Inequalities In Use Research Articles

Inequalities in use of health services by type of settlements in Bulgaria

Introduction: The place of residence and the region form the context for the work, education, and income opportunities for individuals. It can be considered as a determinant of health and of health inequalities. The aim of this study is to analyse the disparities in the use of health services among the inhabitants of the different types of settlements in the Northeast region of Bulgaria. Material and Methods: Data from inquiry are retrieved to analyse the use of health services. The inquiry is conducted in 2014 among 618 citizens of Northeast region in Bulgaria, living in district cities, small towns and villages. Results and Discussion: The highest frequency of visits are those with general practitioners. By type of settlements, the average usage of health services is highest in small towns, except for diagnostic tests. In villages, the use of primary and specialised medical care is lower than the total average for the sample, mainly due to the difficulty in access to health services. Statistically significant disparities according to the type of settlement exist in the use of dental and hospital care. Conclusion: The findings show that there are differences in the use of health services and access to medical care, depending on the place of residence, which is an example of health inequities.

Socioeconomic inequalities in dental health services in Sao Paulo, Brazil, 2003-2008.

BackgroundAccess to, and use of, dental health services in Brazil have improved since 2003. The increase of private health care plans and the implementation of the “Smiling Brazil” Program, the largest public oral health care program in the world, could have influenced this increase in access. However, we do not yet know if inequalities in the use of dental health services persist after the improvement in access. The aims of this study are to analyze socioeconomic differences for dental health service use between 2003 and 2008 in São Paulo and to examine changes in these associations since the implementation of the Smiling Brazil program in 2003.MethodData was obtained via two household health surveys (ISA-Capital 2003 and ISA-Capital 2008) which investigated living conditions, lifestyle, health status and use of health care services. Logistic regression was used to analyze associations between socioeconomic factors and dental services use. Additionally, trends from 2003 to 2008 regarding socioeconomic characteristics and dental health service use were explored.ResultsOverall, dental health service use increased between 2003 and 2008 and was at both time points more common among those who had higher income, better education, better housing conditions, private health care plans and were Caucasian. Inequalities in use of dental health care did not decrease over time. Among the reasons for not seeking dental care, not having teeth and financial difficulty were more common in lower socioeconomic groups, while thinking it was unnecessary was more common in higher socioeconomic groups.ConclusionsThe Brazilian oral health policy is still in a period of expansion and seems to have contributed slightly to increased dental health service use, but has not influenced socioeconomic inequalities in the use of these services. Acquiring deeper knowledge about inequalities in dental health service use will contribute to better understanding of potential barriers to reducing them.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1928-y) contains supplementary material, which is available to authorized users.

Inequality in the use of maternal and child health services in the Philippines: do pro-poor health policies result in more equitable use of services?

BackgroundThe Philippines failed to achieve its Millennium Development Goal (MDG) commitment to reduce maternal deaths by three quarters. This, together with the recently launched Sustainable Development Goals (SDGs), reinforces the need for the country to keep up in improving reach of maternal and child health (MCH) services. Inequitable use of health services is a risk factor for the differences in health outcomes across socio-economic groups. This study aims to explore the extent of inequities in the use of MCH services in the Philippines after pro-poor national health policy reforms.MethodsThis paper uses data from the 2008 and 2013 Demographic and Health Survey (DHS) in the Philippines. Socio-economic inequality in MCH services use was measured using the concentration index. The concentration index was also decomposed in order to examine the contribution of different factors to the inequalities in the use of MCH services.ResultsIn absolute figures, women who delivered in facilities increased from 2008 to 2013. Little change was noted for women who received complete antenatal care and caesarean births. Facility deliveries remain pro-rich although a pro-poor shift was noted. Women who received complete antenatal care services also remain concentrated to the rich. Further, there is a highly pro-rich inequality in caesarean deliveries which did not change much from 2008 to 2013. Household income remains as the most important contributor to the resulting inequalities in health services use, followed by maternal education. For complete antenatal care use and deliveries in government facilities, regional differences also showed to have important contribution.ConclusionThe findings suggest inequality in the use of MCH services had limited pro-poor improvements. Household income remains to be the major driver of inequities in MCH services use in the Philippines. This is despite the recent national government-led subsidy for the health insurance of the poor. The highly pro-rich caesarean deliveries may also warrant the need for future studies to determine the prevalence of medically unindicated caesarean births among high-income women.Trial registrationNot applicable.

Health Inequalities in use of contraceptive Methods among women in developing country, Pakistan

Health Inequalities in use of contraceptive Methods among women in developing country, Pakistan

Explaining patterns of inequality in childcare service use across 31 developed economies: A welfare state perspective

Childcare services are increasingly regarded a major policy lever to combat social inequalities in early life. Yet, it was shown that inequality in the use of childcare services is the norm rather than the exception in European and Organisation for Economic Co-operation and Development (OECD) countries. As a result, social inequalities between disadvantaged and advantaged children are likely to be reinforced instead of being narrowed. The aim of this article is to conduct a macro-level analysis exploring which welfare state characteristics are associated with inequality in childcare use. We find that government involvement in the availability, affordability and quality of service provision is related to lower levels of inequality in childcare use. The results also suggest an impact of labour market opportunities and parental leave schemes. The findings contribute to a proper understanding of the institutional mechanisms underlying inequality in childcare service use.

Polypill-based therapy likely to reduce ethnic inequities in use of cardiovascular preventive medications: Findings from a pragmatic randomised controlled trial.

The purpose of this study was to investigate the consistency of the proportional effect of fixed-dose combination therapy (the 'polypill') on the use of recommended cardiovascular preventative medications among indigenous Māori and non-indigenous adults in New Zealand. We randomised Māori and non-Māori primary care patients at high risk of cardiovascular disease (either because of a prior event or with an estimated 5-year risk of a first event of at least 15%) to a polypill (containing aspirin, statin and two antihypertensives) or usual care for a minimum of 12 months. All patients had indications for all polypill components according to their general practitioner, and all medications (including the polypill) were prescribed by the patient's general practitioner and dispensed at community pharmacies. The main outcome for this study was the use of all recommended medications (antiplatelet, statin and two antihypertensives) at 12 months. Heterogeneity in the effect of polypill-based care compared with usual care on this outcome by ethnicity was assessed by logistic regression. Baseline use of recommended medications was 36% (93/257) among Māori and 51% (130/156) among non-Māori participants. Polypill-based care was associated with an increase in the use of recommended medications among Māori (relative risk [RR]: 1.87; 95% confidence interval [CI]: 1.50-2.34) and non-Māori (RR: 1.66; 95% CI: 1.37-2.00) when compared with usual care at 12 months, and there was no statistically significant heterogeneity in this outcome by ethnicity (p = 0.92). Polypill-based care is likely to reduce absolute inequities between Māori and non-Māori in the use of recommended cardiovascular preventative medications given baseline absolute differences and the consistency of the proportional effect of this intervention by ethnicity in this pragmatic trial in primary care.

Inequalities in use of total hip arthroplasty for hip fracture: population based study

Objectives To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there...

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Inequality in Fetal Autopsy in Canada.

Inequality in use of fetal autopsy is poorly understood, despite the importance of autopsy in establishing the cause of stillbirth for future prevention. We examined fetal autopsy rates between linguistic minorities in Quebec, Canada, and assessed trends over three decades. Using registry data on 11,992 stillbirths from 1981-2011, we calculated fetal autopsy rates for Francophones, Anglophones, and Allophones by decade. We found lower fetal autopsy rates for Allophones (54.4%) than Francophones (68.5%) and Anglophones (63.4%), but rates decreased over time for all language groups. After 2000, Allophones had 25% higher risk of non-autopsy relative to Francophones, with 8.8 fewer autopsies for every 100 stillbirths. Allophones who were not autopsied had 32% higher risk of having an undetermined cause of death. Inequality in use of fetal autopsy may be widespread for minorities in Canada. Efforts to decrease stillbirth in minorities may require policies to increase autopsy rates.

Private finance of services covered by the National Health Insurance package of benefits in Israel.

BackgroundPrivate health expenditure in systems of national health insurance has raised concern in many countries. The concern is mainly about the accessibility of care to the poor and the sick, and inequality in use and in health. The concern thus refers specifically to the care financed privately rather than to private health expenditure as defined in the national health accounts.ObjectivesTo estimate the share of private finance in total use of services covered by the national package of benefits. and to relate the private finance of use to the income and health of the users.MethodsThe Central Bureau of Statistics linked the 2009 Health Survey and the 2010 Incomes Survey. Twenty-four thousand five hundred ninety-five individuals in 7175 households were included in the data. Lacking data on the share of private finance in total cost of care delivered, we calculated instead the share of uses having any private finance—beyond copayments—in total uses, in primary, secondary, paramedical and total care. The probability of any private finance in each type of care is then related, using random effect logistic regression, to income and health state.ResultsFifteen percent of all uses of care covered by the national package of benefits had any private finance. This rate ranges from 10 % in primary care, 16 % in secondary care and 31 % in paramedical care. Twelve percent of all uses of physicians’ services had any private finance, ranging from 10 % in family physicians to 20 % in pulmonologists, psychiatrists, neurologists and urologists. Controlling for health state, richer individuals are more likely to have any private finance in all types of care. Controlling for income, sick individuals (1+ chronic conditions) are 30 % in total care and 60 % in primary care more likely to have any private finance compared to healthy individuals (with no chronic conditions).ConclusionsThe national accounts’ “private health spending” (39 % of total spending in 2010) is not of much use regarding equity of and accessibility to medical care by the population. The mean share of uses financed privately in 2010, a more relevant measure, is 15 % with large variation between types of care and physicians. While, as under national health insurance, richer persons contribute more into the finance of (private) medical care , and sicker persons are more likely to use it, the solidarity principle—cross subsidization from the rich to the sick, which is a fundamental principle of national health insurance systems, is clearly violated.

Experimental detection of quantum coherent evolution through the violation of Leggett-Garg-type inequalities.

We discuss the use of inequalities of the Leggett-Garg type (LGtI) to witness quantum coherence and present the first experimental violation of this type of inequalities using a light-matter interfaced system. By separately benchmarking the Markovian character of the evolution and the translational invariance of the conditional probabilities, the observed violation of a LGtI is attributed to the quantum coherent character of the process. These results provide a general method to benchmark "quantumness" when the absence of memory effects can be independently certified and confirm the persistence of quantum coherent features within systems of increasing complexity.

Impact of an integrated community case management programme on uptake of appropriate diarrhoea and pneumonia treatments in Uganda: A propensity score matching and equity analysis study.

IntroductionPneumonia and diarrhoea disproportionately affect children in resource-poor settings. Integrated community case management (iCCM) involves community health workers treating diarrhoea, pneumonia and malaria. Studies on impact of iCCM on appropriate treatment and its effects on equity in access to the same are limited. The objective of this study was to measure the impact of integrated community case management (iCCM) as the first point of care on uptake of appropriate treatment for children with a classification of pneumonia (cough and fast breathing) and/or diarrhoea and to measure the magnitude and distribution of socioeconomic status related inequality in use of iCCM.MethodsFollowing introduction of iCCM, data from cross-sectional household surveys were examined for socioeconomic inequalities in uptake of treatment and use of iCCM among children with a classification of pneumonia or diarrhoea using the Erreygers’ corrected concentration index (CCI). Propensity score matching methods were used to estimate the average treatment effects on the treated (ATT) for children treated under the iCCM programme with recommended antibiotics for pneumonia, and ORS plus or minus zinc for diarrhoea.FindingsOverall, more children treated under iCCM received appropriate antibiotics for pneumonia (ATT = 34.7 %, p < 0.001) and ORS for diarrhoea (ATT = 41.2 %, p < 0.001) compared to children not attending iCCM. No such increase was observed for children receiving ORS-zinc combination (ATT = -0.145, p < 0.05).There were no obvious inequalities in the uptake of appropriate treatment for pneumonia among the poorest and least poor (CCI = -0.070; SE = 0.083). Receiving ORS for diarrhoea was more prevalent among the least poor groups (CCI = 0.199; SE = 0.118). The use of iCCM for pneumonia was more prevalent among the poorest groups (CCI = -0.099; SE = 0.073). The use of iCCM for diarrhoea was not significantly different among the poorest and least poor (CCI = -0.073; SE = 0.085).ConclusioniCCM is a potentially equitable strategy that significantly increased the uptake of appropriate antibiotic treatment for pneumonia and ORS for diarrhoea, but not the uptake of zinc for diarrhoea. For maximum impact, interventions increasing zinc uptake should be considered when scaling up iCCM programmes.

GENERALIZATION OF INEQUALITIES ANALOGOUS TO HERMITE-HADAMARD INEQUALITY VIA FRACTIONAL INTEGRALS

Abstract. Some Hermite–Hadamard type inequalities for the fractionalintegrals are established and these results have some relationship withthe obtained results of [11, 12]. 1. IntroductionThe usefulness of inequalities involving convex functions is realized from thevery beginning and is now widely acknowledged as one of the prime drivingforces behind the development of several modern branches of mathematics andhas been given considerable attention. One of the most famous inequalities forconvex functions is Hermite–Hadamard inequality, stated as [8]:Let f : I ⊂ R→ Rbe a convex function on the interval I of real numbersand a,b ∈ I with a < b. Then(1) fa+b2≤1b−aZ ba f(x)dx ≤f(a) +f(b)2.Both inequalities hold in the reversed direction for f to be concave.In recent years, numerous generalizations, extensions and variants of Her-mite–Hadamard inequality (1) were studied extensively by many researchersand appeared in a number of papers, see [8, 10, 11, 12, 13].Now, somenecessarydefinitions and mathematicalpreliminariesoffractionalcalculus theory are presented, which are used further in this paper.Definition 1 ([9]). Let f ∈ L

Estimating Inequality with Tax Data: The Problem of Pass-Through Income

In recent decades, a growing share of U.S. business income has been taxed on a pass-through basis. When taxed on a pass-through basis, business income is attributed to a firm’s owners and taxed to them as individual income, rather than being subject to a separate entity-level tax. Among its many implications, the growth of pass-through taxation complicates our ability to estimate historical trends in income inequality. Prominent studies of income inequality use data from individual income tax returns to measure changes in the distribution of income over time yet fail to control for the increasing amounts of business income reflected in this data. Accordingly, to the extent that pass-through income flows to high-income individuals, such studies may overestimate the recent growth in income inequality. This paper explores the effect of pass-through income taxation at the high-end of the income distribution. Using data from the World Top Incomes Database, it shows that the growth of pass-through income has been concentrated among the top 0.5 percent of taxpayers. The trend towards taxing business income on a pass-through basis may thus be responsible for some of the growth in income inequality that researchers have observed.

Trends and inequities in use of maternal health care services in Bangladesh, 1991-2011.

Background and MethodsMonitoring use-inequity is important to measure progress in efforts to address health-inequities. Using data from six Bangladesh Demographic and Health Surveys (BDHS), we examine trends, inequities and socio-demographic determinants of use of maternal health care services in Bangladesh between 1991 and 2011.FindingsAccess to maternal health care services has improved in the last two decades. The adjusted yearly trend was 9.0% (8.6%-9.5%) for any antenatal care (ANC), 11.9% (11.1%-12.7%) for institutional delivery, and 18.9% (17.3%-20.5%) for C-section delivery which is above the WHO recommended rate of 5-15%. Use-inequity was significant for all three indicators but is reducing over time. Between 1991-1994 and 2007-2011 the rich:poor ratio reduced from 3.65 to 1.65 for ANC and from 15.80 to 6.77 for institutional delivery. Between 1995-1998 and 2007-2011, the concentration index reduced from 0.27 (0.25-0.29) to 0.15 (0.14-0.16) for ANC, and from 0.65 (0.60-0.71) to 0.39 (0.37-0.41) for institutional delivery during that period. For use of c-section, the rich:poor ratio reduced from 18.17 to 13.39 and the concentration index from 0.66 (0.57-0.75) to 0.47 (0.45-0.49). In terms of rich:poor differences, there was equity-gain for ANC but not for facility delivery or C-section delivery. All socio-demographic variables were significant predictors of use; of them, maternal education was the most powerful. In addition, the contribution of for-profit private sector is increasingly growing in maternal health.ConclusionBoth access and equity are improving in maternal health. We recommend strengthening ongoing health and non-health interventions for the poor. Use-inequity should be monitored using multiple indicators which are incorporated into routine health information systems. Rising C-section rate is alarming and indication of C-sections should be monitored both in private and public sector facilities.

Local government and public dental health services: an analysis of inequality in use

The aim of this study was to identify factors associated with the use of primary and specialized public dental health services and private services. A population-based household survey was conducted in two cities of Bahia State, Brazil. Key informants provided data on socioeconomic variables and use of dental health services. Organization of the local public dental health service was ranked as worse versus better. Univariate and multivariate polytomous logistic regression was performed. Of the total of 1,290 individuals, 38.76% used private services, 33.80% used public primary care, and 17.29% used both primary care and the Center for Dental Specialties. Less use of both primary care and specialized public services was associated with lower education (OR = 1.47; 95%CI: 1.03-2.10) and worse organization of services (OR = 1.74; 95%CI: 1.22-2.48), when compared to the exclusive use of primary care. The study showed inequality in the use of dental services, even when comparing more homogeneous groups, namely users of public services.

Income-related inequality and inequity in the use of dental services in Finland after a major subsidization reform.

In Finland, a major oral healthcare reform (OHCR), implemented during 2001-2002, opened the public dental services (PDS) and extended subsidies for private dental services to entire adult population. Before the reform, adults born earlier than 1956 were not entitled to use PDS nor did they receive any reimbursements for their private dental costs. We aimed to examine changes in the income-related inequality and inequity in the use of dental services among the adult Finns after the reform. Representative data from Finnish adults born in 1970 or earlier were gathered from three identical postal surveys concerning the use of dental services and subjective perceptions of oral health. Those surveys were conducted before the OHCR in 2001 (n = 1907) and after the OHCR in 2004 (n = 1629) and 2007 (n = 1509). We used concentration index and its decomposition to analyse income-related inequality and inequity in the use of dental services and factors associated with them. Results showed that pro-rich inequality and inequity in the overall use of dental services narrowed from 2001 to 2004. However, between 2004 and 2007, pro-rich inequality and inequity widened, so it returned to a rather similar level in 2007 as it had been in 2001. Most of the pro-rich inequality and inequity were related to regular dental visiting habit and income level. While there was pro-poor inequality and inequity in the use of PDS, there was pro-rich inequality and inequity in the use of private dental services throughout the study years. It seems that income-related inequality and inequity in the use of dental services narrowed only temporarily after the reform.

Countries With Public Dental Care Coverage Have Lower Social Inequalities in the Use of Dental Services Than Countries Without Such Coverage

Socioeconomic inequalities in the use of dental care services in Europe: what is the role of public coverage? Palència L, Espelt A, Cornejo-Ovalle M, Borrell C.Community Dent Oral Epidemiol 2014;42:97-105. Stefan Listl, Priv-Doz, Dr rer pol, Dr med dent, MSc The authors analyzed samples of persons age 50years or older from 11 European countries to examine whether social inequalities in dental care use are lower in countries with than in countries without public dental care coverage. None Cross-sectional study Level 3: Other evidence Not applicable.

Does socioeconomic inequality in health care utilisation vary across different health care needs in low- and middle-income countries?

Background Despite recognition that universal health coverage should include a continuum of care, including for non-communicable diseases (NCDs), little is known about equality of care for chronic needs in low- and middle-income countries (LMICs). Past research has focused on maternal health care inequalities. Comparing equality of care for different care needs may identify priorities and generate new hypotheses about causal pathways. Methods This analysis uses data on 38 LMICs surveyed in the 2002-2004 World Health Survey. Wealth-related inequality in use …

BOUNDEDNESS IN PERTURBED FUNCTIONAL DIFFERENTIAL SYSTEMS

In this paper, we investigate bounds for solutions of the the perturbed functional difierential systems. As is traditional in a pertubation theory of nonlinear difierential sys- tems, the behavior of solutions of a perturbed system is determined in terms of the behavior of solutions of an unperturbed system. Among useful methods for investigating the qualitative behavior of the solu- tions of perturbed nonlinear system of difierential systems, there are the method of variation of constants formula, Lyapunov' second method, and the use of inequalities. The theory of integral inequalities can be employed to study various properties of nonlinear difierential systems. In the presence the method of integral inequalities is as e-cient as the direct Lyapunov's method. Pinto(13,14) introduced h-stability(hS) which is an important exten- tion of the notions of exponential asymptotic stability and uniform Lip- schitz stability. Also, he obtained some properties about asymptotic be- havior of solutions of perturbed h-systems, some general results about asymptotic integration and gave some important examples in (14). He obtained a general variational h-stability and some properties about as- ymptotic behavior of solutions of difierential systems called h-systems. Also, he studied some general results about asymptotic integration and gave some important examples in (13). Choi and Ryu (3), Choi, Koo(5), and Choi et al. (4) investigated bounds of solutions for the perturbed