The Evolution of Inequity in the Access to Health Care in Spain: 1987-2001

This paper reports an analysis of the evolution of income related health inequalities in Spain over the period 1987-2001. We use recently developed methods in order to cardinalise and model self assessed health within a regression framework, decompose the sources of inequality and explain the observed differences between 1987 (one year after the 1986 General Health Act was approved) and 2001 (the latest available representative data on health for the Spanish population). The results show that the period has witnessed a reduction in income related health inequality. The driver of such reduction has been the weakening of the income health gradient, which lends support to the hypothesis that the important health policy reforms implemented over the period have been successful in the objective of reducing socio-economic inequalities in health. Our results also suggest that actions aimed at improving the health of those with low levels of education and of those who are not actively participating in the labor market would lead to further reductions in income related health inequality.

Health correlates of overweight and obesity in adults aged 50 years and over: results from the Survey of Health, Ageing and Retirement in Europe (SHARE)

QUESTIONS UNDER STUDY: To examine the association between overweight/obesity and several self-reported chronic diseases, symptoms and disability measures. METHODS: Data from eleven European countries participating in the Survey of Health, Ageing and Retirement in Europe were used. 18,584 non-institutionalised individuals aged 50 years and over with BMI > or = 18.5 (kg/m2) were included. BMI was categorized into normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9) and obesity (BMI > or = 30). Dependent variables were 13 diagnosed chronic conditions, 11 health complaints, subjective health and physical disability measures. For both genders, multiple logistic regressions were performed adjusting for age, socioeconomic status and behaviour risks. RESULTS: The odds ratios for high blood pressure, high cholesterol, diabetes, arthritis, joint pain and swollen legs were significantly increased for overweight and obese adults. Compared to normal-weight individuals, the odds ratio (OR) for reporting > or = 2 chronic diseases was 2.4 (95% CI 1.9-2.9) for obese men and 2.7 (95% CI 2.2-3.1) for obese women. Overweight and obese women were more likely to report health symptoms. Obesity in men (OR 0.5, 95% CI 0.4-0.6), and overweight (OR 0.5, 95% CI 0.4-0.6) and obesity (OR 0.4, 95% CI 0.3-0.5) in women, were associated with poorer subjective health (i.e. a decreased risk of reporting excellent, very good or good subjective health). Disability outcomes were those showing the greatest differences in strength of association across BMI categories, and between genders. For example, the OR for any difficulty in walking 100 metres was non-significant at 0.8 for overweight men, at 1.9 (95% CI 1.3-2.7) for obese men, at 1.4 (95% CI 1.1-1.8) for overweight women, and at 3.5 (95% CI 2.6-4.7) for obese women. CONCLUSIONS: These results highlight the impact of increased BMI on morbidity and disability. Healthcare stakeholders of the participating countries should be aware of the substantial burden that obesity places on the general health and autonomy of adults aged over 50.

The evolution of inequity in the access to health care in Spain: 1987-2001

This paper reports an analysis of the evolution of equity in access to health care in Spain over the period 1987-2001, a time span covering the development of the modern Spanish National Health System. Our measures of access are the probabilities of visiting a doctor, using emergency services and being hospitalised. For these three measures we obtain indices of horizontal inequity from microeconometric models of utilization that exploit the individual information in the Spanish National Health Surveys of 1987 and 2001. We find that by 2001 the system has improved in the sense that differences in income no longer lead to different access given the same level of need. However, the tenure of private health insurance leads to differences in access given the same level of need, and its contribution to inequity has increased over time, both because insurance is more concentrated among the rich and because the elasticity of utilization for the three services has increased too.

Cumulative risk factors for adolescent alcohol misuse and its perceived consequences among 16 to 20 year old adolescents in Switzerland.

AIMS: To assess the cumulative impact of environmental and individual factors associated with adolescent alcohol misuse and their correlation with self-reported consequences of drinking. METHOD: Cross-sectional school-based survey of a nationally representative sample of 7548 post-mandatory school students and apprentices aged 16-20 years, Switzerland 2002. Alcohol misuse defined by frequency of alcohol use, episodes of drunkenness and driving while drunk. RESULTS: Fifteen significant risk factors were identified among both boys, and girls. An individual score of cumulated risk factors was created by adding the risk factors. The association between the score and the likelihood of being engaged in alcohol misuse was highly significant and dose-dependent (p<.001). A significant proportion of adolescents report perceived adverse consequences of their alcohol consumption. A linear trend (p<.001) was found between the score of risk factors and the proportion of respondents reporting problems related to drinking such as diminished school performance, physical hazard, relational problems and current risky sexual behavior. CONCLUSION: Risk factors for adolescent alcohol misuse are cumulative and can be synthesized into an individual score correlated with the likeliness of misuse. A further indication of the validity of this score is its linear relationship with self-reported problems related to drinking.

Parents' willingness to pay for diminishing children's pain during blood sampling.

BACKGROUND: Blood sampling is a frequent medical procedure, very often considered as a stressful experience by children. Local anesthetics have been developed, but are expensive and not reimbursed by insurance companies in our country. We wanted to assess parents' willingness to pay (WTP) for this kind of drug. PATIENTS AND METHODS: Over 6 months, all parents of children presenting for general (GV) or specialized visit (SV) with blood sampling. WTP was assessed through three scenarios [avoiding blood sampling (ABS), using the drug on prescription (PD), or over the counter (OTC)], with a payment card system randomized to ascending or descending order of prices (AO or DO). RESULTS: Fifty-six responses were collected (34 GV, 22 SV, 27 AO and 29 DO), response rate 40%. Response distribution was wide, with median WTP of 40 for ABS, 25 for PD, 10 for OTC, which is close to the drug's real price. Responses were similar for GV and SV. Median WTP amounted to 0.71, 0.67, 0.20% of respondents' monthly income for the three scenarios, respectively, with a maximum at 10%. CONCLUSIONS: Assessing parents' WTP in an outpatient setting is difficult, with wide result distribution, but median WTP is close to the real drug price. This finding could be used to promote insurance coverage for this drug.

Adherence to and effectiveness of highly active antiretroviral treatment for HIV infection: assessing the bidirectional relationship.

BACKGROUND: It is well established that high adherence to HIV-infected patients on highly active antiretroviral treatment (HAART) is a major determinant of virological and immunologic success. Furthermore, psychosocial research has identified a wide range of adherence factors including patients' subjective beliefs about the effectiveness of HAART. Current statistical approaches, mainly based on the separate identification either of factors associated with treatment effectiveness or of those associated with adherence, fail to properly explore the true relationship between adherence and treatment effectiveness. Adherence behavior may be influenced not only by perceived benefits-which are usually the focus of related studies-but also by objective treatment benefits reflected in biological outcomes. METHODS: Our objective was to assess the bidirectional relationship between adherence and response to treatment among patients enrolled in the ANRS CO8 APROCO-COPILOTE study. We compared a conventional statistical approach based on the separate estimations of an adherence and an effectiveness equation to an econometric approach using a 2-equation simultaneous system based on the same 2 equations. RESULTS: Our results highlight a reciprocal relationship between adherence and treatment effectiveness. After controlling for endogeneity, adherence was positively associated with treatment effectiveness. Furthermore, CD4 count gain after baseline was found to have a positive significant effect on adherence at each observation period. This immunologic parameter was not significant when the adherence equation was estimated separately. In the 2-equation model, the covariances between disturbances of both equations were found to be significant, thus confirming the statistical appropriacy of studying adherence and treatment effectiveness jointly. CONCLUSIONS: Our results, which suggest that positive biological results arising as a result of high adherence levels, in turn reinforce continued adherence and strengthen the argument that patients who do not experience rapid improvement in their immunologic and clinical statuses after HAART initiation should be prioritized when developing adherence support interventions. Furthermore, they invalidate the hypothesis that HAART leads to "false reassurance" among HIV-infected patients.

Social inequalities of functioning and perceived health in Switzerland: a representative cross-sectional analysis.

Many people worldwide live with a disability, i.e. limitations in functioning. The prevalence is expected to increase due to demographic change and the growing importance of non-communicable disease and injury. To date, many epidemiological studies have used simple dichotomous measures of disability, even though the WHO's International Classification of Functioning, Disability, and Health (ICF) provides a multi-dimensional framework of functioning. We aimed to examine associations of socio-economic status (SES) and social integration in 3 core domains of functioning (impairment, pain, limitations in activity and participation) and perceived health. We conducted a secondary analysis of representative cross-sectional data of the Swiss Health Survey 2007 including 10,336 female and 8,424 male Swiss residents aged 15 or more. Guided by a theoretical ICF-based model, 4 mixed effects Poisson regressions were fitted in order to explain functioning and perceived health by indicators of SES and social integration. Analyses were stratified by age groups (15-30, 31-54, ≥55 years). In all age groups, SES and social integration were significantly associated with functional and perceived health. Among the functional domains, impairment and pain were closely related, and both were associated with limitations in activity and participation. SES, social integration and functioning were related to perceived health. We found pronounced social inequalities in functioning and perceived health, supporting our theoretical model. Social factors play a significant role in the experience of health, even in a wealthy country such as Switzerland. These findings await confirmation in other, particularly lower resourced settings.

A constructivist grounded theory of firefighter perceptions of stress, coping and the relationship to health

This qualitative research was a constructivist grounded theory designed to develop an understanding of how firefighters perceive and cope with stressful situations and the impact this has on their perceptions of health. This study was framed in a social ecological perspective with the community of firefighting providing the environment within which to explore stress and coping. Of particular concern here are the stressors associated with firefighting. Prior research with firefighters has often been epidemiological and statistical in nature, focusing on measures of cardiovascular disease, cancer, and depression (Baker & Williams, 2001 ; Brown et al., 2002; Murphy et al.,1999; Regehr et al., 2002; Regehr et al., 2003). Qualitative research examining the perception of stress among firefighters that includes personal stories allows firefighters the opportunity to describe what it is like to be met with physically and mentally challenging situations on a daily basis. Twelve in-depth, semi-structured, face-to-face interviews with a brief questionnaire were conducted with firefighters from a Southern Ontario Fire Department. Four main themes emerged describing the persona of the firefighter, the stressors of firefighters, coping strategies of firefighters, and firefighters' perceptions of health. Stressors include requirements of the job, traumatic calls, tensions with co-workers, the struggle between the family at home and the family at work, political stressors with the City, and the inner struggle. Avoidance coping, approach coping, and gaining perspective emerged as the three coping styles of firefighters. Health was defined as including physical, mental, social and spiritual aspects. A model of the findings is provided that depicts the cyclical nature of the stress-coping-health relationship among firefighters.

The right to health, the TRIPS agreement and the public health safeguards to encourage the universal access to essential medicines

The privileges arising from patent protection on pharmaceutical products often prevent the full realization of the right to health, especially in developing countries with scarce resources. This thesis first identifies the international agreements that have established the right to health in international law, obligations and violations associated with it, the problems encountered in the implementation of human rights on the field, compared with the implementation and sanctions associated with economic rights from the World Trade Organization regulatory framework. A comparative study of the legislative frameworks of both developed and developing countries will reveal to what extent Canada, the United States, the European Union, Brazil, India, and South Africa conformed with patent protection exceptions arising from international patent law to protect public health. Finally, the author identifies the crucial indicators that need to be considered in order to assess the conformity of a given approach with the right to health, before he underscores the temporary character of the relevant WTO measures, and the future stakes concerning an increased access to essential medicines.