Geographic distribution of need and access to health care in rural population: an ecological study in Iran

Abstract Introduction Equity in access to and utilization of health services is a common goal of policy-makers in most countries. The current study aimed to evaluate the distribution of need and access to health care services among Iran's rural population between 2006 and 2009. Methods Census data on population's characteristics in each province were obtained from the Statistical Centre of Iran and National Organization for civil registration. Data about the Rural Health Houses (RHHs) were obtained from the Ministry of Health. The Health Houses-to-rural population ratio (RHP), crude birth rate (CBR) and crude mortality rate (CMR) in rural population were calculated in order to compare their distribution among the provinces. Lorenz curves of RHHs, CMR and CBR were plotted and their decile ratio, Gini Index and Index of Dissimilarity were calculated. Moreover, Spearman rank-order correlation was used to examine the relation between RHHs and CMR and CBR. Results There were substantial differences in RHHs, CMR and CBR across the provinces. CMR and CBR experienced changes toward more equal distributions between 2006 and 2009, while inverse trend was seen for RHHs. Excluding three provinces with markedly changes in data between 2006 and 2009 as outliers, did not change observed trends. Moreover; there was a significant positive relationship between CMR and RHP in 2009 and a significant negative association between CBR and RHP in 2006 and 2009. When three provinces with outliers were excluded, these significant associations were disappeared. Conclusion Results showed that there were significant variations in the distribution of RHHs, CMR and CBR across the country. Moreover, the distribution of RHHs did not reflect the needs for health care in terms of CMR and CBR in the study period.</p

Road traffic injuries in the context of rapid motorization- Studies on access, provision and utilization of trauma care in Iran

Background: Iran has one of the highest traffic-related mortality and morbidity rates in the world. Evidence shows that improvements in trauma care can prevent a substantial number of road traffic deaths and disabilities. Aim: The overall aim of this thesis is to explore factors influencing access, provision and utilization of trauma care for road traffic injuries (RTIs) in Iran. Methods: The thesis is based on four studies. Study I is a national ecological study in order to assess if the distribution of pre-hospital trauma care resources reflects the needs in terms of traffic-related mortality and morbidity in different provinces in Iran. Inequality measures and correlation analysis were used in the analysis. In Study II, qualitative interviews were conducted with 15 health professionals to explore factors influencing the provision of pre-hospital trauma care for RTI victims. In Study III, qualitative interviews were conducted with 15 health professionals and 20 RTI victims to explore factors influencing an effective trauma care delivery at emergency departments (EDs). The grounded theory approach was used in both Study II and III. Study IV utilized the Iranian National Trauma Registry Database to assess hospital resource utilization (hospital charges and length of stay (LOS)) associated with RTIs in Iran and also to evaluate the association with the patients’ socio-demographic characteristics, insurance status and injury-related factors. Univariable and multivariable analysis were used in this study. Findings: There was no significant association between traffic-related mortality and morbidity and pre-hospital trauma care resources (I). Seven main factors that could hinder or facilitate an effective pre-hospital trauma care process were identified: administration and organization; staff qualifications and competences; availability and distribution of resources; communication and transportation; involved organizations; laypeople; and infrastructure (II). Lack of a systematic approach to providing trauma care at EDs emerged as the core category in Study III. Unclear national policies and poor organization of care at the ED were perceived as the main factors contributed to non-systematic approach but the contextual factors in the hospitals and those specific to the context of Iran also played a role. The mean (SD) total hospital charges and LOS for the patients were US$165 (US$ 290) and 6.8 days (8), respectively. Older age, being female, lower level of education, higher injury severity and longer LOS were associated with higher hospital charges. Longer LOS was associated with being male, lower education, having a medical insurance, being a farmer or a blue-collar worker and having more severe injuries (IV). Conclusion: Pre-hospital trauma care resources across the country were not distributed based on needs in terms of traffic-related mortality and morbidity. For the provision of trauma care, the studies identified that there is a lack of interaction and common understanding among different actors involved in the pre-hospital trauma care and a non-systematic approach as the main barrier to managing trauma patients in the EDs. The findings indicated that the hospital resource utilization associated with RTI victims is substantial and varied based on the victims’ socio-demographic characteristics, insurance status and injury-related factors. Both the pre-hospital and hospital organization, and interaction between them, need to be considered in order to reduce the high burden of RTIs in Iran

The "ComPAS Trial" combined treatment model for acute malnutrition: study protocol for the economic evaluation.

BACKGROUND: Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM. METHOD: This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant. DISCUSSION: We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies. TRIAL REGISTRATION: ISRCTN 30393230 , date: 16/03/2017

A systematic review of barriers and facilitators to antenatal screening for HIV, syphilis or hepatitis B in Asia: Perspectives of pregnant women, their relatives and health care providers

Background: Despite improvements, the prevalence of HIV, syphilis, and hepatitis B remains high in Asia. These sexually transmitted infections (STIs) can be transmitted from infected mothers to their children. Antenatal screening and treatment are effective interventions to prevent mother-to-child transmission (MTCT), but coverage of antenatal screening remains low. Understanding factors influencing antenatal screening is essential to increase its uptake and design effective interventions. This systematic literature review aims to investigate barriers and facilitators to antenatal screening for HIV, syphilis, and hepatitis B in Asia. // Methods: We conducted a systematic review by searching Ovid (MEDLINE, Embase, PsycINFO), Scopus, Global Index Medicus and Web of Science for published articles between January 2000 and June 2023, and screening abstracts and full articles. Eligible studies include peer-reviewed journal articles of quantitative, qualitative and mixed-method studies that explored factors influencing the use of antenatal screening for HIV, syphilis or hepatitis B in Asia. We extracted key information including study characteristics, sample, aim, identified barriers and facilitators to screening. We conducted a narrative synthesis to summarise the findings and presented barriers and facilitators following Andersen’s conceptual model. // Results: The literature search revealed 23 articles suitable for inclusion, 19 used quantitative methods, 3 qualitative and one mixed method. We found only three studies on syphilis screening and one on hepatitis B. The analysis demonstrates that antenatal screening for HIV in Asia is influenced by many barriers and facilitators including (1) predisposing characteristics of pregnant women (age, education level, knowledge) (2) enabling factors (wealth, place of residence, husband support, health facilities characteristics, health workers support and training) (3) need factors of pregnant women (risk perception, perceived benefits of screening). // Conclusion: Knowledge of identified barriers to antenatal screening may support implementation of appropriate interventions to prevent MTCT and help countries achieve Sustainable Development Goals’ targets for HIV and STIs

Socio-economic inequalities in adolescent mental health in the UK: Multiple socio-economic indicators and reporter effects

There are socio-economic inequalities in the experience of mental ill-health. However, less is known about the extent of inequalities by different indicators of socio-economic position (SEP). This is relevant for insights into the mechanisms by which these inequalities arise. For young people's mental health there is an additional layer of complexity provided by the widespread use of proxy reporters. Using data from the UK Millennium Cohort Study (N ​= ​10,969), we investigated the extent to which five SEP indicators (parent education, household income, household wealth, parent occupational status, and relative neighbourhood deprivation) predict adolescent internalising mental health (at ages 14 and 17 years) and how this varies as a function of reporter. Both parent report and adolescent self-report were considered. Regression models demonstrated that whilst greater disadvantage in all five SEP indicators were associated with greater parent-reported adolescent mental health symptoms, only income, wealth, and occupational status were associated with self-reported mental health symptoms at ages 14 and 17 years. The magnitude of these effects was greater for parent-reported than self-reported adolescent internalising symptoms: SEP indicators jointly predicted 4.73% and 4.06% of the variance in parent-reported symptoms at ages 14 and 17 compared to 0.58% and 0.60% of the variance in self-reported internalising mental health. Household income predicted the most variance in parent reported adolescent internalising symptoms (2.95% variance at age 14 & 2.64% at age 17) and wealth the most for self-reported internalising symptoms (0.42% variance at age 14 & 0.36% at age 17). Interestingly, the gradient and variance explained of parent-reported adolescent mental health across SEP indicators mirrors that of parent's own mental health (for example, income explained 4.89% variance at the age 14 sweep). Our findings highlight that the relevance of different SEP indicators to adolescent internalising mental health differs between parent and adolescent reports. Therefore, it is important to consider the various perspectives of mental health inequalities gained from different types of reporter

Cost-effectiveness of integrated maternal HIV, syphilis, and hepatitis B screening opt-out strategies in Nepal: a modelling study

Background: The World Health Organisation (WHO) developed a comprehensive framework encouraging an integrated approach to achieve triple elimination of vertical transmission of HIV, syphilis, and hepatitis B in Asia. Current screening practices in Nepal show significantly lower coverage for syphilis and hepatitis B compared to HIV suggesting potential for integration. In this study, we aimed to model the cost-effectiveness of triple screening during antenatal care in Nepal. // Methods: We modelled maternal HIV, hepatitis B, and syphilis cascade of care and their corresponding disease states using disease-specific Markov models over a 20-year horizon with a cycle length of one year. We compared dual integrated screening for HIV and syphilis and triple integrated screening for HIV, syphilis, and hepatitis B with HIV screening only. Costs were estimated from a provider's perspective. Results were presented as incremental cost-effectiveness ratios (ICERs). Univariable and probabilistic sensitivity analyses were conducted. // Findings: Our modelling analysis showed that dual-integrated screening for HIV and syphilis was highly cost-effective when compared to current strategy of screening for HIV only (ICERs of US$18). Triple-integrated antenatal screening for HIV, syphilis, and hepatitis B was highly cost-effective compared with dual-integrated strategy with an ICER of US$114. Moreover, 100% and 98% of the probabilistic sensitivity analysis estimates for dual- and triple-integrated screening were proven cost-effective, compared to HIV-only screening. // Interpretation: Our results support WHO recommendations for implementing integrated triple antenatal screening in Nepal and Asia more broadly, aiming to reduce maternal and neonatal morbidity through early detection and intervention. // Funding: No funding was reported

Assessing the efficiency of countries in making progress towards universal health coverage: a data envelopment analysis of 172 countries.

INTRODUCTION: Maximising efficiency of resources is critical to progressing towards universal health coverage (UHC) and the sustainable development goal (SDG) for health. This study estimates the technical efficiency of national health spending in progressing towards UHC, and the environmental factors associated with efficient UHC service provision. METHODS: A two-stage efficiency analysis using Simar and Wilson's double bootstrap data envelopment analysis investigates how efficiently countries convert health spending into UHC outputs (measured by service coverage and financial risk protection) for 172 countries. We use World Bank and WHO data from 2015. Thereafter, the environmental factors associated with efficient progress towards UHC goals are identified. RESULTS: The mean bias-corrected technical efficiency score across 172 countries is 85.7% (68.9% for low-income and 95.5% for high-income countries). High-achieving middle-income and low-income countries such as El Salvador, Colombia, Rwanda and Malawi demonstrate that peer-relative efficiency can be attained at all incomes. Governance capacity, income and education are significantly associated with efficiency. Sensitivity analysis suggests that results are robust to changes. CONCLUSION: We provide a 2015 baseline for cross-country UHC technical efficiency scores. If countries wish to improve their UHC outputs within existing budgets, they should identify their current efficiency and try to emulate more efficient peers. Policy-makers should focus on strengthening institutions and implementing known best practices to replicate efficient systems. Using resources more efficiently is likely to positively impact UHC coverage goals and health outcomes, and without addressing gaps in efficiency progress towards achieving the SDGs will be impeded

Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: A qualitative study

In Nepal, national guidelines recommend free HIV and syphilis screening for pregnant women at their first antenatal visit, using an opt-out approach. However, screening uptake is low and the guidelines do not include hepatitis B screening. It is essential to understand the factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B, as recommended by WHO, to improve uptake and prevent vertical transmission. This study explored the knowledge, attitudes, and perceptions of pregnant women, their families, healthcare providers and policymakers on integrated prenatal screening. We conducted 12 in-depth interviews with pregnant women, 10 with their husbands and 4 with mothers-in-law in Kapilvastu and Kathmandu. In addition, we interviewed 7 health workers and 4 decision-makers. These interviews were sufficient to reach saturation. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting data. The analysis showed that antenatal screening in Nepal involved many stakeholders and was influenced by various factors. Implementation issues were found in the building blocks service delivery, health workforce and medical products. Husbands and in-laws play an important role in the acceptance of screening by pregnant women, especially in rural areas. High levels of stigma and discrimination against people with sexually transmitted diseases were reported, and knowledge of hepatitis B and syphilis was low. Access and uptake of screening could be improved through rapid testing, by strengthening the health system and by integrating hepatitis B screening through an opt-out approach like that for HIV and syphilis. Effective community involvement through awareness campaigns and investment in lower-level health facilities is essential to improve screening rates. This study provides information for decision-makers about challenges in implementing integrated screening to guide the design of targeted interventions to reduce vertical transmission

Factors associated with women's healthcare decision-making during and after pregnancy in urban slums in Mumbai, India: a cross-sectional analysis

BACKGROUND: Understanding factors associated with women's healthcare decision-making during and after pregnancy is important. While there is considerable evidence related to general determinants of women's decision-making abilities or agency, there is little evidence on factors associated with women's decision-making abilities or agency with regards to health care (henceforth, health agency), especially for antenatal and postnatal care. We assessed women's health agency during and after pregnancy in slums in Mumbai, India, and examined factors associated with increased participation in healthcare decisions. METHODS: Cross-sectional data were collected from 2,630 women who gave birth and lived in 48 slums in Mumbai. A health agency module was developed to assess participation in healthcare decision-making during and after pregnancy. Linear regression analysis was used to examine factors associated with increased health agency. RESULTS: Around two-thirds of women made decisions about perinatal care by themselves or jointly with their husband, leaving about one-third outside the decision-making process. Participation increased with age, secondary and higher education, and paid employment, but decreased with age at marriage and household size. The strongest associations were with age and household size, each accounting for about a 0.2 standard deviation difference in health agency score for each one standard deviation change (although in different directions). Similar differences were observed for those in paid employment compared to those who were not, and for those with higher education compared to those with no schooling. CONCLUSION: Exclusion of women from maternal healthcare decision-making threatens the effectiveness of health interventions. Factors such as age, employment, education, and household size need to be considered when designing health interventions targeting new mothers living in challenging conditions, such as urban slums in low- and middle-income countries