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Inequalities in child mortality in Mozambique: differentials by parental socio-economic position.

This study investigates the relation between socio-economic parental position (education and occupation) and child death in Mozambique using data from the Mozambican Demographic and Health Survey carried out between March and July 1997. The analysis included 9142 children born within 10 years before the survey. In spite of the Western system of classification used in the study, the results partly showed a parental socio-economic gradient of infant and child mortality in Mozambique. Father's education seemed to reflect the family's social standing in the Mozambique context, showing a strong statistical association with postneonatal and child mortality. However, maternal education as a measure of socio-economic position was not statistically significantly associated with child mortality. This finding may partly be explained by the extreme hardships experienced by the country (civil war and natural disasters) and the implementation of the Economic Structural Adjustment Programme that have also affected the health of women and their children during the years covered by this study. Other measures of socio-economic position applicable to the rural African setting should be investigated.

Adolescent↗

Making economic evaluations respectable.

Policy-makers worldwide are on a quest to control national spending for health care and to enhance the value received for whatever is being spent on health care. One should think that the economic evaluation of clinical practice would play a major role in this quest. Alas, so far it has not, in spite of considerable progress in the development of suitable methodology for such evaluations. The central point of this paper is that the sheer conceptual and practical complexities of economic evaluations in this context are not the only and possibly not the major barrier to a more widespread use of this type of analysis. Just as important may be the suspicion among lay persons that such analyses are easily driven by the assumptions the analyst packages into the analysis which, in turn, opens economic evaluation to hidden bias toward favored results. It is proposed in this paper that this particular barrier to the use of economic evaluations in health policy could be overcome if these analyses were more routinely subjected to the rigorous and penetrating audits that are customary in financial accounting. Typically, research papers in economics are audited through peer review only as to the methodology employed. The suggestions here is that a proper, respectable audit ought to penetrate all the way to the data that were used to produce the findings in a study. The paper concludes with some suggestions on how to develop such an audit infrastructure.

Cost Control↗

Quality of sleep during economic recession in Finland: a longitudinal cohort study.

To assess the association between the economic recession of the 1990s in Finland and sleep behaviour, a longitudinal study was conducted in an adult Finnish population cohort. Baseline data were obtained by means of reports on sleep behaviour, health-related behaviour, health status, and objective laboratory tests in 1983-1987. The second screening conducted in 1992-1995, i.e. during economic recession, repeated data collection by postal questionnaires. The prevalences of various sleep symptoms including insomnia, daytime tiredness, fatigue, parasomnias and the use of hypnotics remained similar in the same age cohorts during economic recession. Alcohol consumption and snoring increased among the middle-aged (30-49 years), though snoring shows the greatest individual stability among various sleep symptoms. Despite some baseline differences in the sleep/health behaviour frequencies, the changes were independent of gender and socioeconomic class. The prevalences over eight years of insomnia and snoring show fair chronicity, whereas daytime tiredness and fatigue seem to be less chronic. Middle-aged participants who were stably employed at the initial screening but became unemployed during economic recession were studied separately. Prospectively unemployed persons suffered more from insomnia and used more hypnotics than the continuously employed. We conclude that the sleep quality of the general Finnish population has not drastically deteriorated during severe economic recession except among unemployed blue-collar workers.

Adult↗

Economic impact of angioplasty salvage techniques, with an emphasis on coronary stents: a method incorporating costs, revenues, clinical effectiveness and payer mix.

OBJECTIVES: We sought to broaden assessment of the economic impact of percutaneous transluminal coronary angioplasty (PTCA) revascularization salvage strategies by taking into account costs, revenues, the off-setting effects of prevented clinical complications and the effects of payer mix. BACKGROUND: Previous economic analyses of PTCA have focused on the direct costs of treatment but have not accounted either for associated revenues or for the ability of costly salvage techniques such as coronary stenting to reduce even costlier complications. METHODS: Procedural costs, revenues and contribution margins (i.e., "profit") were measured for 765 consecutive PTCA cases to assess the economic impact of salvage techniques (prolonged heparin administration, thrombolysis, intracoronary stenting or use of perfusion balloon catheters) and clinical complications (myocardial infarction, coronary artery bypass graft surgery [CABG] or acute vessel closure with repeat PTCA). To assess the economic impact of various salvage techniques for failed PTCA, we used actual 1995 financial data as well as models of various mixes of fee-for-service, diagnosis-related group (DRG) and capitated payers. RESULTS: Under fee-for-service arrangements, most salvage techniques were profitable for the hospital. Stents were profitable at almost any level of clinical effectiveness. Under DRG-based systems, most salvage techniques such as stenting produced a financial loss to the hospital because one complication (CABG) remained profitable. Under capitated arrangements, stenting and other salvage modalities were profitable only if they were clinically effective in preventing complications in > 50% of cases in which they were used. CONCLUSIONS: The economic impact of PTCA salvage techniques depends on their clinical effectiveness, costs and revenues. In reimbursement systems dominated by DRG payers, salvage techniques are not rewarded, whereas complications are. Under capitated systems, the level of clinical effectiveness needed to achieve cost savings is probably not achievable in current practice. Further studies are needed to define equitable reimbursement schedules that will promote clinically effective practice.

Angioplasty, Balloon, Coronary↗

Grazing management as it affects nutrition, animal production and economics of beef production.

Until recently, the nutritional fate of the grazing animal has been largely ignored by both animal and range scientists despite the economic dependence of the extensive livestock industry on nutrition from grass. Of the three factors that can be manipulated to improve profit gross margin per animal, is one that is directly affected by nutrition and, hence, grazing management. The relationship between economics and grazing management may be summarized as: Gross margin = f(Animal Performance); Animal Performance = f(nutrition); Nutrition = f(grazing). Economical beef production must consider the needs of the animal and the forage plant at the same time. The health of the sward must be maintained while improving individual animal performance and simultaneously increasing stocking rate. Generally, plants that have been defoliated require a period of recovery before again being grazed. A sward is kept in a vigorous state by preventing repetitive defoliation at the one extreme, and avoiding excessive shading (mature growth) of photosynthetic material at the other. This state is best achieved where livestock grazing is controlled. For any individual paddock, periods of grazing are followed by periods that allow adequate physiologic recovery of the plants. A grazing regimen that keeps the plant in a healthy state is fortuitously also well suited to the nutritional requirements of the animal. Animals on overgrazed pastures are likely to suffer from inadequate feed intake because of deficiencies in feed quantity. Conversely, on over-rested pastures, intake deficiency results from paucity in feed quality. On most unmanaged ranges, overgrazed and over-rested plants are likely to be found side by side. By controlling duration of the rest period as well as duration of the grazing period through pasture subdivision, requirements of both the plant and the animal can be met. With artificially high economic demands placed on animal production, some form of supplementation is required in most modern livestock situations. Whereas energy is frequently the nutrient limiting production it is seldom economically feasible to supplement the grazing animal directly with energy. Protein supplementation to increase forage intake, and thus indirectly energy intake, has become standard practice in many grazing situations. When there is adequate forage with a low crude protein content (less than or equal to 7%), microbially degradable protein is the preferred choice. However, when the animals are in an energy deficient state, either through a shortage of available forage or because their requirements exceed energy intake levels, by-pass protein is required.

Animal Feed↗

Influence of heavy traffic, city dwelling and socio-economic status on nasal symptoms assessed in a postal population survey.

BACKGROUND: The association between social position, living environment and nasal symptoms is inconsistent. We wanted to test how living environment, occupation and social position were associated with nasal symptoms. METHODS: In a postal survey study of a random sample of 12,079 adults, aged 20-59 years living in the southern part of Sweden the relationship between nasal symptoms, socio-economic status and environmental factors was analysed. RESULTS: The response rate was 70% (n = 8469) of whom 33% reported significant nasal symptoms. Nasal discharge, thick yellow discharge, a blocked nose, sneezing and itching were strongly associated with living close to heavy traffic or living in cities. Most of the nasal symptoms provoked by extrinsic factors were more frequently reported among subjects who lived close to heavy traffic and in cities. Apart from thick yellow discharge and nasal symptoms provoked by damp/cold air which were more common in the socio-economic position "low" no relation to the socio-economic group was found. The prevalence of self-reported hay fever was neither affected by site of living nor by socio-economic status. Nasal symptoms evoked by "allergic" factors were linked to asthma but symptoms evoked by non-allergic factors were linked to chronic bronchitis/emphysema CBE. CONCLUSIONS: To conclude, we found a strong relation between geographical site and the prevalence of self-reported nasal symptoms which emphasizes the environment as a risk factor for nasal symptoms. Only by merging the socio-economic groups into "low" and "middle/high" an association to nasal symptoms was apparent. Nasal symptoms evoked by "allergic" factors were linked to asthma but symptoms evoked by "non allergic factors" were linked to CBE.

Adult↗

Health Economics Unit achievements.

This article describes the activities of the EORTC Health Economics Unit since its inception in early 1994. The aim of the unit is to carry out economic evaluations of competing treatment options in common cancers in order to provide health care decision makers with useful information about the relative benefits and costs of the therapies they have to choose between. These assessments are mainly carried out by integrating collection of economic data in selected phase III randomized controlled clinical trials conducted by the EORTC collaborative groups. Studies with an economic evaluation integrated are currently becoming mature enough for analysis and several publications have resulted or are in press. Some studies with data from other sources than EORTC trials have also been performed and published. In addition, the unit has actively followed and contributed to the continuous methodological development in the field of economic evaluation of health care interventions.

Clinical Trials, Phase III as Topic↗

Methodological and statistical issues of quality of life (QoL) and economic evaluation in cancer clinical trials: report of a workshop.

In recent years, quality of life (QoL) and economic evaluations have become increasingly important as additional outcome measures in cancer clinical trials. However, both fields of research are relatively new and in need of finding solutions to a substantial number of specific methodological problems. This paper reports on the proceedings of a symposium aimed at summarising and discussing some of the most contentious methodological and statistical issues in QoL and economic evaluations. In addition, possible solutions are indicated and the most pertinent areas of research are identified. Issues specific to QoL evaluations that are addressed include clinically meaningful changes in QoL scores; how to analyse QoL data and to handle missing and censored data and integration of length of life and QoL outcomes. Issues specific to economic evaluations are the advantages and disadvantages of various outcome measures; statistical methods to analyse economic data and choice of decision criteria and analytical perspective. How to perform QoL and economic evaluations in large and simple trials and whether the gap between QoL and utility measures can be bridged are also discussed.

Clinical Trials as Topic↗

Economic impact of reduced milk production associated with Johne's disease on dairy operations in the USA.

Accurately assessing the economic impacts of diseases and other factors that affect milk production requires that the demand for milk be taken into account. Because demand for milk in the USA is relatively inelastic (i.e., consumers generally purchase a somewhat fixed amount over a given time frame, regardless of fluctuations in price), consumers tend to reap much of the benefit of enhanced production. An examination of the economic impacts of Johne's disease indicated that reduced milk production, associated with the determination of dairy operations as Johne's-positive, reduced consumer surplus by 770 million dollars+/- 690 million dollars, and resulted in a total loss of 200 million dollars+/- 160 million dollars to the US economy in 1996. Most of the economic surplus lost by consumers was transferred to producers, whose economic surplus increased by 570 million dollars+/- 550 million dollars as a result of the reduced milk production associated with Johne's disease. Uncertainty analysis showed that the estimated reduction in milk production on Johne's-positive dairy operations accounted for most of the uncertainty in the economic-impact estimates. If Johne's disease had not been present on US dairy operations, then an additional 580 million+/-460 million kg of milk would have been produced, but the price would have fallen by 1.1+/-1.0 cents/kg, and the total value of the milk would have decreased by 580 million dollars+/- 560 million dollars.

Animals↗

The association between suicide and the socio-economic characteristics of geographical areas: a systematic review.

BACKGROUND: Despite an extensive literature, there have been widely divergent findings regarding the direction of the association between area socio-economic characteristics and area suicide rates, with high-quality studies finding either a direct relation (higher rates of suicide in higher socio-economic areas), an inverse relation (lower rates of suicide in higher socio-economic areas) or no association. METHOD: We performed a systematic review of the literature dating from 1897 to 2004 and identified 86 publications with 221 separate analyses that met our inclusion criteria. We examined the percent of direct, inverse and null findings stratified by key study characteristics including size of aggregated area, socio-economic measure used, region of study, control variables and study design. RESULTS: Analyses at the community level are significantly more likely to demonstrate lower rates of suicide among higher socio-economic areas than studies using larger areas of aggregation. Measures of area poverty and deprivation are most likely to be inversely associated with suicide rates and median income is least likely to be inversely associated with suicide rates. Analyses using measures of unemployment and education and occupation were equally likely to demonstrate inverse associations. Study results did not vary significantly by gender or by study design. CONCLUSIONS: The heterogeneity of associations is mostly accounted for by study design features that have largely been neglected in this literature. Enhanced attention to size of region and measurement strategies provide a clearer picture of how suicide rates vary by region. Resources for suicide prevention should be targeted to high poverty/deprivation and high unemployment areas.

Educational Status↗

Standardizing methodologies for economic evaluation in health care. Practice, problems, and potential.

There has been an exponential growth in the literature on economic evaluation in health care. As the range and quality of analytical work has improved, economic studies are becoming more influential with health care decision makers. The development of standards for economic evaluation methods would help maintain the scientific quality of studies, facilitate the comparison of economic evaluation results for different health care interventions, and assist in the interpretation of results from setting to setting. However, standardization might unnecessarily stifle methodological developments. This paper reviews the arguments for and against standardization, assesses attempts to date, outlines the main areas of agreement and disagreement on methods for economic evaluation, and makes recommendations for further work.

Evaluation Studies as Topic↗

Hemophilia home treatment. Economic analysis and implications for health policy.

This analysis describes the development of technology for home self-infusion of factor VII in the treatment of hemophilia and its clinical, economic, and social consequences, and uses the case study of such home care treatment to illustrate the potentials and pitfalls of formal economic analyses of programs to treat chronically ill children. A comprehensive review of all original data on hemophilia programs, their related costs, and outcomes, conducted from 1966 through 1993, examined the economic outcomes for two hypothetical cohorts, one aged 0-4 years and the other aged 30-34 years. Including the measurement of treatment effects on the productivity of parental caregivers substantially increases the benefit-cost relationship of an intervention directed at chronically ill children. Increased economic productivity and societal return resulting from such a program for young adults exceeds those for a cohort of children, primarily due to assumptions related to discounting. However, estimation of quality-adjusted life years favors the younger age cohort, since children survive for a longer period of time and with each year survived comes a higher quality of life. Unlike simpler instances in which economic benefits can be shown to outweigh resource costs, policy decisions concerning services for chronically ill children raise an additional set of complex analytic issues. Inclusion of the benefits in productivity experienced by family caregivers provides an important added dimension to such analyses. The development of cost-benefit or cost-effectiveness analyses of these programs illustrates the importance of careful measurement of outcomes and explicit statements of underlying assumptions. Such an analysis of home care for children with hemophilia therefore demonstrates both the strengths and the limitations of this approach.

Adult↗

Trials and tribulations. Emerging issues in designing economic evaluations alongside clinical trials.

Decisions relating to designing and implementing economic evaluations alongside clinical trials are dependent on a number of issues initial consideration should focus on whether an economic evaluation is appropriate, whether a randomized controlled trial (RCT) is a suitable vehicle, and whether the design of the specific RCT is appropriate for integration of economic evaluation. If an economic evaluation is appropriate, decisions are required on how economic data are to be collected and analyzed. This paper discusses these and other issues and, where appropriate, provides recommendations for future studies.

Costs and Cost Analysis↗

Assessing the economics of vaccination for Neisseria meningitidis in industrialized nations: a review and recommendations for further research.

OBJECTIVES: To review the existing health economic literature on meningococcal disease vaccination. METHODS: A Medline search for economic evaluations of vaccination programs for meningococcal disease in developed countries was conducted. All identified studies were reviewed. RESULTS: Nine published studies were identified examining either mass vaccination during outbreaks or routine vaccination. Although net expenses were estimated in almost all studies, the resulting cost-effectiveness ratios varied widely. Vaccination of college-age students was found to be potentially cost-effective in Australia but not in the United States. With one exception, routine vaccination of children and adolescents in Europe was predicted to be cost-effective. Many simplifying assumptions were made, and important elements were often left out, in particular the potential for reduced transmission of disease. CONCLUSIONS: The methods used and the vaccination strategies vary widely, and results do not provide strong grounds for making conclusions as to whether vaccination is cost-effective. Furthermore, in all instances, transmission of disease, changes in population carriage rates, and outbreaks are either ignored, dealt with using very broad simplifying assumptions, or are not necessarily generalizable to other settings. The analyses provide some insight into the potential cost-effectiveness of vaccination, but more importantly, they highlight areas requiring further study. Economic evaluations based on observed outcomes from recently implemented strategies would be helpful, as would more sophisticated health economic models. The choice of vaccination strategies cannot be based on the results of existing economic analyses.

Developed Countries↗

School-aged children's vulnerability to depressive symptomatology: the role of attachment security, maternal depressive symptomatology, and economic risk.

The influences of three risk factors (insecure attachment, maternal depressive symptoms, and economic risk) on children's depressive symptomatology were examined. Subjects were 85 children from a range of income levels; all subjects were between 7 and 9 years of age. Children's depressive symptomatology was assessed with the Dimensions of Depression Profile for Children and Adolescents. Results indicated that children at high economic risk were more likely to exhibit depressive symptomatology than were children at low economic risk. Security of attachment was significantly related to children's depressive symptomatology. In addition, a significant relation was noted between children's depressive symptomatology and the depressive symptomatology of their mothers. Contrary to expectations, no significant relation was found between maternal depressive symptomatology and security of attachment. A multiple regression analysis revealed that security of attachment, maternal depressive symptomatology, and economic risk accounted for 47% of the variability in children's depression scores. Secure attachment served as a buffer; economic risk was associated with depressive symptoms only among insecurely attached children.

Child↗

Economic crisis and malnutrition: socioeconomic determinants of anthropometric status of preschool children and their mothers in an African urban area.

OBJECTIVE: To assess the relative importance of socioeconomic and maternal/prenatal determinants of the nutritional situation of children < 6 years old in an urban African area after several years of economic crisis. DESIGN: Cross-sectional cluster sample survey. SETTING: Brazzaville, capital city of the Congo. SUBJECTS: Information on socioeconomic characteristics was gathered from a random sample of 1368 households by house visits and anthropometric measurements were performed using standardized procedures on preschool children (n = 2373) and their mothers (n = 1512). RESULTS: The influence of socioeconomic factors on the nutritional status of children, taking into account adjustment variables such as mother's age and child's age and sex was assessed. For stunting, as well as for the mean height-for-age index among children, the main determinants were economic level of the household (P = 0.048 and P = 0.004, respectively), schooling of the mother (P = 0.004 and P < 10(-3)) and living in the peripheral district (P = 0.005 and P < 10(-3)). The influence of socioeconomic determinants on weight-for-age and wasting was less straightforward. When adjusting, in addition, for maternal and prenatal factors (mother's height and body mass index (BMI) and birth weight), most of the effects of the socioeconomic determinants on the nutritional status of children persisted somewhat, but the effect of the economic level on the stunting became not significant (P = 0.11). The mean BMI of mothers appeared to be related to the economic level of the household (P < 10(-4)), to the marital status (P = 0.01) and to the occupation of the mother (P < 10(-4)). CONCLUSIONS: Among the socioeconomic determinants of malnutrition in children, some, such as economic level of the household or schooling of the mother, seem to act mainly through prenatal factors, whereas others, mainly dwelling district characteristics, seem to influence more directly the children's nutritional status.

Adult↗

A comparative economic analysis of smallholder cattle and small ruminant production systems in Botswana.

Cattle rearing is the single most important activity in the agricultural sector of Botswana, and cattle enjoy a high status among both rural and urban dwellers. In recent years, farmers have begun to intensify the production of small ruminants owing to an increasing recognition by policy makers that they are a potential alternative source of farm income. However, as yet, small ruminants have not approached the social importance of cattle. This may be attributable to several factors, including economic considerations. The present study focused on the economic factor. It comprised a comparative economic assessment of cattle- and goat-rearing enterprises for an average smallholder farm-household to throw light on their relative economic efficiency. It was concluded that rearing either cattle or small ruminants is economically viable in the study area. The net profit measured as the net margin either per enterprise or per animal was far higher for a cattle-rearing enterprise. Nevertheless, when expressed in terms of the return on the capital invested in each enterprise, cattle rearing had only a slight edge (1.93%) over rearing of small ruminants.

Animal Husbandry↗

Influence of socio-economic crisis on epidemiological characteristic of suicide in the region of Nis (southeastern part of Serbia, Yugoslavia).

It is well known that gross social crises greatly influence the change in epidemiological features of suicide. The aim of this study is to determine whether the social-economic crisis in Yugoslavia influenced the change in epidemiological features of suicide in the region of Nis (southeastern Serbia). The material included death certificates for 1987-1999. The rates were calculated per 100,000 inhabitants (1991 Census) and standardization was performed by direct method (Segi's world population was used as standard population). Generally, trends for suicide rates in the region of Nis from 1987 to 1999 have decreasing tendency among both sexes. The average annual suicide rate in the region during the period 1987/1989 (relatively economically and politically stable) was 14.8 among males, and 6.8 among females. In 1999 (maximum influence of socio-economical and political crisis) suicide rate among males was 13.8 and among females it was 3.7. The decrease in suicide rate in females can be observed in all age groups, and in males in the age groups 15-29 and 50-64. During 1999, compared to 1987/1989, the increase in the number of suicides is perceived in the summer months (1999 -41.5%; 95% CI: 30.8-52.2%; 1987/ 1989 -23.8%; 95% CI: 18.9-28.7%), as well as the decrease of suicide on Monday (1987/1989 -21.2%; 95% CI: 16.2-26.1%; 1999 -9.8%; 95% CI: 3.4 16.2%). During 1999 the rate of suicides committed by fire arms increased (from 8.1 to 14.5%), while there was a decrease in poisoning, in both males (from 26.3 to 9.7%; p < 0.05) and females (from 39.1 to 10.0%; p < 0.05). During 1999 significant changes in epidemiological features of suicide were registered, compared to 1987/1989. These changes were probably enhanced by changed socio-economic factors (primarily war action and the bombing of Serbia, as well as the decline of standard of living and other aspects of economic and political crisis), which requires additional, more complete and thorough research.

Adolescent↗