Intermediary and structural determinants of early childhood health in Colombia: exploring the role of communities

This study examines how structural determinants influence intermediary factors of child health inequities and how they operate through the communities where children live. In particular, we explore individual, family and community level characteristics associated with a composite indicator that quantitatively measures intermediary determinants of early childhood health in Colombia. We use data from the 2010 Colombian Demographic and Health Survey (DHS). Adopting the conceptual framework of the Commission on Social Determinants of Health (CSDH), three dimensions related to child health are represented in the index: behavioural factors, psychosocial factors and health system. In order to generate the weight of the variables and take into account the discrete nature of the data, principal component analysis (PCA) using polychoric correlations are employed in the index construction. Weighted multilevel models are used to examine community effects. The results show that the effect of household’s SES is attenuated when community characteristics are included, indicating the importance that the level of community development may have in mediating individual and family characteristics. The findings indicate that there is a significant variance in intermediary determinants of child health between-community, especially for those determinants linked to the health system, even after controlling for individual, family and community characteristics. These results likely reflect that whilst the community context can exert a greater influence on intermediary factors linked directly to health, in the case of psychosocial factors and the parent’s behaviours, the family context can be more important. This underlines the importance of distinguishing between community and family intervention programmes.

Health care provider choice in the case of patient-initiated contacts. An extended version of discrete choice of model demand

This paper analyzes the nature of health care provider choice inthe case of patient-initiated contacts, with special reference toa National Health Service setting, where monetary prices are zeroand general practitioners act as gatekeepers to publicly financedspecialized care. We focus our attention on the factors that mayexplain the continuously increasing use of hospital emergencyvisits as opposed to other provider alternatives. An extendedversion of a discrete choice model of demand for patient-initiatedcontacts is presented, allowing for individual and town residencesize differences in perceived quality (preferences) betweenalternative providers and including travel and waiting time asnon-monetary costs. Results of a nested multinomial logit model ofprovider choice are presented. Individual choice betweenalternatives considers, in a repeated nested structure, self-care,primary care, hospital and clinic emergency services. Welfareimplications and income effects are analyzed by computingcompensating variations, and by simulating the effects of userfees by levels of income. Results indicate that compensatingvariation per visit is higher than the direct marginal cost ofemergency visits, and consequently, emergency visits do not appearas an inefficient alternative even for non-urgent conditions.

Demand for private health insurance: Is there a quality gap?

Quality of care is qualified as a main determinant of the demand forvoluntary private health insurance (PHI) in National Health Systems(NHS). This paper provides new evidence on the influence of the qualitygap between public and private health insurance and other demanddeterminants in the demand for PHI in Catalonia. The demand for PHI ismodelled as a demand for health care quality. Unlike previous studies, the database employed allows for the development of a link between thetheoretical and the empirical model dealing with unobserved heterogeneityand endogeneity issues. Results suggest that a rise in PHI qualityenhances an equivalent influence in the demand for PHI as an equalreduction of NHS quality. Income and price elasticity estimates areconsistent with the observed feature that PHI appears to be a luxurygood and individuals tend to be relatively insensible to tax relief'sand monetary co-payments in insurance contracts.

A multilevel analysis on the determinants of regional health care expenditure. A note

We apply a multilevel hierarchical model to explore whether anaggregation fallacy exists in estimating the income elasticity of healthexpenditure by ignoring the regional composition of national healthexpenditure figures. We use data for 110 regions in eight OECD countriesin 1997: Australia, Canada, France, Germany, Italy, Spain, Sweden andUnited Kingdom. In doing this we have tried to identify two sources ofrandom variation: within countries and between-countries. Our resultsshow that: 1- Variability between countries amounts to (SD) 0.5433, andjust 13% of that can be attributed to income elasticity and the remaining87% to autonomous health expenditure; 2- Within countries, variabilityamounts to (SD) 1.0249; and 3- The intra-class correlation is 0.5300. Weconclude that we have to take into account the degree of fiscaldecentralisation within countries in estimating income elasticity ofhealth expenditure. Two reasons lie behind this: a) where there isdecentralisation to the regions, policies aimed at emulating diversitytend to increase national health care expenditure; and b) without fiscaldecentralisation, central monitoring of finance tends to reduce regionaldiversity and therefore decrease national health expenditure.

Drug innovation, prices and health

This article tries to reconcile economic-industrial policy with health policy when dealing with biomedical innovation and welfare state sustainability. Better health accounts for an increasingly large proportion of welfare improvements. Explanation is given to the welfare losses coming from the fact than industrial and health policy tend to ignore each other. Drug s prices reflecting their relative relative effectiveness send the right signal to the industry rewarding innovation with impact on quantity and quality of life- and to the buyers of health care services.The level of drug s public reimbursement indicates the social willingness to pay of the different national health systems, not only by means of inclusion, or rejection, in the basket of services covered, but especially establishing the proportion of the price that is going to be financed publicly.Reference pricing for therapeutic equivalents as the upper limit of the social willingness to pay- and two-tiered co-payments for users (avoidable and inversely related with the incremental effectiveness of de drug) are deemed appropriate for those countries concerned at the same time with increasing their productivity and maintaining its welfare state. Profits drive R&D but not its location. There is no intrinsic contradiction between high productivity and a consolidated National Health Service (welfare state) as the European Nordic Countries are telling us every day.

Eliciting preferences for collectively financed health programmes : the "willingness to assign" approach

Improving public involvement in health system decision making stands as a primary goal in health systems reform. However, still limited evidence is found on how best to elicit preferences for health care programs. This paper examines a contingent choice technique to elicit preferences among health programs so called, willingness to assign (WTAS): Moreover, we elicited contingents rankings as well as the willingness to pay extra taxes for comparative purposes. We argue that WTAS reveals relative ( monetary-based) values of a set of competing public programmes under a hypothetical healthcare budget assessment. Experimental evidence is reported from a delibertive empirical study valuing ten health programmes in the context of the Catalan Health Services. Evidence from a our experimental study reveals that perferences are internally more consistent and slightly less affected by "preference reversals" as compared to values revealed from the willingness to pay (WTP) extra taxes approach. Consistent with prior studies, we find that the deliberative approach helped to avoid possible misunderstandings. Interestingly, although programmes promoting health received the higher relative valuation, those promoting other health benefits also ranked highly

Eliciting preferences for collectively financed health programmes : the "willingness to assign" approach

Improving public involvement in health system decision making stands as a primary goal in health systems reform. However, still limited evidence is found on how best to elicit preferences for health care programs. This paper examines a contingent choice technique to elicit preferences among health programs so called, willingness to assign (WTAS): Moreover, we elicited contingents rankings as well as the willingness to pay extra taxes for comparative purposes. We argue that WTAS reveals relative ( monetary-based) values of a set of competing public programmes under a hypothetical healthcare budget assessment. Experimental evidence is reported from a delibertive empirical study valuing ten health programmes in the context of the Catalan Health Services. Evidence from a our experimental study reveals that perferences are internally more consistent and slightly less affected by "preference reversals" as compared to values revealed from the willingness to pay (WTP) extra taxes approach. Consistent with prior studies, we find that the deliberative approach helped to avoid possible misunderstandings. Interestingly, although programmes promoting health received the higher relative valuation, those promoting other health benefits also ranked highly

E-Health and Society : An Empirical Study of Catalonia. Research report (synthesis document)

Aquest estudi va analitzar la interacció del canvi organitzatiu, els valors culturals i el canvi tecnològic en el sistema sanitari català. L'estudi se subdivideix en cinc parts diferents. La primera és una anàlisi de contingut de webs relacionats amb la salut a Catalunya. La segona és un estudi dels usos d'Internet en qüestions relacionades amb la salut entre la població en general, les associacions de pacients i els professionals de la salut, i es basa en un sondeig per Internet adaptat a cada un d'aquests grups. La tercera part és un estudi de treball de camp dels programes experimentals duts a terme pel Govern català en diverses àrees i hospitals locals per a integrar electrònicament la història clínica dels pacients. La quarta és un estudi de les implicacions organitzatives de la introducció de sistemes d'informació en la gestió d'hospitals i centres d'assistència primària a l'Institut Català de Salut, el principal proveïdor de salut pública a Catalunya, i es basa en un sondeig per Internet i entrevistes en profunditat. La cinquena part és un estudi de cas dels efectes organitzatius i socials de la introducció de les tecnologies de la informació i la comunicació en un dels principals hospitals de Catalunya, l'Hospital Clínic de Barcelona. L'estudi es va dur a terme entre el maig del 2005 i el juliol del 2007.

Comparison of the consumption of antidepressants in the immigrant and native populations in a Spanish health region: an observational study

BACKGROUND: Health professionals and organizations in developed countries adapt slowly to the increase of ethnically diverse populations attending health care centres. Several studies report that attention to immigrant mental health comes up with barriers in access, diagnosis and therapeutics, threatening equity. This study analyzes differences in exposure to antidepressant drugs between the immigrant and the native population of a Spanish health region. METHODS: Cross-sectional study of the dispensation of antidepressant drugs to the population aged 15 years or older attending the public primary health centres of a health region, 232,717 autochthonous and 33,361 immigrants, during 2008. Data were obtained from computerized medical records and pharmaceutical records of medications dispensed in pharmacies. Age, sex, country of origin, visits, date of entry in the regional health system, generic drugs and active ingredients were considered. Statistical analysis expressed the percentage of persons exposed to antidepressants stratified by age, gender, and country of origin and prevalence ratios of antidepressant exposition were calculated. RESULTS: Antidepressants were dispensed to 11% of native population and 2.6% of immigrants. Depending on age, native women were prescribed antidepressants between 1.9 and 2.7 times more than immigrant women, and native men 2.5 and 3.1 times more than their immigrant counterparts. Among immigrant females, the highest rate was found in the Latin Americans (6.6%) and the lowest in the sub-Saharans (1.4%). Among males, the highest use was also found in the Latin Americans (1.6%) and the lowest in the sub-Saharans (0.7%). The percentage of immigrants prescribed antidepressants increased significantly in relation to the number of years registered with the local health system. Significant differences were found for the new antidepressants, prescribed 8% more in the native population than in immigrants, both in men and in women. CONCLUSIONS: All the immigrants, regardless of the country of origin, had lower antidepressant consumption than the native population of the same age and sex. Latin American women presented the highest levels of consumption, and the sub-Saharan men the lowest. The prescription profiles also differed, since immigrants consumed more generics and fewer recently commercialized active ingredients.

Measuring Intermediary Determinants of Early Childhood Health: A Composite Index Comparing Colombian Departments

In recent years there has been growing interest in composite indicators as an efficient tool of analysis and a method of prioritizing policies. This paper presents a composite index of intermediary determinants of child health using a multivariate statistical approach. The index shows how specific determinants of child health vary across Colombian departments (administrative subdivisions). We used data collected from the 2010 Colombian Demographic and Health Survey (DHS) for 32 departments and the capital city, Bogotá. Adapting the conceptual framework of Commission on Social Determinants of Health (CSDH), five dimensions related to child health are represented in the index: material circumstances, behavioural factors, psychosocial factors, biological factors and the health system. In order to generate the weight of the variables, and taking into account the discrete nature of the data, principal component analysis (PCA) using polychoric correlations was employed in constructing the index. From this method five principal components were selected. The index was estimated using a weighted average of the retained components. A hierarchical cluster analysis was also carried out. The results show that the biggest differences in intermediary determinants of child health are associated with health care before and during delivery.

Measuring early childhood health : a composite index comparing Colombian departments

This paper presents a composite index of early childhood health using a multivariate statistical approach. The index shows how child health varies across Colombian departments, -administrative subdivisions-. In recent years there has been growing interest in composite indicators as an efficient analysis tool and a way of prioritizing policies. These indicators not only enable multi-dimensional phenomena to be simplified but also make it easier to measure, visualize, monitor and compare a country’s performance in particular issues. We used data collected from the Colombian Demographic and Health Survey, DHS, for 32 departments and the capital city, Bogotá, in 2005 and 2010. The variables included in the index provide a measure of three dimensions related to child health: health status, health determinants and the health system. In order to generate the weight of the variables and take into account the discrete nature of the data, we employed a principal component analysis, PCA, using polychoric correlation. From this method, five principal components were selected. The index was estimated using a weighted average of the components retained. A hierarchical cluster analysis was also carried out. We observed that the departments ranking in the lowest positions are located on the Colombian periphery. They are departments with low per capita incomes and they present critical social indicators. The results suggest that the regional disparities in child health may be associated with differences in parental characteristics, household conditions and economic development levels, which makes clear the importance of context in the study of child health in Colombia.

A qualitative analysis of immigrant population health practices in the Girona Healthcare Region

The research we present here forms part of a two-phase project - one quantitative and the other qualitative - assessing the use of primary health care services. This paper presents the qualitative phase of said research, which is aimed at ascertaining the needs, beliefs, barriers to access and health practices of the immigrant population in comparison with the native population, as well as the perceptions of healthcare professionals. Moroccan and sub-Saharan were the immigrants to who the qualitative phase was specifically addressed. The aims of this paper are as follows: to analyse any possible implications of family organisation in the health practices of the immigrant population; to ascertain social practices relating to illness; to understand the significances of sexual and reproductive health practices; and to ascertain the ideas and perceptions of immigrants, local people and professionals regarding health and the health system. Methods: qualitative research based on discursive analysis. Data gathering techniques consisted of discussion groups with health system users and semi-structured individual interviews with healthcare professionals. The sample was taken from the Basic Healthcare Areas of Salt and Banyoles (belonging to the Girona Healthcare Region), the discussion groups being comprised of (a) 6 immigrant Moroccan women, (b) 7 immigrant sub-Saharan African women and (c) 6 immigrant and native population men (2 native men, 2 Moroccan men and 2 sub-Saharan men); and the semi-structured interviews being conducted with the following healthcare professionals: (a) 3 gynaecologists, (b) 3 nurses and 1 administrative staff. Results: use of the healthcare system is linked to the perception of not being well, knowledge of the healthcare system, length of time resident in Spain and interiorization of traditional Western medicine as a cure mechanism. The divergences found among the groups of immigrants, local people and healthcare professionals with regard to healthcare education, use of the healthcare service, sexual and reproductive healthcare and reticence with regard to being attended by healthcare personnel of the opposite sex demonstrate a need to work with the immigrant population as a heterogeneous group. Conclusions: the results we have obtained support the idea that feeling unwell is a psycho-social process, as it takes place within a specific socio-cultural situation and spans a range of beliefs, perceptions and ideas regarding symptomology and how to treat it

Percepció i coneixements dels estudiants d'infermeria sobre la violència en la parella

Les últimes dades de l'estudi europeu del 2014, sobre la violència de parella indiquen que gairebé 62 milions de dones europees, havien sofert actes de violència de gènere, entre els quals es destaca els relacionats amb la violència de parella (VP). Els maltractaments constitueixen un problema molt greu que genera al nostre país cada vegada més alarma social i més actuacions legals i professionals per fer-li front. El sistema de salut és, amb freqüència, el primer lloc al que les víctimes de violència domèstica acudeixen a la recerca d'assessorament i ajuda, sent aquest el motiu pel qual els professionals de la salut tenen un paper central per a la seva assistència. Aquests formen part implicada en el sistema de detecció, atenció i actuació. Per això, els plans d'estudi de Grau d'Infermeria recullen en el BOE la formació en VP des de l’àmbit universitari. L’objectiu del nostre estudi consisteix en la identificació de la percepció i dels coneixements en relació a la violència de parella dels estudiants del Grau d’Infermeria de la Universitat de Girona durant el curs acadèmic 2012-2013. Per a dur-lo a terme es va realitzar un anàlisi quantitatiu dels resultats a través de l’administració d’una enquesta sobre sis aspectes de la VP, l’enquesta incloïa el perfil demogràfic (sexe, edat i anys d'estudi) dels estudiants i les declaracions relatives a les seves percepcions i coneixements sobre la VP: causes d'abús; la identificació de les dones objecte de VP i del seus autors; creences de les infermeres; funcions perceptibles; i la preparació educativa. Els estudiants del Grau d’Infermeria mostren tenir un bon coneixement sobre les causes del abús en VP, així com una formació adequada. També cal destacar que un 54,42% dels alumnes enquestats es veuen capacitats per afrontar un cas de VP com a infermer/a. S’observa una millora de la formació educativa en el transcurs acadèmic. En 1r curs un 40,09% té una bona formació, aquest valor augmenta fins a un 56,58% a tercer curs, baixant lleugerament fins un 44,27% a 4rt curs. Els resultats obtinguts són semblats a estudis de mostres similars en estudiants d'infermeria de Memphis (EUA) i de la University of Southern Queensland (Austràlia) quant a coneixements i percepció sobre la VP. Encara que els resultats mostren un coneixement i una percepció sobre la VP adequada, destaquem que això no succeeix en gairebé un 40% dels enquestats. La introducció de matèries específiques sobre igualtat i sobre violència contra la dona en els plans d’estudis, pot esdevenir una mesura preventiva per revisar i corregir possibles mites i creences en VP. Per tant, és necessari millorar la formació del currículum en estudiants d'infermeria per la importància d'aquest greu problema de salut pública, donant major èmfasis en la satisfacció de les necessitats emocionals i en la comprensió dels diferents enfocaments en VP, especialment en mesures de prevenció i educació