Out-of-pocket expenditures for hospital care in Iran : who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.

Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach : a longitudinal study

Background The high recurrence rate of chronic venous leg ulcers has a significant impact on an individual’s quality of life and healthcare costs. Objectives This study aimed to identify risk and protective factors for recurrence of venous leg ulcers using a theoretical approach by applying a framework of self and family management of chronic conditions to underpin the study. Design Secondary analysis of combined data collected from three previous prospective longitudinal studies. Setting The contributing studies’ participants were recruited from two metropolitan hospital outpatient wound clinics and three community-based wound clinics. Participants Data were available on a sample of 250 adults, with a leg ulcer of primarily venous aetiology, who were followed after ulcer healing for a median follow-up time of 17 months after healing (range: 3 to 36 months). Methods Data from the three studies were combined. The original participant data were collected through medical records and self-reported questionnaires upon healing and every 3 months thereafter. A Cox proportion-hazards regression analysis was undertaken to determine the influential factors on leg ulcer recurrence based on the proposed conceptual framework. Results The median time to recurrence was 42 weeks (95% CI 31.9–52.0), with an incidence of 22% (54 of 250 participants) recurrence within three months of healing, 39% (91 of 235 participants) for those who were followed for six months, 57% (111 of 193) by 12 months, 73% (53 of 72) by two years and 78% (41 of 52) of those who were followed up for three years. A Cox proportional-hazards regression model revealed that the risk factors for recurrence included a history of deep vein thrombosis (HR 1.7, 95% CI 1.07–2.67, p=0.024), history of multiple previous leg ulcers (HR 4.4, 95% CI 1.84–10.5, p=0.001), and longer duration (in weeks) of previous ulcer (HR 1.01, 95% CI 1.003–1.01, p<0.001); while the protective factors were elevating legs for at least 30 minutes per day (HR 0.33, 95% CI 0.19–0.56, p<0.001), higher levels of self-efficacy (HR 0.95, 95% CI 0.92–0.99, p=0.016), and walking around for at least three hours/day (HR 0.66, 95% CI 0.44–0.98, p=0.040). Conclusions Results from this study provide a comprehensive examination of risk and protective factors associated with leg ulcer recurrence based on the chronic disease self and family management framework. These results in turn provide essential steps towards developing and testing interventions to promote optimal prevention strategies for venous leg ulcer recurrence.

Male and female cyclist and driver perceptions of crash risk

Many drivers and non-cyclists perceive cycling as an extremely risky activity with women in particular being concerned about the risk of injury. The low rates of cycling participation by women pose a threat to the achievement of government targets for cycling participation and restrict the potential transport, health and environmental benefits that increased levels of cycling could provide. This study seeks to extend earlier research in gender and cycling by comparing the risks perceived by female and male cyclists and drivers in specific on-road situations while accounting for other potentially gender-related factors such as travel patterns and experience, perceived skill, and risk taking behaviors. In an online survey, 444 regular cyclists and 151 (non-cyclist) car drivers rated the level of risk in six situations: Failing to yield; Going through a red light; Not signaling when turning; Swerving; Tailgating; and Not checking traffic. The study found that the higher levels of risk perceived by women are not completely accounted for by differences in cycling patterns or perceptions of skill. Compared to their male counterparts, female cyclists and car drivers had similarly elevated perceptions of risk suggesting that these gender differences are not specific to cycling, but reflect wider differences in risk perception. Not all of the gender differences were consistent across cyclists and drivers. Higher levels of perceived skill were evident for male cyclists but not for male car drivers. Further research is needed to explore the robustness and interpretation of this finding.

Extinction risk analysis of exploited green turtle stocks in the Indo-Pacific

In parts of the Indo-Pacific, large-scale exploitation of the green turtle Chelonia mydas continues to pose a serious threat to the persistence of this species; yet very few studies have assessed the pattern and extent of the impact of such harvests. We used demographic and genetic data in an age-based model to investigate the viability of an exploited green turtle stock from Aru, south-east Indonesia. We found that populations are decreasing under current exploitation pressures. The effects of increasingly severe exploitation activities at foraging and nesting habitat varied depending on the migratory patterns of the stock. Our model predicted a rapid decline of the Aru stock in Indonesia under local exploitation pressure and a shift in the genetic composition of the stock. We used the model to investigate the influence of different types of conservation actions on the persistence of the Aru stock. The results show that local management actions such as nest protection and reducing harvests of adult nesting and foraging turtles can have considerable conservation outcomes and result in the long-term persistence of genetically distinct management units. © 2010 The Authors. Animal Conservation © 2010 The Zoological Society of London.

Extinction risk in cloud forest fragments under climate change and habitat loss

Aim: To quantify the consequences of major threats to biodiversity, such as climate and land-use change, it is important to use explicit measures of species persistence, such as extinction risk. The extinction risk of metapopulations can be approximated through simple models, providing a regional snapshot of the extinction probability of a species. We evaluated the extinction risk of three species under different climate change scenarios in three different regions of the Mexican cloud forest, a highly fragmented habitat that is particularly vulnerable to climate change. Location: Cloud forests in Mexico. Methods: Using Maxent, we estimated the potential distribution of cloud forest for three different time horizons (2030, 2050 and 2080) and their overlap with protected areas. Then, we calculated the extinction risk of three contrasting vertebrate species for two scenarios: (1) climate change only (all suitable areas of cloud forest through time) and (2) climate and land-use change (only suitable areas within a currently protected area), using an explicit patch-occupancy approximation model and calculating the joint probability of all populations becoming extinct when the number of remaining patches was less than five. Results: Our results show that the extent of environmentally suitable areas for cloud forest in Mexico will sharply decline in the next 70 years. We discovered that if all habitat outside protected areas is transformed, then only species with small area requirements are likely to persist. With habitat loss through climate change only, high dispersal rates are sufficient for persistence, but this requires protection of all remaining cloud forest areas. Main conclusions: Even if high dispersal rates mitigate the extinction risk of species due to climate change, the synergistic impacts of changing climate and land use further threaten the persistence of species with higher area requirements. Our approach for assessing the impacts of threats on biodiversity is particularly useful when there is little time or data for detailed population viability analyses. © 2013 John Wiley & Sons Ltd.

Psychological health and the risk of diabetes mellitus in Australian women: A 21-year prospective study

Background Symptoms of depression can be recurrent or limited to one episode. This study discusses the prospective association between psychological health, measured as change in depression symptoms, and the risk of diabetes mellitus in Australian women. Methods Data obtained from the Mater-University of Queensland Study of Pregnancy. Depression was measured using the Delusions-Symptoms: States Inventory. To examine possible transitions over time, depression was grouped into four categories and assessed at different phases over the 21-year period. Multiple logistic regression models and sensitivity analysis to assess the robustness of our analytical strategy were performed. Results Three hundred and one women reported diabetes 21 years after the index pregnancy. Almost one-third of the women who reported depression symptoms continued to report these at a subsequent follow-up (FU) phase. About 1 in 20 women who had not reported depression symptoms at the 5-year FU did so at the subsequent 14-year FU. In prospective analyses, we did not find a significant association between diabetes and negative change (not depressed to depressed, at subsequent phase); however, for women with positive history of symptoms of depression and women with persistent symptoms, there was a 1.97-fold (95% confidence interval [CI]: 1.14–3.40) to 2.23-fold (95% CI: 1.09–4.57) greater risk of diabetes. Conclusions Our study suggests that an increased risk of diabetes is significantly associated with persistent depression symptoms. It highlights the importance of recognizing depression symptoms in terms of women's psychological wellbeing and thus provides a basis for targeting those most at risk.

Bicycle commuting and exposure to air pollution: A questionnaire-based investigation of perceptions, symptoms and risk management strategies

Background An increase in bicycle commuting participation may improve public health and traffic congestion in cities. Information on air pollution exposure (such as perception, symptoms and risk management) contributes to the responsible promotion of bicycle commuting participation. Methods To determine perceptions, symptoms and willingness for specific exposure risk management strategies of exposure to air pollution, a questionnaire-based cross-sectional investigation was conducted with adult bicycle commuters (n = 153; age = 41 ± 11 yr; 28% female). Results Frequency of acute respiratory signs and symptoms are positively-associated with in- and post-commute compared to pre-commute time periods (p < 0.05); greater positive-association is with respiratory disorder compared to healthy, and female compared to male, participants. The perception (although not signs or symptoms) of in-commute exposure to air pollution is positive-associated with the estimated level of in-commute proximity to motorised traffic. The majority of participants indicated a willingness (which varied with health status and gender) to adopt risk management strategies (with certain practical features) if shown to be appropriate and effective. Conclusions While acute signs and symptoms of air pollution exposure are indicated with bicycle commuting, and more so in susceptible individuals, there is willingness to manage exposure risk by adopting effective strategies with desirable features.

The challenge of developing a fleet driving risk assessment tool: What can be learned from the process?

One of the riskiest activities in the course of a person's work is driving. By developing and testing a new work driving risk assessment measurement tool for use by organisations this research will contribute to the safety of those who drive for work purposes. The research results highlighted limitations associated with current self-report measures and provided evidence that the work driving environment is extremely complex and involves constant interactions between humans, vehicles, the road environment, and the organisational context.

Risk factors associated with an outbreak of dengue fever/dengue haemorrhagic fever in Hanoi, Vietnam

Dengue fever/dengue haemorrhagic fever (DF/DHF) appears to be emerging in Hanoi in recent years. A case-control study was performed to investigate risk factors for the development of DF/DHF in Hanoi. A total of 73 patients with DF/DHF and 73 control patients were included in the study. The risk factor analysis indicated that living in rented housing, living near uncovered sewers, and living in a house discharging sewage directly into to ponds were all significantly associated with DF/DHF. People living in rented houses were 2·2 times more at risk of DF/DHF than those living in their own homes [adjusted odds ratio (aOR) 2·2, 95% confidence interval (CI) 1·1–4·6]. People living in an unhygienic house, or in a house discharging sewage directly to the ponds were 3·4 times and 4·3 times, respectively, more likely to be associated with DF/DHF (aOR 3·4, 95% CI 1–11·7; aOR 4·3, 95% CI 1·1–16·9). These results contribute to the understanding of the dynamics of dengue transmission in Hanoi, which is needed to implement dengue prevention and control programmes effectively and efficiently.

Predicting intentions and behaviours in populations with or at-risk of diabetes: A systematic review

Purpose To systematically review the Theory of Planned Behaviour studies predicting self-care intentions and behaviours in populations with and at-risk of diabetes. Methods A systematic review using six electronic databases was conducted in 2013. A standardised protocol was used for appraisal. Studies eligibility included a measure of behaviour for healthy eating, physical activity, glucose monitoring, medication use (ii) the TPB variables (iii) the TPB tested in populations with diabetes or at-risk. Results Sixteen studies were appraised for testing the utility of the TPB. Studies included cross-sectional (n=7); prospective (n=5) and randomised control trials (n=4). Intention (18% – 76%) was the most predictive construct for all behaviours. Explained variance for intentions were similar across cross-sectional (28 -76%); prospective (28 -73%); and RCT studies (18 - 63%). RCTs (18 - 43%) provided slightly stronger evidence for predicting behaviour. Conclusions Few studies tested predictability of the TPB in populations with or at-risk of diabetes. This review highlighted differences in the predictive utility of the TPB suggesting that the model is behaviour and population specific. Findings on key determinants of specific behaviours contribute to a better understanding of mechanisms of behaviour change and are useful in designing targeted behavioural interventions for different diabetes populations.

Inferring lung cancer risk factor patterns through joint Bayesian spatio-temporal analysis

Background: Preventing risk factor exposure is vital to reduce the high burden from lung cancer. The leading risk factor for developing lung cancer is tobacco smoking. In Australia, despite apparent success in reducing smoking prevalence, there is limited information on small area patterns and small area temporal trends. We sought to estimate spatio-temporal patterns for lung cancer risk factors using routinely collected population-based cancer data. Methods: The analysis used a Bayesian shared component spatio-temporal model, with male and female lung cancer included separately. The shared component reflected exposure to lung cancer risk factors, and was modelled over 477 statistical local areas (SLAs) and 15 years in Queensland, Australia. Analyses were also run adjusting for area-level socioeconomic disadvantage, Indigenous population composition, or remoteness. Results: Strong spatial patterns were observed in the underlying risk factor exposure for both males (median Relative Risk (RR) across SLAs compared to the Queensland average ranged from 0.48-2.00) and females (median RR range across SLAs 0.53-1.80), with high exposure observed in many remote areas. Strong temporal trends were also observed. Males showed a decrease in the underlying risk across time, while females showed an increase followed by a decrease in the final two years. These patterns were largely consistent across each SLA. The high underlying risk estimates observed among disadvantaged, remote and indigenous areas decreased after adjustment, particularly among females. Conclusion: The modelled underlying exposure appeared to reflect previous smoking prevalence, with a lag period of around 30 years, consistent with the time taken to develop lung cancer. The consistent temporal trends in lung cancer risk factors across small areas support the hypothesis that past interventions have been equally effective across the state. However, this also means that spatial inequalities have remained unaddressed, highlighting the potential for future interventions, particularly among remote areas.

Is Foxtel most at risk in the new Game of Screens?

If the experience in other major television markets like the United States and Canada is anything to go by, the omens are mixed for Foxtel.

Malaria imported from Ghana by returning gold miners, China, 2013

During May-August 2013, a malaria outbreak comprising 874 persons in Shanglin County, China, was detected among 4,052 persons returning from overseas. Ghana was the predominant destination country, and 92.3% of malarial infections occurred in gold miners. Preventive measures should be enhanced for persons in high-risk occupations traveling to malaria-endemic countries.

Country review on the main building energy-efficiency policy instrument

Building energy-efficiency (BEE) is the key to drive the promotion of energy saving in building sector. A large variety of building energy-efficiency policy instrument exist. Some are mandatory, some are soft scheme, and some use economic incentives from country to country. This paper presents the current development of implementing BEE policy instruments by examining the practices of BEE in seven selected countries and regions. In the study, BEE policy instruments are classified into three groups, including mandatory administration control instruments, economic incentive instruments and voluntary scheme instruments. The study shows that different countries have adopted different instruments in their practices for achieving the target of energy-saving and gained various kinds of experiences. It is important to share these experiences gained.