reduction in cost (in Canadian dollars) per patient of switching from the standard nondissolving sutures was $49.60 for switching to tissue adhesive and $37.90 for dissolving sutures. Sensitivity analyses performed on key variables did not significantly alter our conclusions. Of those parents surveyed; 90% (95% confidence interval, 74% to 98%) chose tissue adhesive and 10% (95% confidence interval, 2% to 26%) chose dissolving sutures as their first choice for wound closure. Nondissolving sutures were ranked third by 29 of 30 parents. Parents were willing to pay a median (25th to 75th percentile) of $40 ($25 to $100) for tissue adhesive and $25 ($10 to $56) for dissolving sutures if only nondissolving sutures provided by the health care system (p = 0.1). CONCLUSIONS: Tissue adhesive is the preferred method of closure of pediatric facial lacerations because it results in the most efficient use of resources and is preferred by the majority of parents.

Adolescent↗
PubMed2003

Use of complementary therapy among internal medical inpatients. Prevalence, costs and association with mental disorders and physical diseases.

OBJECTIVES: The aims of this study were to determine the prevalence of complementary therapy/medicine (CT) use among internal medical inpatients. Furthermore, to examine the association between the use of CT and (a) mental disorders, (b) physical diseases, and (c) use of health care. METHODS: A total of 294 consecutive medical inpatients were interviewed about their use of CT. A stratified subsample of 157 people was assessed for current mental disorders, using an extensive, standardized, semistructured interview (Schedules for Clinical Assessment in Neuropsychiatry version 2.1 [SCAN]). Health care use was assessed by use of national patient registers. RESULTS: There were 22.5% CT utilizers. More females than males used CT (P=.033). CT utilization was not associated with age, mental disorders, life-threatening or chronic physical diseases or with use of health care services. CONCLUSIONS: The use of CT is common among medical inpatients. More research is needed to understand why a significant proportion of patients seeks CT.

Adolescent↗
PubMed1997

A study of suicide in farmers in England and Wales.

The proportional mortality ratio for suicide is higher in farmers than in the general population. The reasons for this are likely to be complex, but may include easy availability of firearms, stress related to work, financial difficulties, and family problems. A psychological autopsy study of suicide in 84 farmers who died between 1991-1994 is presented and some preliminary findings are discussed.

Adolescent↗
PubMed1999

Hearing aids.

The first step in the hearing aid fitting and selection process is to determine the patient's hearing disability, motivation, lifestyle, finances, and cosmetic concerns. Most hearing impairments can be helped with a modern hearing aid. With a symmetric hearing loss, a binaural fitting provides the most benefit and should be attempted initially. The binaural fitting may not be successful in cases with large asymmetries in auditory function. The advances in electronic technology, such as the digital hearing aid, are moving faster than the research to determine which is the most effective signal processing method. The near future should yield more significant improvements in hearing aids that will provide a better quality of life of the hearing-impaired population.

Attitude to Health↗
PubMed2002

Career transitions:planning for alternative futures.

Transition to retirement is a necessary step for all physicians because of the physical and emotional changes that occur with the aging process, the physician's ethical responsibilities to patients, and at times, because there is a desire to pursue different goals. It is important to begin to plan for this transition early in one's career so that some planning for postretirement vocation and avocation can be made and financial concerns can be addressed. A recent ACOG survey of 1000 Fellows ages 40-60 demonstrates that this planning is not occurring universally and the assistance of Fellows in preparation for this transition is now becoming an ACOG initiative.

Adaptation, Psychological↗