Are estimates of socioeconomic inequalities in chronic disease artefactually narrowed by self-reported measures of prevalence in low-income and middle-income countries? Findings from the WHO-SAGE survey

Background: The use of self-reported measures of chronic disease may substantially underestimate prevalence in low-income and middle-income country settings, especially in groups with lower socioeconomic status (SES). We sought to determine whether socioeconomic inequalities in the prevalence of non-communicable chronic diseases (NCDs) differ if estimated by using symptom-based or criterion-based measures compared with self-reported physician diagnoses. Methods: Using population-representative data sets of the WHO Study of Global Ageing and Adult Health (SAGE), 2007–2010 (n=42 464), we calculated wealth-related and education-related concentration indices of self-reported diagnoses and symptom-based measures of angina, hypertension, asthma/chronic lung disease, visual impairment and depression in three ‘low-income and lower middle-income countries’—China, Ghana and India—and three ‘upper-middle-income countries’—Mexico, Russia and South Africa. Results: SES gradients in NCD prevalence tended to be positive for self-reported diagnoses compared with symptom-based/criterion-based measures. In China, Ghana and India, SES gradients were positive for hypertension, angina, visual impairment and depression when using self-reported diagnoses, but were attenuated or became negative when using symptom-based/criterion-based measures. In Mexico, Russia and South Africa, this distinction was not observed consistently. For example, concentration index of self-reported versus symptom-based angina were: in China: 0.07 vs −0.11, Ghana: 0.04 vs −0.21, India: 0.02 vs −0.16, Mexico: 0.19 vs −0.22, Russia: −0.01 vs −0.02 and South Africa: 0.37 vs 0.02. Conclusions: Socioeconomic inequalities in NCD prevalence tend to be artefactually positive when using self-report compared with symptom-based or criterion-based diagnostic criteria, with greater bias occurring in low-income countries. Using standardised, symptom-based measures would provide more valid estimates of NCD inequalities

The political economy of universal health coverage. Background paper for the global symposium on health systems research

This paper is one of several in a series commissioned by the World Health Organization for the First Global Symposium on Health Systems Research, held 16-19 November, 2010, in Montreux, Switzerland. The goal of these papers is to initiate a dialogue on the critical issues in health systems research. The opinions expressed in these papers are those of the authors and do not necessarily reflect those of the symposium organizers. This paper has financial support from the Rockefeller Foundation; the Alliance for Health Policy and Systems Research; and the German Federal Ministry for Economic Cooperation and Development (GTZ)

Fit-for-work or fit-for-unemployment? Does the reassessment of disability benefit claimants using a tougher work capability assessment help people into work?

Background Many governments have introduced tougher eligibility assessments for out-of-work disability benefits, to reduce rising benefit caseloads. The UK government initiated a programme in 2010 to reassess all existing disability benefit claimants using a new functional checklist. We investigated whether this policy led to more people out-of-work with long-standing health problems entering employment. Method We use longitudinal data from the Labour Force Survey linked to data indicating the proportion of the population experiencing a reassessment in each of 149 upper tier local authorities in England between 2010 and 2013. Regression models were used to investigate whether the proportion of the population undergoing reassessment in each area was independently associated with the chances that people out-of-work with a long-standing health problem entered employment and transitions between inactivity and unemployment. We analysed whether any effects differed between people whose main health problem was mental rather than physical. Results There was no significant association between the reassessment process and the chances that people out-of-work with a long-standing illness entered employment. The process was significantly associated with an increase in the chances that people with mental illnesses moved from inactivity into unemployment (HR=1.22, 95% CI 1.03 to 1.45). Conclusions The reassessment policy appears to have shifted people with mental health problems from inactivity into unemployment, but there was no evidence that it had increased their chances of employment. There is an urgent need for services that can support the increasing number of people with mental health problems on unemployment benefits

A systematic review on health resilience to economic crises

Background The health effects of recent economic crises differ markedly by population group. The objective of this systematic review is to examine evidence from longitudinal studies on factors influencing resilience for any health outcome or health behaviour among the general population living in countries exposed to financial crises. Methods We systematically reviewed studies from six electronic databases (EMBASE, Global Health, MEDLINE, PsycINFO, Scopus, Web of Science) which used quantitative longitudinal study designs and included: (i) exposure to an economic crisis; (ii) changes in health outcomes/behaviours over time; (iii) statistical tests of associations of health risk and/or protective factors with health outcomes/behaviours. The quality of the selected studies was appraised using the Quality Assessment Tool for Quantitative Studies. PRISMA reporting guidelines were followed. Results From 14,584 retrieved records, 22 studies met the eligibility criteria. These studies were conducted across 10 countries in Asia, Europe and North America over the past two decades. Ten socio-demographic factors that increased or protected against health risk were identified: gender, age, education, marital status, household size, employment/occupation, income/ financial constraints, personal beliefs, health status, area of residence, and social relations. These studies addressed physical health, mortality, suicide and suicide attempts, mental health, and health behaviours. Women’s mental health appeared more susceptible to crises than men’s. Lower income levels were associated with greater increases in cardiovascular disease, mortality and worse mental health. Employment status was associated with changes in mental health. Associations with age, marital status, and education were less consistent, although higher education was associated with healthier behaviours. Conclusions Despite widespread rhetoric about the importance of resilience, there was a dearth of studies which operationalised resilience factors. Future conceptual and empirical research is needed to develop the epidemiology of resilience

Gender segregation, underemployment and subjective well-being in the UK labour market

This article argues that gender segregation influences patterns of underemployment and the relationships that underemployment has with the subjective well-being of men and women. Previous studies have paid little attention to how gender segregation shapes underemployment, an increasingly prominent feature of the UK and European labour markets since the economic crisis of 2008. Using data from the UK Annual Population Surveys, this article examines time-related underemployment: people working part time because they cannot find a full-time job. The article asks whether there are gender differences in underemployment trends and in the links between underemployment and subjective well-being. The results suggest that the probability of underemployment is growing at a faster rate among women rather than men and that underemployment is most common in the jobs that women are more likely to perform, namely in femaledominated occupations, the public sector and small organizations. Underemployment is least common in male-dominated occupations and industries and in the private sector. Moreover, for employees with longer tenures, underemployment has more negative relationships with the subjective well-being of women than with that of men. These findings imply that gender segregation in labour markets is a crucial factor to consider when researching underemployment and its consequences

‘Dead people don’t claim’: A psychopolitical autopsy of UK austerity suicides

One of the symptoms of post financial crisis austerity in the UK has been an increase in the numbers of suicides, especially by people who have experienced welfare reform. This article develops and utilises an analytic framework of psychopolitical autopsy to explore media coverage of ‘austerity suicide’ and to take seriously the psychic life of austerity (internalisation, shame, anxiety), embedding it in a context of social dis-ease. Drawing on three distinct yet interrelated areas of literature (the politics of affect and psychosocial dynamics of welfare, post and anti-colonial psychopolitics, and critical suicidology), the article aims to better understand how austerity ‘kills’. Key findings include understanding austerity suicides as embedded within an affective economy of the anxiety caused by punitive welfare retrenchment, the stigmatisation of being a recipient of benefits, and the internalisation of market logic that assigns value through ‘productivity’ and conceptualises welfare entitlement as economic ‘burden’. The significance of this approach lies in its ability to widen analytic framing of suicide from an individual and psychocentric focus, to illuminate culpability of government reforms while still retaining the complexity of suicide, and thus to provide relevant policy insights about welfare reform

Paediatric radiology seen from Africa. Part I: providing diagnostic imaging to a young population

Article approval pendingPaediatric radiology requires dedicated equipment, specific precautions related to ionising radiation, and specialist knowledge. Developing countries face difficulties in providing adequate imaging services for children. In many African countries, children represent an increasing proportion of the population, and additional challenges follow from extreme living conditions, poverty, lack of parental care, and exposure to tuberculosis, HIV, pneumonia, diarrhoea and violent trauma. Imaging plays a critical role in the treatment of these children, but is expensive and difficult to provide. The World Health Organisation initiatives, of which the World Health Imaging System for Radiography (WHIS-RAD) unit is one result, needs to expand into other areas such as the provision of maintenance servicing. New initiatives by groups such as Rotary and the World Health Imaging Alliance to install WHIS-RAD units in developing countries and provide digital solutions, need support. Paediatric radiologists are needed to offer their services for reporting, consultation and quality assurance for free by way of teleradiology. Societies for paediatric radiology are needed to focus on providing a volunteer teleradiology reporting group, information on child safety for basic imaging, guidelines for investigations specific to the disease spectrum, and solutions for optimising imaging in children

Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space

Background It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation’s consistency with trade rules may lead to ‘policy or regulatory chill’ effects whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data. Methods and findings Here, we analyse a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. We thematically describe the scope and frequency of trade challenges, analyse economic asymmetries between countries raising and defending them, and summarise 4 cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. ‘Unnecessary’ trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% (n = 72) of all challenges raised against low- and lower-middle–income countries. We further identified 4 cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity. Conclusions Policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. Trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes

Foreign Currency Debt, Financial Crises and Economic Growth: A Long Run View

Foreign currency debt is widely believed to increase risks of financial crisis, especially after being implicated as a cause of the East Asian crisis in the late 1990s. In this paper, we study the effects of foreign currency debt on currency and debt crises and its indirect short and long run effects on output between 1880-1913 and 1973-2003 for 45 countries. Greater ratios of foreign currency debt to total debt are associated with increased risks of currency and debt crises, although the strength of the association depends crucially on the size of a country’s reserve base and its policy credibility. We find that financial crises, driven by exposure to foreign currency, resulted in significant permanent output losses. We evaluate our findings by looking at the risk posed by high levels of foreign currency liabilities in eastern Europe in late 2008.

Misalignment between perceptions and actual global burden of disease: evidence from the US population

Significant funding of health programs in low-income countries comes from external sources, mainly private donors and national development agencies of high-income countries. How these external funds are allocated remains a subject of ongoing debate, as studies have revealed that external funding may misalign with the underlying disease burden. One determinant of the priorities set by both private donors and development agencies is the perceptions of populations living in high-income countries about which diseases are legitimate for global health intervention. While research has been conducted on the priorities expressed by recipient communities, relatively less has been done to assess those of the donating country. To investigate people's beliefs about the disease burden in high-income countries, we compared publicly available data from U.S. surveys of people's perceptions of the leading causes of death in developing countries against measures of the actual disease burden from the World Health Organization. We found little correlation between the U.S. public's perception and the actual disease burden, measured as either mortality or disability-adjusted life years. While there is potential for reverse causality, so that donor programs drive public perceptions, these findings suggest that increasing the general population's awareness of the true global disease burden could help better align global health funding with population health needs