Psychosocial Cost Research Articles

Real-world lived experience of older adults with type 1 diabetes after an automated insulin delivery trial.

First-generation closed-loop automated insulin delivery improves glycaemia and psychosocial outcomes among older adults with type 1 diabetes in clinical trials. However, no study has previously assessed real-world lived experience of older adults using closed-loop therapy outside a trial environment. Semi-structured interviews were conducted with older adults who were pre-existing insulin pump users and previously completed the OldeR Adult Closed-Loop (ORACL) randomised trial. Interviews focused on perceptions of diabetes technology use, and factors influencing decisions regarding continuation. Twenty-eight participants, mean age 70 years (SD 5), were interviewed at median 650 days (IQR 608-694) after their final ORACL trial visit. At interview, 23 participants (82%) were still using a commercial closed-loop system (requiring manual input for prandial insulin bolus doses). Themes discussed in interviews relating to closed-loop system use included sustained psychosocial benefits, cost and retirement considerations and usability frustrations relating to sensor accuracy and system alarms. Of the five participants who had discontinued, reasons included cost, continuous glucose monitoring-associated difficulties and usability frustrations. Cost was the largest consideration regarding continued use; most participants considered the increased ease of diabetes management to be worth the associated costs, though cost was prohibitive for some. Almost 2 years after completing a closed-loop clinical trial, closed-loop automated insulin delivery remains the preferred type 1 diabetes therapy for the majority of older adult participants. Chronological age is not a barrier to real-world successful use of diabetes technology. Identifying age-related barriers, and solutions, to diabetes technology use among older adults is warranted.

The Moral Dimensions of Family Caregiving for Patients with Advanced Cancer: A Qualitative Study

Background. Family caregivers in charge of patients with advanced cancer play an essential role. The psychosocial cost of these caregiving activities has been studied, and psychosocial interventions have been developed to improve the quality of life of family caregivers. A deeper understanding of caregivers’ burden is essential in order to enhance the benefits of these interventions. The aim of this study was to explore the socioeconomic and cultural factors responsible for shaping the complex personal experience of family caregiving and to analyse the moral dimensions of the caring experience so as to understand its effects on family caregivers more clearly. Materials and Methods. A qualitative study based on in-depth interviews was conducted with patients with advanced cancer (n = 20) and their family caregivers (n = 19) from 2017 to 2020. These interviews were analysed using an inductive approach and an iterative procedure. A thematic analysis was then performed using Tronto’s “ethic of care” framework in order to identify the various levels of responsibility and the relationships and effects involved. Results. Providing patients with advanced cancer with informal care is highly valuable work requiring various moral qualities, including attentiveness, responsibility, competence, and responsiveness. The mental load resulting from the moral aspects of care results from the cumulative effects of carers’ attentiveness and the responsibilities they have taken on. Conclusion. The present findings could guide healthcare professionals to develop best practice resources and guidelines in order to alleviate the hitherto underestimated effects of caring and promote a coordinated public health approach addressing the needs of caregivers. These efforts are particularly important as contemporary health policies tend to promote the shift from inpatient to outpatient treatment, which increases the importance of informal caregiving and the burden involved.

Psychosocial Support and Cost Burden of Cancer Among Patients Attending Tertiary Oncology Clinics in Lagos State, Nigeria.

Cancer management brings about changes in patients' paths of life, in their daily activities, work, relationships, and family roles, and it is associated with a high level of patient psychological stress and financial toxicity. The objective of this study was to assess the psychosocial support and financial burden of cancer patients and determine socioeconomic factors that impact them. Methodology and Methods: This was a descriptive cross-sectional study among 240 cancer patients in Lagos University Teaching Hospital (LUTH) and Lagos State University Teaching Hospital (LASUTH) in Nigeria. The respondents were recruited consecutively and data was collected using structured, adapted, interviewer administered questionnaires. The data was analyzed using epi info software version 7.1 with chi-square used to test for associations and the level of significance was set at p<0.05. Overall, 74.6% of respondents had perceived psychosocial support scores higher than 50 out of 100. The family was the most common source of support across the emotional, financial and tangible support dimension's (91.7%, 83.8% and 85.4%) while healthcare professionals (60%) were the commonest for informational support. Overall, 69.6% had COST scores less than 50% indicating worse financial toxicity. Statistical associations were found between cost burden and cancer type (p=0.01), age (p<0.0001) and financial support (p<0.0001). Older patients, those who had financial support, and those with gynecological cancers had a decreased financial burden For psychosocial support associations were seen with employment status (p=0.02), and treatment (p<0.0001). Higher psychosocial support for patients who were employed and had begun treatment. The majority of respondents experienced high levels of financial toxicity but adequate psychosocial support. More research is needed, as well as the inclusion of support groups into clinics and the availability of loans to help with the initial costs.

INTRODUCTION OF A MULTIMODAL PAIN REHABILITATION INTERVENTION IN PRIMARY CARE: A PILOT STUDY.

To evaluate patient-reported outcome measures in patients with chronic musculoskeletal pain 1 year after participation in a case manager-led multimodal rehabilitation intervention in a Finnish primary care centre. Changes in healthcare utilization (HCU) were also explored. A prospective pilot study with 36 participants. The intervention consisted of screening, multidisciplinary team assessment, a rehabilitation plan and case manager follow-up. Data were collected through questionnaires filled in after the team assessment and 1 year later. HCU data 1 year before and 1 year after team assessment were compared. At follow-up, satisfaction with vocational situation, self-reported work ability and health-related quality of life (HRQoL) had improved and pain intensity had diminished significantly for all participants. The participants who reduced their HCU improved their activity level and HRQoL. Early intervention by a psychologist and mental health nurse was distinctive for the participants who reduced HCU at follow-up. The findings demonstrate the importance of early biopsychosocial management of patients with chronic pain in primary care. Identification of psychological risk factors at an early stage may lead to better psychosocial wellbeing, improve coping strategy and reduce HCU. A case manager may free up other resources and thereby contribute to cost savings.

Substance abuse, knowledge of its long-term effects and occurrence of depressive symptoms among health students in a Nigerian tertiary institution

Introduction: Substance abuse confers enormous health, psychosocial and economic cost on the society, it has been found to be prevalent among young people in both developing and developed countries alike. Depression is one of the commonest byproducts of drugs abuse. In this study we evaluated the knowledge of the long term effects of drugs abuse and its prevalence among students of the college of health sciences of Nnamdi Azikiwe. Methodology: The study is a descriptive cross-sectional survey done among final year undergraduate students of the College of Health Sciences, and the Faculty of Pharmaceutical sciences, Nnamdi Azikiwe University. A total of 200 students took part in the study. Data collection was with the use of semi structured, self-administered questionnaires, which were developed according to the specific objectives. Data analysis was done using SPSS version 22. Result: The result showed a high prevalence of substance abuse among students of health sciences. Alcohol, with a rate of 31.5% is the most abused substance among the students surveyed, it is also the most abused substance among students in the school environment. The prevalence of depression for this study, which was done using the Beck's Depression Inventory (BDI), is 60.5%, with 12% having borderline clinical depression, 30% having moderate depression, 14% having severe depression and 4.5% having extreme depression. Conclusion: Substance use and Depressive symptoms remains high among young people and is more in college students who represent the economic fulcrum and future of any society. It is recommended that further studies be done to evaluate for the depression distribution using other demographic indices as well as the causal relationship between substance use and depression.

Complications in adolescent pregnancy: bibliographic review

Pregnancy has a profound effect on adolescence, since it brings about a total change in the trajectory of women's lives. It can lead to situations of high obstetric risk, becoming a public health problem of great importance with a high biological and psychosocial cost. Objective: To examine the frequent complications of pregnancy in adolescents. Methodology: The research design is bibliographic; with the purpose of obtaining a notable scientific base that contributes to the information, an organized exploration of original articles was carried out through different digital databases such as: Google Scholar, PubMed, SciELO, Scopus, Web of Sciencie using the keywords: complications, adolescence and pregnancy, with a maximum age of 5 years and without language limitations. The search strategies used were based on the following search criteria: "adolescent pregnancy", "complications of adolescent pregnancy" and "adolescent pregnancy complications", in order to identify, select and refer to the sources which, in the most summarized manner, could be used to explain this topic. Results: Various analyses mentioned above indicate that obstetric complications in adolescents translate into health, labor, economic and educational terms in developing countries and among less favored social classes. Conclusions: It is vitally important to address this problem to increase prevention and promotion programs in order to improve their sexual and reproductive health.

Management of diabetic foot ulcer &amp; atherosclerosis using tibial transverse bone lengthening technique; Bangladesh experience

Diabetic foot ulcers (DFU) are chronic skin ulcers associated with deep tissue destruction around the foot and ankle region with varying degrees of lower extremity vasculopathy and neuropathy. Diabetic foot ulcer is associated with a high rate of morbidity, disability, mortality and psycho-social cost.

Domestic Violence and its Economic Costs

Domestic violence is a growing concern for Albanian society. Gender-based violence-oriented studies have focused on physical, sexual, and psychological manifestations or their consequences. There is still no study to refer to the socioeconomic cost of violence against women in Albania. Knowledge of the economic causes and consequences of the problem is important to enable society to deal with it constructively and correctly. It should be noted that the financial / economic costs that accompany the phenomenon of domestic violence, result as one of the factors that lead the family to deepen poverty and also limit women’s opportunities for development. The purpose of this study is to describe the economic cost of violence against women. This study seeks to draw attention to the economic aspect of this phenomenon – the economic cost of violence experienced by women. Although the socio-economic cost of domestic violence requires a very complex and advanced study and especially an efficient statistical system (administrative resources), it is important to clarify that this study is an attempt to present how much it costs a family, violence against women in marital relationships. An important finding of this study is the fact that there is a cause-and-effect relationship in the relationship between domestic violence and the economic situation of the family. So in a family in which violence is present in many forms, its economic situation is significantly affected. In addition to the individual consequences of the psychosocial cost of pain and suffering, interpersonal violence has a number of economic effects at the population level, including reduced credibility in economic, legal and social structures.

Patient-level predictors of diabetes-related lower extremity amputations at a quaternary hospital in South Africa.

Diabetes-related lower extremity amputation has a major psycho-social and economic cost on the patient as well as a direct impact on financial expenditure within health facilities. This study aimed to determine the incidence and patient-related factors related to diabetes-related amputations amongst patients that were referred to the quaternary hospital between 1 January 2014 and 31 December 2015. A retrospective cohort study. Data were retrieved from the medical record for each diabetes patient that was managed at IALCH during the study period. The following variables were collected: sociodemographic parameters (age, gender, and ethnicity) and diabetes-related parameters (type of diabetes) and additional complications. Ninety-nine patients (0, 73%) of all diabetes patients managed were new diabetes-related lower-extremity amputations. There were statistically significant increased odds of female patients (OR: 1, 7) and patients with non-insulin dependent diabetes (OR: 1, 64) to have new diabetes-related amputations. Patients older than 60 years (OR: 1, 31); African patients (OR: 1, 35) patients with cardiovascular complications (OR: 1, 04) and patients with retinopathy (OR: 1, 48) were more likely to have diabetes-related amputations but not statistically significant. A combination of primary preventive strategies, early detection and appropriate management of patients with diabetes and specific guidelines on the frequency, clinical and laboratory tests required for early diagnosis and referrals with early signs of diabetes-related complicationsat primary care level will assist in reducing the long term adverse outcomes including amputations.

The psychosocial cost burden of cancer: A systematic literature review.

Background and ObjectivePsychosocial costs, or quality of life costs, account for psychological distress, pain, suffering and other negative experiences associated with cancer. They contribute to the overall economic burden of cancer that patients experience. But this category of costs remains poorly understood. This hinders opportunities to make the best cancer control policy decisions. This study explored the psychosocial cost burden associated with cancer, how studies measure psychosocial costs and the impact of this burden.MethodsA systematic literature review of academic and grey literature published from 2008 to 2018 was conducted by searching electronic databases, guided by the Institute of Medicine’s conceptualization of psychosocial burden. Results were analyzed using a narrative synthesis and a weighted proportion of populations affected was calculated. Study quality was assessed using the Ottawa‐Newcastle instrument.ResultsA total of 25 studies were included. There was variation in how psychosocial costs were conceptualized and an inconsistent approach to measurement. Most studies measured social dimensions and focused on the financial consequences of paying for care. Fewer studies assessed costs associated with the other domains of this burden, including psychological, physical, and spiritual dimensions. Fourty‐four percent of cancer populations studied were impacted by psychosocial costs and this varied by disease site (38%‐71%). Two studies monetized the psychosocial cost burden, estimating a lifetime cost per case ranging from CAD$427753 to CAD$528769. Studies were of varying quality; 60% of cross‐sectional studies had a high risk of bias.ConclusionsConsistency in approach to measurement would help to elevate this issue for researchers and decision makers. At two‐thirds of the total economic burden of cancer, economic evaluations should account for psychosocial costs to better inform decision‐making. More support is needed to address the psychosocial cost burden faced by patients and their families.

A review of socio-demographic and clinical correlates of stillbirth at a teaching hospital with limited advanced fetal surveillance

Background: Stillbirth has a heavy burden of psychosocial and economic cost on women, families and nations. The study aimed at determining the rate of stillbirth and identifying the factors contributing to stillbirths in Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti over the study period. Materials and Methods: The study was a retrospective descriptive one carried out at the Obstetric Unit of Obstetrics, Gynaecology and Perinatology Department of Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti from 1st of January, 2012 to 31st of December, 2016. The data obtained were processed using Statistical Package for Social Sciences (SPSS) computer software version 20. Descriptive statistics was utilized to analyze the data; continuous variables were summarized with mean and discrete variables were summarized using numbers and percentages. Results: There were 532 stillbirths out of a total of 9,364 deliveries during the study period. This gave a stillbirth rate of 56.8/1000 total births. Macerated stillbirths accounted for 232 (43.6%) while fresh stillbirths accounted for 300 (56.4%) of the cases; with majority of the bereaved mothers (86.8%) being unbooked. Stillbirth rate was highest among women aged 15 to 19 years followed by those aged 40 years and above. Infections (chorioamnionitis), 69 (13.0%), obstructed labour. 59 (11.1.%) and antepartum haemorrhage 38 (7.1%) were the leading maternal causes of stillbirth. Prematurity 81 (15.2%) and multiple gestation 38 (7.1%) were the leading fetal causes. In 43 cases (8.1%), there were unexplained causes of stillbirth.Conclusion: As stillbirth remains a largely preventable condition, more aggressive measures should be instituted to ensure comprehensive maternity care for pregnant women; with more emphasis on advanced fetal surveillance arm of antenatal/intrapartum care. Appropriate evidence based post-delivery management, especially in the areas of conduct of baby autopsy and handling of bereavement, should be given to the mothers of the deceased.

Making a Difference in ABC Patients´ Quality of Life: Uganda´s Case

Background: According to UWOCASO's research “Assessment of clinical and psychological needs of metastatic breast cancer patients, challenges and gaps in meeting their needs in Uganda” metastatic breast cancer (MBC) is not well understood, patients often feel isolated, invisible and stigmatized, have limited access to targeted treatment, specialized and comprehensive supportive services. Provision of information for available services and options for their care including open communication with health care providers, access to psychosocial services, pain control, financial support and cost of the treatment were important needs during the study. Patients end into depression, drop out of care thus compromising their quality of life. This project was designed as an intervention to address the unmet needs and barriers that limit access to supportive services. Aim: To improve access to supportive services for ABC patients and their families in Kampala and Wakiso districts. Methods: Fifteen (15) patients with advanced and metastatic breast cancer who were not respondents for the SAPRC research were recruited from the patients who sought psychosocial support from UWOCASO for a systematic follow-up. Using a bio-psycho-social (BPS) tool baseline data were collected to assess their psychosocial situation before our intervention and after 12 months. Baseline data were compared with the outcome. Results: At seven months more than 70% of patients had restored hope, pain kept under control, resumed treatment, reunited with families and some received in-kind and financial support. 30% of the patients passed on with no pain and legally supported. 2 patients were enrolled into a compassionate program for a targeted therapy. Conclusion: Patients living with advanced breast cancer have various needs that can only be met by a well-coordinated team of experts. UWOCASO's patient navigation program is important to bridge the gap between experts and improve access to supportive services.

Does striving to succeed come at a physiological or psychosocial cost for adults who experienced child maltreatment?

While striving to succeed in the face of adversity may provide individuals with outward benefits, it may come at a cost to individuals' physical health. The current study examines whether striving predicts greater physiological or psychosocial costs among those who experienced child maltreatment, a stressor that disrupts the caregiving environment and threatens relationship security. Using data from the National Longitudinal Study of Adolescent to Adult Health, we tested whether greater striving after childhood maltreatment would come at a cost, increasing underlying cardiovascular disease (CVD) risk and depressive symptoms despite showing outward success via income and college degree attainment. The study included 13,341 Black, Hispanic, and White adolescents who self-reported striving and their experiences of childhood neglect, physical abuse, and sexual abuse. As young adults, participants reported depressive symptoms, income, and college degree attainment and completed a health assessment from which a 30-year Framingham-based CVD risk score was calculated. Higher striving was associated with lower CVD risk and depressive symptoms, and higher income and college degree attainment, regardless of maltreatment history. These findings highlight the potential for striving as a target for interventions and support the need to examine multiple biological and behavioral outcomes to understand the multifaceted nature of resilience.

ExplorinG frailty and mild cognitive impairmEnt in kidney tRansplantation to predict biomedicAl, psychosocial and health cost outcomeS (GERAS): protocol of a nationwide prospective cohort study.

To present the rationale, design and methodology of the GERAS project, which examines whether assessment of frailty and mild cognitive impairment could enhance risk prediction for biomedical, psychosocial outcomes and foster efficient resource allocation in kidney transplantation. For the burgeoning cohort of older patients considered for kidney transplantation, evidence gaps regarding frailty and mild cognitive impairment limit clinical decision-making and medical management. As known risk factors for 'hard' clinical outcomes in chronic illness, both require further study in transplantation. Integrating these and other bio-psychosocial factors into a comprehensive pre-transplant patient assessment will provide insights regarding economic implications and may improve risk prediction. A nation-wide multi-centre prospective cohort study nested in the Swiss Transplant Cohort Study. Our nationally representative convenience sample includes 250 adult kidney transplant recipients. Data sources include the Swiss Transplant Cohort Study and primary data collected at time of transplantation, 6months, 1 and 2years post-transplant via established measures (the Montreal Cognitive Assessment, Psychosocial Questionnaire, Fried Frailty Instrument and a blood analysis), investigator-developed instruments and datasets compiled by hospitals' management control units, sickness funds, the Swiss Federal Statistical Office and the European Renal Association. Descriptive, competing risk survival and mixed effects analyses will be performed. Research Ethics Committee approval was obtained in January 2016. This pioneering project jointly examines frailty and mild cognitive impairment from bio-psychosocial and health economic perspectives. Results may significantly inform risk prediction, care tailoring and resource optimization to improve health outcomes in the ageing kidney transplant cohort.

Picturing health: stories of stillbirths

At the start of this year The Lancet published the Ending Preventable Stillbirths Series highlighting the global burden of stillbirths, and their psychosocial cost. In the images shown here I have tried to capture more personal aspects of stillbirths.

The Current Landscape of Genetic Testing in Cardiovascular Malformations: Opportunities and Challenges.

Human cardiovascular malformations (CVMs) frequently have a genetic contribution. Through the application of novel technologies, such as next-generation sequencing, DNA sequence variants associated with CVMs are being identified at a rapid pace. While clinicians are now able to offer testing with NGS gene panels or whole exome sequencing to any patient with a CVM, the interpretation of genetic variation remains problematic. Variable phenotypic expression, reduced penetrance, inconsistent phenotyping methods, and the lack of high-throughput functional testing of variants contribute to these challenges. This article elaborates critical issues that impact the decision to broadly implement clinical molecular genetic testing in CVMs. Major benefits of testing include establishing a genetic diagnosis, facilitating cost-effective screening of family members who may have subclinical disease, predicting recurrence risk in offsprings, enabling early diagnosis and anticipatory management of CV and non-CV disease phenotypes, predicting long-term outcomes, and facilitating the development of novel therapies aimed at disease improvement or prevention. Limitations include financial cost, psychosocial cost, and ambiguity of interpretation of results. Multiplex families and patients with syndromic features are two groups where disease causation could potentially be firmly established. However, these account for the minority of the overall CVM population, and there is increasing recognition that genotypes previously associated with syndromes also exist in patients who lack non-CV findings. In all circumstances, ongoing dialog between cardiologists and clinical geneticists will be needed to accurately interpret genetic testing and improve these patients’ health. This may be most effectively implemented by the creation and support of CV genetics services at centers committed to pursuing testing for patients.

From grief, guilt pain and stigma to hope and pride - a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth.

BackgroundDespite improvements in maternity healthcare services over the last few decades, more than 2.7 million babies worldwide are stillborn each year. The global health agenda is silent about stillbirth, perhaps, in part, because its wider impact has not been systematically analysed or understood before now across the world. Our study aimed to systematically review, evaluate and summarise the current evidence regarding the psychosocial impact of stillbirth to parents and their families, with the aim of improving guidance in bereavement care worldwide.MethodsSystematic review and meta-summary (quantitative aggregation of qualitative findings) of quantitative, qualitative, and mixed-methods studies. All languages and countries were included.ResultsTwo thousand, six hundred and nineteen abstracts were identified; 144 studies were included. Frequency effect sizes (FES %) were calculated for each theme, as a measure of their prevalence in the literature.Themes ranged from negative psychological symptoms post bereavement (77 · 1) and in subsequent pregnancies (27 · 1), to disenfranchised grief (31 · 2), and incongruent grief (28 · 5), There was also impact on siblings (23 · 6) and on the wider family (2 · 8).They included mixed-feelings about decisions made when the baby died (12 · 5), avoidance of memories (13 · 2), anxiety over other children (7 · 6), chronic pain and fatigue (6 · 9), and a different approach to the use of healthcare services (6 · 9).Some themes were particularly prominent in studies of fathers; grief suppression (avoidance)(18 · 1), employment difficulties, financial debt (5 · 6), and increased substance use (4 · 2). Others found in studies specific to mothers included altered body image (3 · 5) and impact on quality of life (2 · 1). Counter-intuitively, Some themes had mixed connotations. These included parental pride in the baby (5 · 6), motivation for engagement in healthcare improvement (4 · 2) and changed approaches to life and death, self-esteem, and own identity (25 · 7).In studies from low/middle income countries, stigmatisation (13 · 2) and pressure to prioritise or delay conception (9) were especially prevalent.ConclusionExperiencing the birth of a stillborn child is a life-changing event. The focus of the consequences may vary with parent gender and country. Stillbirth can have devastating psychological, physical and social costs, with ongoing effects on interpersonal relationships and subsequently born children. However, parents who experience the tragedy of stillbirth can develop resilience and new life-skills and capacities. Future research should focus on developing interventions that may reduce the psychosocial cost of stillbirth.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0800-8) contains supplementary material, which is available to authorized users.

Navigating Sexual and Religious Identity Conflict: A Mormon Perspective

This study examined navigation of sexual and religious identity conflict among 1,493 same-sex attracted current or former members of the Church of Jesus Christ of Latter-day Saints. Participants were classified into four groups: (a) rejected a lesbian, gay, or bisexual identity (5.5%); (b) compartmentalized sexual and religious identities (37.2%); (c) rejected religious identity (53%); and (d) integrated religious and sexual identities (4.4%). Systematic differences emerged among the groups in sexual identity development histories, developmental milestones, relationship experiences, religious engagement, and psychosocial health. The findings suggest that rejection or compartmentalization of sexual identity may be difficult to sustain over time and likely comes at a significant psychosocial cost. Integration of identities may be equally difficult to achieve, and appears to be associated with optimal outcomes.

HPV vaccination for cervical cancer prevention is not cost-effective in Japan.

Our study objectives were to evaluate the medical economics of cervical cancer prevention and thereby contribute to cancer care policy decisions in Japan. Model creation: we created presence- absence models for prevention by designating human papillomavirus (HPV) vaccination for primary prevention of cervical cancer. Cost classification and cost estimates: we divided the costs of cancer care into seven categories (prevention, mass-screening, curative treatment, palliative care, indirect, non-medical, and psychosocial cost) and estimated costs for each model. Cost-benefit analyses: we performed cost-benefit analyses for Japan as a whole. HPV vaccination was estimated to cost $291.5 million, cervical cancer screening $76.0 million and curative treatment $12.0 million. The loss due to death was $251.0 million and the net benefit was -$128.5 million (negative). Cervical cancer prevention was not found to be cost-effective in Japan. While few cost-benefit analyses have been reported in the field of cancer care, these would be essential for Japanese policy determination.

Household Bargaining and Excess Fertility: An Experimental Study in Zambia

We posit that household decision-making over fertility is characterized by moral hazard since most contraception can only be perfectly observed by the woman. Using an experiment in Zambia that varied whether women were given access to contraceptives alone or with their husbands, we find that women given access with their husbands were 19 percent less likely to seek family planning services, 25 percent less likely to use concealable contraception, and 27 percent more likely to give birth. However, women given access to contraception alone report a lower subjective well-being, suggesting a psychosocial cost of making contraceptives more concealable. (JEL C78, D12, D82, I31, J13, J16, O15)