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PubMed2005

Informal payment for health care: evidence from Hungary.

While there is a growing body of evidence that informal payments for health care are widespread and enduring in the former communist countries of Central and Eastern Europe and Central Asia, evidence on the scale of the phenomenon is not only limited, but what is available is often conflicting. Hungary exemplifies this controversy, as the available literature provides conflicting figures, differing by an order of magnitude among various surveys, with a similarly large difference between survey findings and expert estimates. This study advances understanding of the methodological issues involved in researching informal payments by providing a systematic analysis of the methodology of available empirical research and official statistics on the scale of informal payments in Hungary. The paper explores the potential sources of differences, to assess the scope to reduce the differences between various estimates and to define the upper and lower boundaries within which the true magnitude of informal payments can be expected to lie. Our analysis suggests that in 2001 the overall magnitude of informal payments lay between 16.2 and 50.9 billion HUF (euro 64.8- euro 203.6 million, US dollars 77.1-242.4 million), which amounted to 1.5-4.6% of total health expenditures in Hungary. Looked at this way, informal payments do not seem to be an important source of health care financing. However, as informal payments are unequally distributed among health workers, with the bulk of the money going to physicians, with some not taking any informal payments, family doctors and some specialists may have earned between 60 and 236% of their net official income from this source in 2001. This suggests that it is not the overall amount of informal payment that makes it a policy concern, but the consequences of its unequal distribution among health workers. What is remarkable about informal payments in Hungary is that a relatively small amount of money can keep the system running, which gives rise to the hypothesis that, in certain cases, it is the hope of substantial informal payments in the future that motivates physicians to remain in the system. This is a difficult challenge for policy-makers as it would require a much larger amount of money to achieve equilibrium under any formal alternative.

Delivery of Health Care↗
PubMed1994

[[Aging of the population and social policy: lessons from Sweden]].

"In this paper I tried to show how the ageing of the population influences the change in the growth of employment, employment structure, the savings ratio, economic growth and the cost of social security [in Sweden]. In the latter part of the paper I suggested a close correlation between the average marriage age of women, the total fertility rate and the work participation ratio of women." (SUMMARY IN ENG)

Age Distribution↗
PubMed2006

The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines.

INTRODUCTION: The increase in obesity and disparities in obesity and related chronic diseases across racial and ethnic and income groups have led researchers to focus on the social and environmental factors that influence dietary intake. The question guiding the current study was whether all communities have equal access to foods that enable individuals to make healthy dietary choices. METHODS: We conducted audits of community supermarkets and fast food restaurants to assess location and availability of food choices that enable individuals to meet the dietary guidelines established by the U.S. Department of Agriculture (e.g., fruit and vegetable consumption, low-fat options). We used 2000 census data to assess the racial distribution and the percentage of individuals living below the federal poverty level in a defined area of St Louis, Mo. Spatial clustering of supermarkets and fast food restaurants was determined using a spatial scan statistic. RESULTS: The spatial distribution of fast food restaurants and supermarkets that provide options for meeting recommended dietary intake differed according to racial distribution and poverty rates. Mixed-race or white high-poverty areas and all African American areas (regardless of income) were less likely than predominantly white higher-income communities to have access to foods that enable individuals to make healthy choices. CONCLUSION: Without access to healthy food choices, individuals cannot make positive changes to their diets. If certain eating behaviors are required to reduce chronic disease and promote health, then some communities will continue to have disparities in critical health outcomes unless we increase access to healthy food.

Black or African American↗
PubMed1994

Age, socioeconomic status, and mortality at the aggregate level.

STUDY OBJECTIVE: Indicators of socioeconomic status are associated with age. This study aimed to analyse the influence of the age distribution on the ranking of small areas by socioeconomic status and on the association between their socioeconomic status and standardised mortality. DESIGN: The ranking of small areas by socioeconomic status indicators (educational level, income, and unemployment) was compared with crude values and after correction for their age structure. The age and gender standardised mortality ratios (SMRs) of these areas for the age group 1-64 years was then rank correlated with both crude and age standardised measures of socioeconomic status. SETTING: This study used data for all (n = 22) boroughs of Amsterdam for the period 1986-91. MAIN RESULTS: Correction of indicators of socioeconomic status for the age structure of the population hardly affects the ranking of Amsterdam boroughs by socioeconomic status. All rank correlations between crude and age standardised socioeconomic status measures are above 0.95. Rank correlations between SMR and these socioeconomic status measures also hardly change after correction for the age structure of boroughs except for education. Mean income per earner is the socioeconomic status indicator most strongly associated with the SMR. CONCLUSIONS: This study shows that the age structure of Amsterdam boroughs has almost no influence on their ranking by socioeconomic status and a limited influence on the association between their socioeconomic status and SMR, except for educational level. The latter indicator has the strongest association with age. This result and theoretical considerations indicate that a correction for the age structure of the population will be more important if small areas differ little with regard to socioeconomic status, if they vary considerably in age structure, or if a given indicator of socioeconomic status shows a strong cohort effect or age association.

Adolescent↗
PubMed1995

Health insurance coverage and use of services among low-income elders: does residence influence the relationship?

This research uses a nationally representative sample of 1,425 low-income elders from the 1987 National Medical Expenditure Survey (NMES) to assess the independent and interaction effects of health insurance coverage and residence on the use of seven health care services: doctor visits, visits to other personnel, telephone contact, emergency room visits, overnight hospital stays, outpatient visits, and prescription medicines. It is hypothesized that (a) elders without insurance to supplement Medicare; (b) those who lived in nonmetropolitan areas use fewer health services; and (c) insurance status and residence interact to influence use of health services, with nonmetropolitan elders using fewer services than those living in metropolitan areas, regardless of insurance type. Using multivariate statistical analyses with both main effects and interaction term models, the data indicate that the type of insurance that low-income elders have is associated with their use of health services, and that residence has only modest effect. Individuals who have Medicaid, and to a lesser extent private supplements, use services more frequently than do those without supplements. Finally, despite the hypothesis, residence does not interact with insurance status in influencing use of services; the relationship between insurance and use of services does not vary across area of residence. The data suggest that the ability to pay, rather than supply constraints associated with nonmetropolitan areas, are of primary importance in determining health care use among low-income elders.

Aged↗
PubMed2000

Cancrum oris (noma): Level of education and occupation of parents of affected children in Nigeria.

A total of 173 cancrum oris patients who were brought by their parents to the University College Hospital, Ibadan, Nigeria, were analyzed. Ninety-one (52.6%) were males and 82 (47.4%) females. Their ages ranged from 1.5 to 11 years with a mean of 4.36 (standard deviation 2.13) years. One hundred and twenty-one (69.9%) and 52 (30.1%) were from monogamous and polygamous family respectively. The average number of children per family was 7.0. The number of parents with no formal education was 148 (85.5%) and 98.3% were low-income earners. The relationships between occupation, income and educational status were highly significant. This study suggests that apart from poverty, large family units and low educational status of parents are contributing factors in the aetiology of cancrum oris.

Chi-Square Distribution↗
PubMed2001

The relationship of socio-demographic factors with iron deficiency anaemia in children of 1-2 years of age.

OBJECTIVE: To investigate associations between different socio-demographic factors with iron deficiency anaemia in Pakistani children of 1-2 years of age. METHODOLOGY: A case control study, with 50 cases and 100 controls, was conducted at the Community Health Centre, an outpatient clinic of the Aga Khan University, Karachi, Pakistan, between July 1993-July 1995. Informed consent was taken from mothers for their children's blood tests and a questionnaire was administered to them. The data was analyzed using chi-square, t-tests and logistic regression. RESULTS: The numbers of pregnancies, live births and living children were more among cases than controls but the differences were not statistically significant. Although father's education did not show a significant association (OR 1.35, 95% CI 0.22-8.33), maternal education was significantly associated with the children's anaemic status (OR 3.55, 95% CI 1.40-9.02). The difference in monthly incomes between families of cases and controls was the most significant variable among all those studied (p-value 0.006). CONCLUSION: This study showed that while lack of maternal education and low monthly family incomes are both significantly associated with the development of childhood anaemia, low monthly income is most significant.

Age Distribution↗
PubMed2002

Socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults: a population-based case-control study.

PURPOSE: To investigate the socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults. METHODS: Sixty-three patients 17 years or older with a newly diagnosed unprovoked epileptic seizure from 1985 through 1987 and 107 sex- and age- matched controls were followed up for 10 years to 1996. Studied variables were income, source of income, sickness periods, incapacity rate, diagnosis-specific incapacity rate, vocational status, and education. RESULTS: Relative growth of income was similar between patients and controls during follow-up. Patients had lower income than did controls 2 years before seizure onset and during the entire follow-up. This was related to higher morbidity among patients, as measured by sickness periods and incapacity rate. Employment rates did not evolve negatively among patients after seizure onset and were close to employment rates of controls during follow-up time. There was no difference between patients and controls regarding education. CONCLUSIONS: After a newly diagnosed unprovoked epileptic seizure in adults, no negative development regarding employment and education occurs. Income development is positive unless refractory seizures evolve. However, income is lower among patients with epilepsy than among controls, and this difference can be related to overall morbidity.

Adolescent↗
PubMed2000

Defining characteristics of financially successful orthodontists.

Financially successful personality profiles in most of the business world have been reported to be the choleric (powerful) and the melancholy (perfect) types. In 1996, Hughes proposed that the same relationship possibly exists in the profession of orthodontics. The purpose of this study was to explore whether a dominant personality profile exists for the most financially successful orthodontists. A questionnaire was used to gather information regarding the financial sophistication and the dominant personality profile of each participating orthodontist. One hundred twenty-six of the 300 surveys distributed to orthodontists were returned for a response rate of 42%. For every question, the null hypothesis of independence was tested with the chi-square test. The null hypothesis of independence was rejected for a P value of less than.05. The results revealed that no correlation exists between the financial sophistication of orthodontists and their personality profiles. However, over two thirds of the orthodontists had the choleric (powerful) and the melancholy (perfect) as dominant personality types. Interestingly, the questionnaire shed much light on factors that do contribute to financial success in orthodontics. Although statistical differences are lacking in these data, certain traits about successful practitioners could be identified. These orthodontists (1) allow their practices to grow if it will increase the net income, (2) view control of overhead as a key principle, (3) emphasize the competence of staff in determining the success of practice, and (4) believe in marketing. Implementation of these simple and common sense principles in some orthodontic practices might affect the business significantly.

Chi-Square Distribution↗
PubMed2006

Does height modify the risk of angina associated with economic adversity?

Adult height partly reflects childhood exposures, and we hypothesise that some exposures impairing growth may also increase susceptibility to coronary heart disease--angina pectoris (angina)--risks, such that shorter adults may be more susceptible to some exposures in adulthood that are risks for heart disease. This hypothesis is tested among all adults who participated in the National Health Interview Survey (USA), 1997-2000 [The National Health Survey, 1997-2000. Data file documentation, National Health Interview Survey (machine-readable data file and documentation). National Center for Health Statistics, Hyattsville, Maryland, ]. In the entire study population, height was negatively associated with angina and after adjustment for potential confounding factors; the odds ratio (and 95% confidence interval) for angina risk associated with the tallest height fifth compared with the shortest fifth is 0.77 (0.97, 0.88). The association of low income (less than US 20,000 dollars) with angina was assessed separately in each of five height strata defined by fifths of the height distribution. The magnitude of this association is lower in the shortest than the tallest height fifth, with odds ratios of 1.18 and 1.60, respectively (effect modification). The unexpected results may be explained by the following: childhood adversity resulting in shorter stature may confer resilience against adult economic adversity; the relative disadvantage of low income may be perceived more keenly by those of taller stature thereby increasing stress and thus disease risk; or health-promoting characteristics associated with taller stature may be less effective in the face of adult economic adversity in the low-income group.

Adult↗
PubMed2002

Deteriorated housing contributes to high cockroach allergen levels in inner-city households.

The high prevalence of childhood asthma in low-income, inner-city populations is not fully understood but has been at least partly attributed to the disproportionate exposures associated with socioeconomic disadvantage. The contribution of indoor allergens to asthma is well documented, but links between socioeconomic disadvantage and indoor allergen levels are not clear. We investigated levels of cockroach allergens (Bla g 2) in a sample of 132 Dominican or African American low-income households with young children in northern Manhattan in New York City (40% were receiving public assistance) to determine whether the distribution of allergens is a function of housing deterioration. Deterioration was measured by the presence and number of physical housing problems (holes in the ceilings and walls, water damage, etc.). More than 50% of the sample had two or more types of housing dilapidation, and 67% of the sample reported cockroach sightings in their homes. Samples of dust were collected from kitchen and bedroom surfaces. We hypothesized that the greater the dilapidation, the higher the allergen levels, independent of income, sociocultural factors, and pest-control methods. In addition, we hypothesized that the homes of families characterized by frequent moves (23.5%) would have higher allergen levels than more stable families. Results showed significant positive associations between housing deterioration and allergen levels in kitchens, after adjusting for income and ethnicity, with independent effects of residential stability (p< 0.05). Bedroom allergen levels were associated with housing instability (p < 0.01) and ethnicity (p< 0.01). Findings demonstrated that indoor household allergen levels are related to degree of household disrepair, after adjusting for individual family attributes, suggesting that social-structural aspects of housing may be appropriate targets for public health interventions designed to reduce allergen exposure.

Adolescent↗
PubMed1988

Maternal and child health services for medically indigent children and pregnant women.

Millions of low-income children and women of childbearing age are completely uninsured. Medicaid, the nation's largest public health financing program for the poor, is an inadequate resource for uninsured families with children. By 1984, the program served only 46% of the poor and near-poor, down from 65% in 1976. To assess the availability of maternity and pediatric services for low income uninsured women and children, a survey of 51 Title V Maternal and Child Health agency officials was conducted in 1986. While nearly all states (48) offer some prenatal care programs for indigent women, restrictive eligibility requirements and limited distribution meant that these programs reached only a small proportion of those in need. Only one state, Massachusetts, offered a truly statewide program to all uninsured pregnant women with incomes under 185% of the poverty level. Twenty-three states reported the existence of inpatient maternity programs for indigent women. Yet these, too, were extremely limited. Sixteen programs restricted funds either to women who participated in certain designated maternity programs or else only to those who were identified as high risk prior to the labor and delivery period. Fifteen state agencies reported that hospitals were denying admission to women about to deliver. Another 13 reported that hospitals were denying admission to women not yet in "active" labor. Six additional states were aware of patient dumping but did not identify the specific populations that were affected. Forty-six states reported the existence of pediatric outpatient programs. However, the majority (30) offered only "well-child" care. Seven states maintained pediatric programs limited to only certain ages of children; three of these imposed an age requirement as low as 2 years or younger. Only two states reported the availability of any pediatric inpatient programs financed or administered by Title V agencies other than those for children with special health care needs.

Child↗
PubMed2004

Prevalence and distribution of corrective lenses among school-age children.

BACKGROUND: No population-based data are available regarding the proportion of school-age children who have corrective lenses in the U.S. The objective of this study was to quantify the proportion of children who have corrective lenses (glasses or contact lenses) and to evaluate the association of corrective lenses with age, gender, race/ethnicity, health insurance status, and family income. METHODS: Children 6 to 18 years of age were identified in the 1998 Medical Expenditure Panel Survey. National estimates were made of the proportion with corrective lenses. Logistic regression modeling was used to assess factors that were associated with corrective lenses. RESULTS: Based on the 5,141 children in the 1988 Medical Expenditure Panel Survey, an estimated 25.4% of the 52.6 million children between 6 and 18 years had corrective lenses. Girls had greater odds than boys of having corrective lenses (odds ratio, 1.41; p < 0.001). Insured children, regardless of race/ethnicity, and uninsured nonblack/non-Hispanic children had similar odds of having corrective lenses. Compared with uninsured black or Hispanic children (odds ratio, 1), greater odds of corrective lens use was found among uninsured nonblack/non-Hispanic children (odds ratio, 2.29; p = 0.002) and black or Hispanic children with public (odds ratio, 1.67; p = 0.005) or private health insurance (odds ratio,1.77; p = 0.004). Among families with an income > or =200% of the federal poverty level, the odds of having corrective lenses increased with age (p < or = 0.04). In contrast, among those families <200% of the federal poverty level, the odds of having corrective lenses at 12 to 14 years was similar to 15- to 18-year olds (p = 0.93). CONCLUSIONS: The use of corrective lenses suggests that correctable visual impairment is the most common treatable chronic condition of childhood. Income, gender, and race/ethnicity, depending on insurance status, are associated with having corrective lenses. The underlying causes and the impacts of these differences must be understood to ensure optimal delivery of eye care.

Adolescent↗
PubMed1994

The nutrition transition in low-income countries: an emerging crisis.

Scientists have long recognized the importance of the demographics and epidemiologic transitions in higher income countries. Only recently has it become understood that similar sets of broadly based changes are occurring in lower income countries. What has not been recognized is that concurrent changes in nutrition are also occurring, with equally important implications for resource allocation in many low-income countries. Several major changes seem to be emerging, leading to a marked shift in the structure of diet and the distribution of body composition in many regions of the world: a rapid reduction in fertility and aging of the population, rapid urbanization, the epidemiologic transition, and economic changes affecting populations in different and uneven ways. These changes vary significantly over time. In general, we find that problems of under- and overnutrition often coexist, reflecting the trend in which an increasing proportion of people consume the types of diets associated with a number of chronic diseases. This is occurring more rapidly than previously seen in higher income countries, or even in Japan and Korea. Examples from Thailand, China, and Brazil provide evidence of the changes and trends in dietary intake, physical activity, and body composition patterns.

Africa↗
PubMed2005

Income inequality and alcohol use: a multilevel analysis of drinking and drunkenness in adolescents in 34 countries.

BACKGROUND: Economic inequality has been hypothesized to be a health determinant, independent of poverty and household income. The goal of this study was to explore the contextual influences of income inequality on alcohol use and frequency of drunkenness in adolescents. METHODS: The Health Behaviour in School-aged Children study surveyed 162 305 adolescents (ages 11, 13 and 15 years) in 34 countries, providing self-report data on family affluence, alcohol consumption and episodes of drunkenness. Country-level data on income inequality and overall wealth were retrieved from the United Nations Development Program. RESULTS: Multilevel logistic regression revealed that 11- and 13-year-olds in countries of high income inequality consumed more alcohol than their counterparts in countries of low income inequality (after adjustment for sex, family affluence and country wealth). No such effect on alcohol consumption was found in 15-year-olds. Eleven-year-olds in countries of high income inequality reported more episodes of drunkenness than their counterparts in countries of low income inequality. No such effect of income inequality on drunkenness was found in 13- or 15-year-olds. CONCLUSIONS: Income inequality may have a contextual influence on the use of alcohol among younger adolescents. Findings suggest that economic policies that affect the distribution of wealth within societies may indirectly influence the use of alcohol during early and mid-adolescence.

Adolescent↗