Essays in ‘global’ health utilization: How distance, gender, and stigma condition whether and when we seek care

The landscape of health service use varies across, and even within, countries and health sectors irrespective of payment model or health system, yet the fundamental purpose motivating its study is aimed at overcoming the challenges that prevent better and equitable uptake of effective interventions. This dissertation is fuelled by such purpose. Although each chapter poses a specific utilization question relevant to a unique target population, in its entirety, this work seeks to answer the following cross-cutting questions: (i) what are the factors that encourage and challenge utilization of health services, (ii) under which moderating conditions and through which channels is improved utilization supported, and (iii) how can a better understanding of the antecedents of improved utilization contribute to the design of well-targeted health interventions. In Chapter 1, we show that participation in health insurance increases the probability of meeting medical needs while decreasing the probability of incurring catastrophic out-of-pocket health payments in Ghana. Drawing on nationally representative survey data from India, Chapter 2 offers causal insight into the effect of female empowerment, in the form of marital age, on women’s utilization of cervical and breast screening. Our findings suggest that losses in female empowerment attributed to early marriage partly explain Indian women’s low cervical and breast screening participation. Aiming to contribute a better understanding of health utilization among hard-to-reach groups, Chapter 3 investigates the factors that determine the extent of thought given to screening in a sample of high-risk heavy smokers who attended the first free lung cancer screening program in Italy. We show that individuals with greater life-time smoking exposure, and therefore at higher risk of developing lung cancer, tend to contemplate screening less. Finally, Chapter 4 evaluates the cost-effectiveness of a population-based lung cancer screening program targeting high-risk prior and current heavy smokers (≥20 pack-years) aged between 55 and 74 years, in Italy. In doing so, we explore the economic relevance of programs designed with a view towards improving screening participation within hard-to-reach target populations. We offer evidence that rendering an annual LDCT-based screening – with three varying screening invitation strategies – available to the Italian heavy smoker population is more effective, yet more costly, than current clinical practice from the perspective of the national budget holder. Thus, in seeking to offer insight into the factors that encourage and challenge utilization, the conditions and channels that sustain it, and the design of programs that may, in turn, be sustained by it, this dissertation positions health utilization at centre stage

Social inequality impacts upon mental health, with the less educated more likely to have psychological problems but less likely to seek treatment

Mental health is a key policy issue across Europe. Lucia Fiestas Navarrete, Mahlet Atakilt Woldetsadik and Antoine Flahault take a comprehensive look at the roles education and gender play in mental health problems in 15 European countries. They note that individuals with lower levels of education are more likely to experience psychological problems, but are also less likely to seek treatment by consulting a psychologist or taking medication. The fact that education may function as a proxy for socio-economic status suggests that socially determined inequalities have an impact on mental health outcomes

Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana

A central pillar of universal health coverage (UHC) is to achieve financial protection from catastrophic health expenditure. There are concerns, however, that national health insurance programmes with premiums may not benefit impoverished groups. In 2003, Ghana became the first sub-Saharan African country to introduce a National Health Insurance Scheme (NHIS) with progressively structured premium charges. In this study, we test the impact of being insured on utilization and financial risk protection compared with no enrolment, using the 2012-13 Ghana Living Standards Survey (n = 72 372). Consistent with previous studies, we observed that participating in health insurance significantly decreased the probability of unmet medical needs by 15 percentage points (p.p.) and that of incurring catastrophic out-of-pocket (OOP) health payments by 7 p.p. relative to no enrolment in the NHIS. Households living outside a 1-h radius to the nearest hospital had lower reductions in financial risk from excess OOP medical spending relative to households living closer (-5 p.p. vs -9 p.p.). We also find evidence that in Ghana, the scheme was highly pro-poor. Once insured, the poorest 40% of households experienced significantly larger improvements in medical utilization (18 p.p. vs. 8 p.p.) and substantively larger reductions in catastrophic OOP health expenditure (-10 p.p. vs. -6 p.p.) compared with that of the richest households. However, health insurance did not benefit vulnerable persons equally from financial risk. Once insured, poor, low-educated and self-employed households living far from hospitals had significantly lower reductions in catastrophic OOP medical spending compared with their counterparts living closer. Taken together, we show that enrolment in the NHIS is associated with improved financial protection but less so among geographically remote vulnerable groups. Efforts to boost not just insurance uptake but also health service delivery may be needed as a supplement for insurance schemes to accelerate progress towards UHC

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe.

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached

Recommendations for implementing lung cancer screening with low-dose computed tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39–61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the “Initiative for European Lung Screening (IELS)”—a large international group of physicians and other experts concerned with lung cancer—agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached