The determinants of physician and pharmacist utilization and equity of access under Korean universal health insurance

This study examines the social and behavioral determinants of two types of primary care, seeing a physician or a pharmacist, for Koreans and evaluates the equity of the Korean national health insurance system. The study applies the Aday and Andersen access framework to cross-sectional data from the 1992 Korean National Health Interview Survey (N = 21,841).^ The study found that in Korea, the elderly were most likely, and children least likely, to have used physician services. Women, household heads, those in small families, and the less educated were more likely than their counterparts to use physician and pharmacist services. Health status and need were important determinants of Koreans seeing a doctor or a pharmacist. Differences in need substantially accounted for the original differences observed between subgroups. Resources associated with having insurance coverage, a regular source of care, and place of residence (rural/urban) ameliorated to some extent the subgroup differences in the use of physicians' and pharmacists' services among Koreans. They were also major independent predictors of access. Having insurance remains a particularly important predictor of who uses physician services. Among the insured, trade-offs in the use of physician and pharmacist services were found in the current system, i.e., uninsured and poor Koreans were more likely to use pharmacist services, while insured and rural Koreans were more likely to use doctor services. Among the insured, cost sharing rates are lower for physician than for pharmacist services. Self-employed persons were less likely than government and industrial workers to use physician services. An underlying expectation under universal health insurance was that the Korean health care system would be equitable. The research results, however, did not fully support this expectation.^ The policy implications of these findings are that measures are required to extend insurance coverage to the uninsured, to equalize differences in benefit packages between health plans, and to expand the availability of physicians in rural areas. Further research is also needed to understand those who do not currently have a regular source of care and why and the access barriers that may exist for selected demographic subgroups (those in large families and unmarried or divorced/widowed persons). ^

DETERMINANTS OF THE SELECTIVE PHAGOCYTOSIS OF CARCINOGENIC PARTICULATE NICKEL COMPOUNDS

Certain inorganic nickel compounds such as crystalline NiS and Ni(,3)S(,2) are potent inducers of carcinogenesis and in vitro cell transformation, while several closely-related compounds such as amorphous NiS are essentially devoid of genotoxic activity. The phenomenon of selectivity of phagocytosis among such particulate nickel compounds has been hypothesized to account for their widely varying toxicological potency, yet the determinants of this selectivity have not been well characterized. Extracellular medium composition, particle dissolution, and particle surface charge were examined as potential determinants of selective phagocytosis for the carcinogenic crystalline and noncarcinogenic amorphous modifications of NiS. Selectivity and avidity of uptake of crystalline NiS by CHO cells was not dependent upon serum: phagocytosis of crystalline, but not amorphous NiS proceeded readily in a minimal salts/glucose medium at 37(DEGREES)C. The evolution of phagocytosis-inhibiting Ni(II) from the surface of amorphous NiS particles did not demonstrably contribute to the lower uptake of these noncarcinogenic particles despite their somewhat greater dissolution rate than the readily phagocytosed crystalline NiS particles. Significant differences in surface charge were noted between crystalline and amorphous NiS, the former being more negative in charge in distilled water suspension. Exposure of amorphous NiS particles to the vigorously reducing environment of a LiAlH(,4) solution under an inert atmosphere resulted in the particles' acquisition of a more negative surface charge. Amorphous NiS particles thus treated were phagocytosed by CHO cells to an extent similar to that of untreated crystalline NiS particles and likewise were shown to induce morphological transformation of primary Syrian hamster embryo cells with a similar potency. The potentiation of uptake characteristic of LiAlH(,4)-treated amorphous NiS was lost gradually upon storage of particles in ambient oxygenated atmosphere and was lost rapidly by apparent particle surface oxidation in aerated distilled water suspensions aged for up to 7 days. Concomitant with this loss of uptake there occurred a loss of negative surface charge. These results suggest the predominant role of particle surface charge rather than adsorbed serum components or particle dissolution as a determinant of selective phagocytosis among particulate nickel compounds. ^

Prevalence and determinants of type 2 diabetes among Filipino Americans in Houston metropolitan statistical area, Texas

Diabetes in adults (type 2) has emerged as a world health problem. Prevalence and risk factors have been found to vary in different populations. The wide range of prevalence rates worldwide indicates the importance of genetic and environmental factors in the etiology of the disease. The few available studies suggest that Filipinos are among the higher-risk groups for developing diabetes. This cross-sectional study estimated the overall prevalence rate of type 2 diabetes among Filipino Americans, ages 20–74 years and residents of Houston Metropolitan Statistical Area, Texas, to be 16.1%. The observed high prevalence was associated with age, sex, family history of diabetes, obesity, region of birth; and, in women, gestational diabetes and income. The diabetic Filipino Americans had a higher proportion of parental history of diabetes, medical history of hypertension, and history of smoking; were physically less active, but generally non-obese, compared with the United States diabetic population. ^

Use of cardiac glycosides for treatment of cancer: Determinants of cancer cell sensitivity

Cardiac glycoside compounds have traditionally been used to treat congestive heart failure. Recently, reports have suggested that cardiac glycosides may also be useful for treatment of malignant disease. Our research with oleandrin, a cardiac glycoside component of Nerium oleander, has shown it to be a potent inducer of human but not murine tumor cell apoptosis. Determinants of tumor sensitivity to cardiac glycosides were therefore studied in order to understand the species selective cytotoxic effects as well as explore differential sensitivity amongst a variety of human tumor cell lines. ^ An initial model system involved a comparison of human (BRO) to murine (B16) melanoma cells. Human BRO cells were found to express both the sensitive α3 as well as the less sensitive α1 isoform subunits of Na+,K +-ATPase while mouse B16 cells expressed only the α1 isoform. Drug uptake and inhibition of Na+,K+-ATPase activity were also different between BRO and B16 cells. Partially purified human Na+,K+-ATPase enzyme was inhibited by cardiac glycosides at a concentration that was 1000-fold less than that required to inhibit mouse B16 enzyme to the same extent. In addition, uptake of oleandrin and ouabain was 3–4 fold greater in human than murine cells. These data indicate that differential expression of Na+,K+-ATPase isoform composition in BRO and B16 cells as well as drug uptake and total enzyme activity may all be important determinants of tumor cell sensitivity to cardiac glycosides. ^ In a second model system, two in vitro cell culture model systems were investigated. The first consisted of HFU251 (low expression of Na+,K+-ATPase) and U251 (high Na+ ,K+-ATPase expression) cell lines. Also investigated were human BRO cells that had undergone stable transfection with the α1 subunit resulting in an increase in total Na+,K+-ATPase expression. Data derived from these model systems have indicated that increased expression of Na+,K+-ATPase is associated with an increased resistance to cardiac glycosides. Over-expression of Na +,K+-ATPase in tumor cells resulted in an increase of total Na+,K+-ATPase activity and, in turn, a decreased inhibition of Na+,K+-ATPase activity by cardiac glycosides. However, of interest was the observation that increased enzyme expression was also associated with an elevated basal level of glutathione (GSH) within cells. Both increased Na+,K+-ATPase activity and elevated GSH content appear to contribute to a delayed as well as diminished release of cytochrome c and caspase activation. In addition, we have noted an increased colony forming ability in cells with a high level of Na+,K+-ATPase expression. This suggests that Na+,K+-ATPase is actively involved in tumor cell growth and survival. ^

Determinants of quality of advanced cancer care in Latin America. A look at five countries: Argentina, Brazil, Cuba, Mexico and Peru

The World Health Organization reports that nearly half a million people died of cancer in Latin America in 2001. As a growing public health problem, cancer is now either the first or second leading cause of death among adults in most Latin American nations. Despite these trends, information on the quality of care people with advanced cancer in Latin America receive has been limited. This study assessed the quality of advanced cancer care in diverse Latin American countries and institutions by surveying cancer care providers from: Argentina; Brazil; Cuba; Mexico; and Peru. This study also identified the most salient factors that influence the quality of this care at the national and institutional levels and compared these factors across countries. This study was based on the secondary analyses of data collected by the University of Texas M. D. Anderson's WHO/PAHO Collaborating Center in Supportive Cancer Care from March 2000 to November 2002. The sample for this survey was a convenience sample of physicians and nurses who treat cancer patients in these regions. Strategies for the dissemination of this survey included: mass mailings; distribution at professional meetings/conferences; collaboration with regional institutions, professional organizations and PAHO; and the posting of online surveys. The strongest predictor of providers' assessments of the quality of advanced cancer care was their ratings of access to care. This major finding reflects a shared equitable notion of quality care among providers from diverse countries and medical institutions that is highly interrelated with providing accessible care to those with advanced cancer. Higher ratings of the affordability of care, an increased reported availability of end-of-life services and opioid analgesics, practicing in either a private hospital or specialized cancer center, and practicing in Cuba were also associated with higher provider ratings of the quality of advanced cancer care. The findings of this study contribute towards the much needed body of knowledge that may guide the formulation of policies and interventions aimed at improving the care for people with advanced cancer in Latin America. ^

Social and behavioral determinants of consistent condom use among female commercial sex workers (FCSWs) in Ghana

This study aims at investigating the social and behavioral predictors of consistent condom use among female commercial sex workers (FCSWs) in Ghana. Street commercial sex workers were interviewed in Accra, Kumasi and Techiman. Whereas respondents had attained certain accurate knowledge about HIV transmission routes, misconceptions were still commonly reported. The level of condom education was very low (14%), however consistent condom use (all the time) with clients was relatively high (49.6%), 38.89% reported using condom sometimes and 11.56% reported never using condoms. ^ 277 of the respondent ants did not use condoms all the time. 163 of them reported not using condoms due to refusal by their clients, the remaining 64 respondents did not even request their clients to use condom due to cultural perception of power, lack of authority and the fear of loosing clients. ^ Significant predictive factors associated with consistency of condom use among FCSWs in a multivariate analysis were; age, level of education, religion, and number of customers. Some of the major obstacles to condom use by the FCSWs were refusal by clients, availability of free condoms, trying to communicate trust to their clients, and the lack of empowerment to negotiate safer sex with clients. Some of the respondents may have developed a false sense of safety by subjectively assessing whether their clients were well and do not look sick, but they were unaware that HIV carriers may show no obvious symptoms of illness at all. ^ In summary, this study points to an urgent need for reestablishing effective prevention intervention and some insights of what is required of such program in Ghana. ^

Physician and patient determinants of the treatment of sleep difficulties in U.S. outpatient settings

The prevalence of sleep difficulties among the patients seen in the primary care settings is about 30%. This problem increases with age and is more common among females than males. Variations are noticed in prescription choices for different patients with sleep difficulties. Many factors affect a physician's prescription decision while chosen from a wide array of available medications. Both pharmacological and behavioral therapies are available for the treatment of sleep difficulties. It is important to know the impact of use of different types of prescriptions on health outcomes related to sleep difficulties. Thus the knowledge of prescription patterns among different types of patients (e.g. age, gender, race, insurance type etc.) becomes important for determining a clinical guideline. This study is designed to assist in evidence-based policymaking on understanding the variations in physician prescriptions for sleep difficulties and reasons for such variations. ^ A modified version of the model suggested by Eisenberg was used as a theoretical framework for this study to predict the factors influencing treatment of sleep difficulties. Multivariate logistic regression methods were used to analyze the 1996–2001 National Ambulatory Medical Care Survey data. ^ This study found that increased age, female gender, white race, established patients, and mental comorbidity were associated with significantly increased likelihood for prescription of some type of therapy for sleep difficulties in US outpatient settings. Patients with private insurance were associated with lower likelihood of receipt of many therapies. Psychiatrists were more likely to prescribe some kind of treatment as well as more expensive therapies for sleep difficulty as compared to other physician specialties. HMO enrolled patient visits were more likely to be associated with receipt of behavioral therapy. This study also found that 32% of patients with sleep difficulties received no type of therapy during their visits. Only 5% of the patients received behavioral therapy only. Almost three-quarters of the patients receiving some kind of medication prescription were prescribed benzodiazepines. The study results also suggest a need for wider coverage of behavioral therapy by payers in US outpatient settings. ^

The emergence of the social determinants of health on the policy agenda in Britain: A case study, 1980--2003

Numerous theories have been advanced in the effort to explain how a given policy issue manages to take root in the public sphere and subsequently move forward on the public legislative agenda—or not. This study examined how the social determinants of health (SDOH) came to be part of the legislative policy agenda in Britain from 1980 to 2003. ^ The specific objectives of the research were: (1) to conduct a sociopolitical analysis grounded in alternative agenda-setting theories to identify the factors responsible for moving the social determinants health perspective onto the British policy agenda; and (2) to determine which of the theories and related dimensions best accounted for the emergence of this perspective. ^ A triangulated content and context analysis of British news articles, historical accounts, and research commentaries of the SDOH movement was conducted guided by relevant agenda-setting theories set within a social movement framework to chronicle the emergence of the SDOH as a significant policy issue in Britain. ^ The most influential social movement and agenda setting elements in the emergence of the SDOH in Britain were issue generation tactics, framing efforts, mobilizing structures, and political opportunities grounded in social movement and agenda setting theories. Policy content or the details of the policy had comparatively little impact on the successful emergence of the SDOH. Despite resistance by the government, from 1980 to 1996 interest groups created a political understanding of the SDOH utilizing a framing package encompassing notions of inequality, fairness, and justice. This frame transmitted a powerful idea connected to a core set of British values and beliefs. After 1996, a shift in political opportunities cemented the institutional arrangements needed to sustain an environment conducive to the development and implementation of SDOH policies and programs. ^ This research demonstrates that the U.S. emergence of the SDOH on the policy agenda will depend upon: (1) U.S. ideals and values regarding poverty, inequality, race, health, and health care that will determine issue framing; (2) political opportunities that will emerge—or not—to advance the SDOH policy agenda; and (3) the mobilizing structures that support or oppose the issue. ^

Determinants of malnutrition in two states in Sudan

Nearly one in three children in the developing world is malnourished. Poor nutrition contributes to one out of two deaths (53%) associated with infectious diseases among children aged under five in developing countries. Using data from the 2005 World Food Program’s (WFP) Livelihood Vulnerability and Nutritional Assessment of Rural Kassala and Red Sea State this study examines the impact of female headed households and maternal education on malnutrition in children 6-59 months old. The dependent variable investigated in this study is moderate to severe wasting or less than -2 weight for height Z-score, also known as global acute malnutrition (GAM). ^ The study population consisted of 450 households in Kassala State and Red Sea State, Sudan. A total of 900 children 6-59 months of age were part of the households sampled from these states and one child per household (773 children) was randomly chosen for the analysis along with the child’s mother. Results of the study found that 18 percent of children between 6-59 months of age had GAM/wasting. Maternal education, main source of water, and income were strongly related to wasting. Gender of head of household was not found to have a significant relationship with GAM/wasting. Mothers with at least primary education were much less likely to have malnourished children, even after controlling for income and environmental conditions. Children in households with unsafe sources of water were 2.6 more likely to have wasting than those with piped in/tube wells as their main source of water. For every increase of 100 dinar in a household, the children in the household are approximately two-thirds times (.662) less likely to be wasted. ^ The results of this study support the alternate hypothesis that there is an association between maternal education on wasting of children 6-59 months old. The results do not, however, support the alternate hypothesis that there is an association between gender of head of household on wasting of children 6-59 months old. Better understanding of the association of wasting and other measures of malnutrition with maternal education levels can program managers and other health officials to target important nutritional and non-nutritional interventions. ^

Body mass index of Vietnamese children ages 6--15 years old

Childhood overweight can increase the risk of chronic diseases later in life. To determine the prevalence, trends and determinants of overweight among children ages 6-15 years old in Vietnam, we assessed data on body mass index (BMI) and demographic and socio-economic characteristics obtained from the 1992 Vietnam Living Standard Survey (1992 VLSS), the 1997 Vietnam Living Standard Survey (1997 VLSS), and the 2000 General Nutrition Survey (2000 GNS). These surveys used multi-stage cluster sample designs to produce nationally representative samples of Vietnamese children ages 6-15 years in 1992-1993, 1997-1998 and 2000. BMI classification was determined using cut-off values set by the International Obesity Task Force (IOTF). The mean prevalence of at risk of overweight and overweight among Vietnamese children rapidly increased from 0.4% in 1992 to 2.0% in 2000, along with a high prevalence of underweight (33.4% in 2000). Increases in weight, height and BMI varied according to gender, area of residence and socioeconomic status. Age, areas of residence and education of the household head are statistically significant predictors of at risk of overweight and overweight. This study identified the prevalence and trends of weight among children crucial to understanding the prevention of child overweight in Vietnam. ^

Determinants of adherence to highly active antiretroviral therapy for HIV-infected children: A research synthesis

Highly active antiretroviral therapy (HAART) has taken HIV-infection from a rapidly terminal illness to one that is a slowly progressive, chronic illness. HIV-infected children can now live long, normal lives. Today, four classes of antiretroviral medications are widely used and several antiretrovirals are available in each class, but resistance and cross-resistance to these medications can occur very quickly if the patient does not adhere to strict medication dosing guidelines. One method to improve pediatric adherence to antiretrovirals is to focus on identified determinants of adherence at clinical visits, but very few studies have been conducted to identify determinants of adherence to antiretrovirals and the best methods to measure adherence in the pediatric population. This research synthesis found adherence factors related to children can be divided into child-identified factors and caregiver-identified factors. Child identified factors include medication-related, demographic-related, cognitive-related, psychosocial-related, and biological marker-related barriers to adherence. Caregiver identified factors include medication-related, cognitive-related, relationship-related, and psychosocial-related barriers to adherence. More randomized clinical trials are needed to identify determinants to adherence, identify methods to best measure adherence, and to identify the best interventions to improve adherence in HIV-infected children and adolescents. ^

Determinants of cervical cancer screening among women workers in Monterrey, Mexico

Introduction. Cervical cancer is the most common and lethal cancer among Mexican women. A nationwide cervical cancer screening program established in 1974 has had little impact on cervical cancer incidence or mortality rates. This case-control study was designed to determine the association between knowledge factors and structural, organizational, and sociocultural perceptions related to adherence to cervical cancer screening guidelines among women living and working in Monterrey, Mexico.^ Methods. Cases were defined as sexually active female store clerks ages 18-64 who do not adhere to cervical cancer screening guidelines in accordance with the Official Mexican Standard (Norma Oficial Mexicana, NOM 014-SSA2-1994). Controls were defined as sexually active female store clerks ages 18-64 who do adhere to cervical cancer screening guidelines in accordance with the NOM. Participants (N = 229) answered survey questions regarding cervical cancer screening practices as well as their knowledge and perceptions about screening for cervical cancer. Two multivariate logistic regression models were built to analyze (1) knowledge factors and (2) perceptions significantly associated with adherence in univariate analysis.^ Results. Having no or inaccurate knowledge of national cervical cancer screening guidelines (OR = 11.05, 95%CI: 4.28, 28.54) and no knowledge of the utility of the Papanicolaou (Pap) exam (OR = 6.77, 95%CI: 0.99, 46.43) were risk factors for non-adherence to cervical cancer screening guidelines. Perceptions of fear or embarrassment of the Pap exam (OR = 16.17, 95%CI: 5.08, 51.49) and lower levels of spousal or partner acceptance of the Pap exam (OR = 5.82, 95%CI: 1.34, 25.31) were risk factors for non-adherence to cervical cancer screening guidelines.^ Conclusion. Knowledge factors and sociocultural perceptions related to cervical cancer screening were strong predictors of adherence to screening guidelines. Future studies may be able to further explore these findings with larger sample sizes and in other populations in Mexico. By identifying these factors, future population-specific recommendations and interventions to increase screening rates can be formulated with the long-term goal of reducing morbidity and mortality from cervical cancer among Mexican women.^

The determinants of sexually transmitted infection screening uptake among African American young adults: A systematic review

Objective. To conduct a systematic review of literature to determine the factors associated with STI including HIV screening uptake among African American young adults in the United States. ^ Methods. The electronic databases OVID Medline and OVID PsycINFO were systematically searched to identify potentially relevant articles. Ninety-six articles were initially identified, five of which were included in the final review. ^ Results. The results of this review were inconclusive. There was no definitive evidence to suggest which determinants were predictive of screening uptake. ^ Conclusions. There is a limited body of literature examining the demographic and behavioral risk factors associated with uptake or non-uptake of STI including HIV screening among African American young adult populations. This finding points to the need for more quality research to be conducted in this area. ^

The welfare state determinants of health: Implications of regimes and pathways

Background. Population health within and between nations is heavily influenced by political determinants, yet these determinants have received significantly less attention than socioeconomic factors in public health. It has been hypothesized that the welfare state, as a political variable, may play a particularly prominent role in affecting both health indicators and health disparities in developed countries. The research, however, provides conflicting evidence regarding the health impact of particular regimes over others and the mechanisms through which the welfare state can most significantly affect health.^ Objective. To perform a systematic review of the literature as a means of exploring what the current research indicates regarding the benefits or detriments of particular regimes styles and the pathways through which the welfare state can impact heath indicators and health disparities within developed countries.^ Methods. A thorough search of the EBSCO, Pubmed, Medline, Web of Science, and Scopus electronic databases was conducted and resulted in the identification of 15 studies that evaluated the association between welfare state regime and population health outcomes, and/or pathways through with the welfare state influences health. ^ Results. Social democratic countries tended to perform best when infant mortality rate (IMR) was the primary outcome of interest, whereas liberal countries performed strongly in relation to self perceived health. The results were mixed regarding welfare state effectiveness in mitigating health inequities, with Christian democratic countries performing as well as social democratic countries. In relation to welfare state pathways, public health spending and medical coverage were associated with positive health indicators. Redistributive impact of the welfare state was also consistently associated with better health outcomes while social security expenditures were not.^ Discussion/Conclusions. Studies consistently discovered a significant relationship between the welfare state and population health and/or health disparities, lending support to the hypothesis that the welfare state is, indeed, an important non-medical determinant of health. However, it is still fairly unclear which welfare state regime may be most protective for health, as results varied according to the measured health indicator. The research regarding welfare state pathways is particularly undeveloped, and does not provide much insight into the importance of in-kind service provision or cash transfers, or targeted or universal approaches to the welfare state. Suggestions to direct future research are provided.^

The application of latent variable models to the assessment of determinants of HIV risk behavior

Studies on the relationship between psychosocial determinants and HIV risk behaviors have produced little evidence to support hypotheses based on theoretical relationships. One limitation inherent in many articles in the literature is the method of measurement of the determinants and the analytic approach selected. ^ To reduce the misclassification associated with unit scaling of measures specific to internalized homonegativity, I evaluated the psychometric properties of the Reactions to Homosexuality scale in a confirmatory factor analytic framework. In addition, I assessed the measurement invariance of the scale across racial/ethnic classifications in a sample of men who have sex with men. The resulting measure contained eight items loading on three first-order factors. Invariance assessment identified metric and partial strong invariance between racial/ethnic groups in the sample. ^ Application of the updated measure to a structural model allowed for the exploration of direct and indirect effects of internalized homonegativity on unprotected anal intercourse. Pathways identified in the model show that drug and alcohol use at last sexual encounter, the number of sexual partners in the previous three months and sexual compulsivity all contribute directly to risk behavior. Internalized homonegativity reduced the likelihood of exposure to drugs, alcohol or higher numbers of partners. For men who developed compulsive sexual behavior as a coping strategy for internalized homonegativity, there was an increase in the prevalence odds of risk behavior. ^ In the final stage of the analysis, I conducted a latent profile analysis of the items in the updated Reactions to Homosexuality scale. This analysis identified five distinct profiles, which suggested that the construct was not homogeneous in samples of men who have sex with men. Lack of prior consideration of these distinct manifestations of internalized homonegativity may have contributed to the analytic difficulty in identifying a relationship between the trait and high-risk sexual practices. ^