Health Service Utilization Patterns Research Articles

Rural–urban inequalities in health care utilization in Bhutan: a decomposition analysis

Background and objectiveOn the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences.MethodsWe used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas.ResultsSignificant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services.ConclusionsWhile the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Health Services Utilization and Specialist Care in Pediatric Inflammatory Bowel Disease: A Multiprovince Population-Based Cohort Study.

Patterns of health services utilization among children with inflammatory bowel disease (IBD) are important to understand as the number of children with IBD continues to increase. We compared health services utilization and surgery among children diagnosed <10 years of age (Paris classification: A1a) and between 10 and <16 years of age (A1b). Incident cases of IBD diagnosed <16 years of age were identified using validated algorithms from deterministically linked health administrative data in 5 Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario, Quebec) to conduct a retrospective cohort study. We compared the frequency of IBD-specific outpatient visits, emergency department visits, and hospitalizations across age groups (A1a vs A1b [reference]) using negative binomial regression. The risk of surgery was compared across age groups using Cox proportional hazards models. Models were adjusted for sex, rural/urban residence location, and mean neighborhood income quintile. Province-specific estimates were pooled using random-effects meta-analysis. Among the 1165 (65.7% Crohn's) children with IBD included in our study, there were no age differences in the frequency of hospitalizations (rate ratio [RR], 0.88; 95% confidence interval [CI], 0.74-1.06) or outpatient visits (RR, 0.95; 95% CI, 0.78-1.16). A1a children had fewer emergency department visits (RR, 0.70; 95% CI, 0.50-0.97) and were less likely to require a Crohn's-related surgery (hazard ratio, 0.49; 95% CI, 0.26-0.92). The risk of colectomy was similar among children with ulcerative colitis in both age groups (hazard ratio, 0.71; 95% CI, 0.49-1.01). Patterns of health services utilization are generally similar when comparing children diagnosed across age groups.

Impact of COVID-19 Pandemic on Utilization of Healthcare Services and Spending Patterns in Dubai, United Arab Emirates: A Cross-Sectional Study.

The COVID-19 pandemic affected the utilization of healthcare services in many parts of the world. The response to the healthcare burden imposed by the COVID-19 pandemic was associated with ensuring the provision of optimum healthcare services. This study aimed to estimate the effect of the COVID-19 pandemic on health services utilization and spending patterns in Dubai, the UAE. This cross-sectional study used secondary data on healthcare utilization and spending to compare between 2019 and 2020. The data was extracted from the health insurance claims on the eClaimLink platform. Descriptive and inferential statistics were used to calculate the percent change of service utilization and spending and percentages of total claims by each encounter type across major diagnostic categories (MDCs). In 2020, there was an overall reduction in outpatient visits and inpatient admissions of 27% and 21%, respectively, compared to 2019. Outpatient visits and prescriptions decreased across all the MDCs except mental and behavioral disorders, which showed an increase of 8% in outpatient visits and 29% in prescriptions. The admissions to the healthcare facilities were also reduced significantly across various MDCs, ranging from 10% to 44%. Similarly, a downward trend was seen in diagnostics for different MDCs. An increase in expenditure on diagnostics and drugs for neoplasm was reported, despite a corresponding decrease in outpatient and inpatient admissions for the same. A significant decrease in overall healthcare utilization and corresponding healthcare spending, resulting from a decline in outpatient and inpatient volume in healthcare facilities at all the levels (hospitals, clinics, speciality centres), was reported during the pandemic. The impact of the pandemic on mental health was reported by this study, as it showed an upward trend in utilization and spending. For the neoplasms, although the utilization declined, the expenditure on diagnostics and drugs during each encounter increased significantly.

Effective Factors of Utilization of Inpatient, Outpatient, Diagnostic, and Pharmaceutical Health Services: A Systematic Review

&#x0D; Normal";&#x0D; Utilization is one of the dimensions of equity in health systems. Identifying the factors affecting utilization of health services can be helpful for interventional purposes. This study systematically reviewed the factors affecting the utilization of inpatient, outpatient, diagnostic, and pharmaceutical services. This systematic review was conducted between 2016 and 2017. The search was performed using keywords based on MeSH in valid databases such as Scopus, Embase, ProQuest, ScienceDirect, PubMed, and Web of Science in the fields of title, abstract, and keyword. Related papers published from 2000 to 2017 were searched. First, the retrieved studies were screened and checked for quality; then, the useful data were extracted and analyzed. Out of the 1178 retrieved publications, 20 studies were included in the final analysis. The identified factors were categorized into 5 areas, including demographic (4 items), socioeconomic (13 items), health services–related (13 items), health status–related (7 items), and health insurance–related factors (2 items), and reported. The findings of this study can be a useful source and a comprehensive body of evidence on the utilization of health services. The results can be used by the policy makers and managers in designing interventions for changing the utilization patterns of health services. [GMJ.2019;8:e1236]&#x0D; &#x0D; &lt;!-- [if gte mso 10]&gt;

Engagement With Mental Health Services Among Survivors of Firearm Injury

Despite the prevalence of posttraumatic stress symptoms after firearm injury, little is known about how firearm injury survivors connect with mental health services. To determine facilitators and barriers to mental health care engagement among firearm injury survivors. A qualitative study of 1-on-1, semistructured interviews conducted within a community setting in Indianapolis, Indiana, between June 2021 and January 2022. Participants were recruited via community partners and snowball sampling. Participants who survived an intentional firearm injury, were shot within Indianapolis, were aged 13 years or older, and were English speaking were eligible. Participants were asked to discuss their lives after firearm injury, the emotional consequences of their injury, and their utilization patterns of mental health services. Data were analyzed from August 2022 to June 2023. Survivors' lived experience after firearm injury, sources of emotional support, mental health utilization, and their desired engagement with mental health care after firearm injury. A total of 18 participants (17 were Black [94%], 16 were male [89%], and 14 were aged between 13 and 24 years [77%]) who survived a firearm injury were interviewed. Survivors described family members, friends, and informal networks as their main source of emotional support. Barriers to mental health care utilization were perceived as a lack of benefit to services, distrust in practitioners, and fear of stigma. Credible messengers served as facilitators to mental health care. Survivors also described the emotional impact their shooting had on their families, particularly mothers, partners, and children. In this study of survivors of firearm injury, findings illustrated the consequences of stigma and fear when seeking mental health care, inadequate trusted resources, and the need for awareness of and access to mental health resources for family members and communities most impacted by firearm injury. Future studies should evaluate whether community capacity building, digital health delivery, and trauma-informed public health campaigns could overcome these barriers to mitigate the emotional trauma of firearm injuries to reduce health disparities and prevent future firearm violence.

Comparative analysis of health status and health service utilization patterns among rural and urban elderly populations in Hungary: a study on the challenges of unhealthy aging

The demographic transition poses a significant challenge for health systems, especially in Central and Eastern European (CEE) countries, where the healthcare needs of aging populations are on the rise. This study aimed to describe and compare the health status and utilization of health services among the elderly residing in urban and rural areas of the most deprived region in Hungary. A comprehensive health survey was conducted in 2022, involving a randomly selected sample of 443 older adults (≥ 65 years) in Northeast Hungary. Multivariable logistic regression models adjusting for age, sex, education, financial status, chronic diseases, and activity limitations were used to investigate the association between type of residence and health service use. Among the study participants, 62.3% were female, 38.3% attained primary education, 12.5% reported a bad or very bad financial situation and 52.6% lived in urban areas. Overall, 24% of the elderly rated their health as very good or good (27.8% in urban and 19.7% in rural areas), while 57.8% (52.6% and 63.5% in urban and rural areas) reported limitations in daily activities. Compared to urban residents, rural residents reported lower rates of dentist visits (p = 0.006), specialist visits (p = 0.028), faecal occult blood testing (p < 0.001), colorectal cancer screening with colonoscopy (p = 0.014), and breast cancer screening (p = 0.035), and a higher rate of blood pressure measurement (p = 0.042). Multivariable models indicated that urban residence was positively associated with faecal occult blood testing (OR = 2.32, p = 0.014), but negatively associated with blood pressure (OR = 0.42, p = 0.017) and blood glucose measurements (OR = 0.48, p = 0.009). These findings highlight the influence of residence on health service utilization among older adults in Hungary. Further comprehensive studies are needed to better understand the health needs of the elderly population and to develop policies aimed at promoting healthy aging in CEE countries.

Patterns of mental health service utilisation in people with cancer compared with people without cancer: analysis of the Australian National Study of Mental Health and Wellbeing.

To compare the patterns of mental health service utilisation between people with and without cancer. We performed a cross-sectional study using data of all respondents aged ≥ 25 years from the Australian National Study of Mental Health and Wellbeing 2020-2021 conducted during the COVID-19 pandemic. Comparisons were made between the two groups (cancer versus non-cancer) using logistic regression models. The study comprised 318 people with cancer (55% female) and 4628 people without cancer (54% female). Cancer survivors had a higher prevalence of reporting poor health (38% versus 16%) and mental distress (18% versus 14%) than people without cancer. There were no significant differences between people with and without cancer in the odds of consulting general practitioner, psychiatrist and other health professionals for mental health, although people with cancer were significantly more likely to consult a psychologist than people without cancer (adjusted odds ratio (aOR) = 1.64, 95%CI = 1.05-2.48). While the odds of being hospitalised for physical health was significantly higher in cancer survivors than people without cancer (aOR = 2.32, 95%CI = 1.78-3.01), there was only a negligible number of people reported being hospitalised for mental health between the two groups. Several factors were associated with higher odds of mental health service utilisation including younger age, unpartnered marital status and presence of a current mental condition. Alarmingly, despite experiencing higher prevalence of poor health status and mental distress, cancer survivors did not utilise more mental health services than the general population. That is, there is a higher degree of untreated, or undertreated, distress in cancer than in the general population. Further research to identify optimal approaches of mental health care delivery for cancer survivors are urgently needed.

A Comparative Analysis of Patient Profiles and Health Service Utilization between Patent Medicine Vendors and Community Pharmacists in Nigeria.

This study examined Nigeria's socio-demographic profiles and health service utilization patterns of Patent Medicine Vendors (PMVs) and Community Pharmacists (CPs). A cross-sectional study using a structured self-administered questionnaire among 405 retail outlets (322 PMVs and 83 CPs) across 16 Lagos and Kebbi Local Government Areas (LGAs) between June 2020 and December 2020. Results showed that 60.4% were male, 76.3% from Lagos, 58.3% had tertiary education, and 74.1% had medical training. Cough and fever were common symptoms. Significant differences were found in the utilization of STD services (PMVs: 9.2%, CPs: 12.3%, p = 0.03), services by age <15 (PMVs: 54.3, CPs: 61.2, p < 0.001), and utilization by males (PMVs: 50.8, CPs: 47.1, p = 0.013). The study revealed that men visited PMVs more, while CPs used more STI services and childhood visits. The findings suggest that expanding health services among PMVs could target male-dominant diseases, and capacity building of CPs on syndromic STI management could reduce the STI burden.

Ethnic identity and barriers for using mental health services among Arab-Bedouin women coping with emotional distresses.

The study aimed to explore barriers to mental health service attainment among Bedouin women living in different residential environments in southern Israel. We hypothesized that emotional distress and the utilization of mental health services would be influenced by the living environment and ethnic identityfactors. The sample included 376 Arab-Bedouin women, 126 Arab-Bedouin women from the recognized and unrecognized villages, and 250 Arab-Bedouin women from the central localities. Quantitative methods were used, including emotional distress (GHQ12), ethnic identityscale (EIS), mental health literacy (MHLS), and barriers to mental health services attainment (BACE). Results indicated that participants from the central localities demonstrated a greater inclination to seek and utilize mental health services. Furthermore, higher rates of affirmation of ethnic identity were also found to be a predictive factor for the willingness to attain mental health services. These findings further support the role of residential environment and ethnic identity in shaping mental health service utilization patterns. Current research explored barriers to mental health servicesseek and attainment for Arab-Bedouin women in different residential environments in southern Israel. Ethnic identity factors and barriers such as stigma and access to resources predicted the tendency to seek help. Findings emphasize the need to address barriers to seeking help and the role of ethnic identity in mental health service attainment for Arab-Bedouin women.

Association between the continuum of care and postpartum depression among Angolan mothers

BackgroundThis study investigated the association between maternal and child health service utilization patterns and postpartum depression (PPD). MethodsThis study analyzed a dataset of women who participated in a randomized controlled trial to examine the effectiveness of the Maternal and Child Health Handbook in Angola. We defined probable PPD as an Edinburgh Postpartum Depression Scale (EPDS) score ≥ 10. The EPDS was administered at approximately 6 months postpartum. Service utilization patterns were defined using numbers of antenatal care (ANC), facility delivery, and vaccination visits by 6 months postpartum. The association between service utilization patterns and PPD was examined using logistic regression analyses adjusting for socioeconomic factors and parity. The continuum of care (CoC) complete pattern (four ANC/facility delivery/four vaccination) was used as a reference. ResultsThe data of 7087 participants whose children were alive and aged 6 months or older at the endline survey were analyzed. Prevalence of PPD was 17.9 % in urban and 43.2 % in rural municipalities. In urban municipalities, dropouts from the CoC at delivery and after delivery had significantly higher odds of PPD (AOR = 1.45, 95 % CI = 1.00–2.10; AOR = 1.57, 95 % CI = 1.24–1.99). In rural municipalities, dropouts from the CoC after delivery (AOR = 1.60, 95 % CI = 1.12–2.28) had significantly higher odds of PPD. LimitationsThe onset of depressive symptoms was not assessed. The EPDS was validated in some Portuguese speaking countries but not in Angola. ConclusionPPD was associated with irregular service utilization patterns such as dropouts from the CoC. Therefore, CoC and mental health must be promoted simultaneously.

Health service utilisation by quota, family-sponsored and convention refugees in their first five years in New Zealand

ObjectiveThis study examines and compares health service utilisation patterns between New Zealand’s (NZ) three main refugee groups and the general NZ population. MethodsWe used Statistics NZ’s Integrated Data Infrastructure to identify quota, family-sponsored and convention refugees arriving in NZ (2007–2013). We analysed contact with primary care, emergency department (ED), and specialist mental health services for the first five years in NZ. Logistic regression models, adjusted for age, sex and deprivation, compared health service use between refugee groups and the general NZ population in years 1 and 5. ResultsQuota refugees were more likely to be enrolled and in contact with primary care and specialist mental health services in year 1 than family-sponsored and convention refugees, but differences reduced over time. All refugee groups were more likely than the general NZ population to have presented to ED in year 1. ConclusionsQuota refugees were better connected with health services in year 1 than the other two refugee groups. The types of frontline health services accessed by refugee groups differed from the general NZ population. Implications for Public HealthThere should be systematic and equal support across all NZ regions to help refugees (regardless of visa type) navigate the NZ health system.

Age and gender patterns in health service utilisation: Age-Period-Cohort modelling of linked health service usage records

BackgroundHealth service utilisation changes across the life-course and may be influenced by contextual factors at different times. There is some evidence that men engage less with preventive health services, including attending doctors’ clinics, however the extent to which this varies temporally and across different age groups is unclear. This study aimed to describe age or cohort effects on engagement with GPs among employed mothers and fathers in Australia, and differences in these trends between men and women.MethodsWe linked data from the ‘Growing up in Australia: The Longitudinal Study of Australian Children’ with administrative health service records from Medicare. We used a small-domain estimation Age-Period-Cohort method to describe patterns in health service use among working-age male and female parents in Australia while adjusting for employment status and controlling for time-invariant factors. Our small-domain method assumes a smooth response surface of Age, Period and Cohort.ResultsMale parents have lower health service engagement than women of the same age at the same time period. Men’s pattern of health service use across time is likely explained entirely by ageing. That is, we find that patterns in health service utilisation among men are largely driven by age effects, with no evidence of periods or cohort effects in health service engagement for men between 2002 and 2016.ConclusionsDifferences in health service utilisation between male and female parents at all age-period-cohort combinations highlight a need for more research to examine the extent to which this level of health service use among Australian men meets men’s health needs, as well as barriers and enablers of health service engagement for men. Absence of evidence for period effects suggests that there is little shift in gendered patterns of health service utilisation during the observed period.

Patterns of Health Services Utilization During Pregnancy, Delivery, and Postpartum Period: Evidence from Pakistan Maternal Mortality Survey

Utilization of health services is a multidimensional behavioural phenomenon, particularly when it comes to pregnancy and delivery concerns. The importance of maternal health care services in reducing maternal mortality and morbidity has received a significant recognition. Most of the maternal deaths can be prevented if women have access to basic antenatal, delivery and postnatal care. However, uptake of maternal health care services is very low even in the areas where they are extensively available. The aim of this study is to assess the pattern and identify underlying factors on maternal health care utilization in Pakistan. Data is taken from Pakistan Maternal Mortality Survey (PMMS) 2019. Logistic regression was performed and adjusted odd ratios were calculated by using three dependent variables – Ideal Antenatal Care (IANC), birth assisted by Skilled Birth Attendant (SBA), and Postnatal Care (PNC). Impact of biological and socio-demographic variables were computed, and findings revealed that with the increase in age, education and household wealth, women are more likely to have better opportunities to use ANC, SBA and PNC. The focus of policy considerations should be on the provision of high-quality services as well as on educating women about the value of receiving such services during pregnancy and the postpartum period through education and awareness campaigns. Moreover, skilled staff and voluntary health workers can be recruited to make future agendas in reducing maternal mortality and morbidity more successful.

Mental Health Services Utilization among Suicidal Patients: Comparing the Impact of Co-Occurring Opioid or Other Substance Use Disorders

IntroductionPrior literature establishes bidirectional associations between suicide and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, the context of mental health services utilization remains under-investigated. This analysis examined patterns of mental health services utilization in patients with SUDs and suicidality, identified associated risk factors, and evaluated the impact of patient engagement on subsequent mental health outcomesObjectivesSee above.MethodsElectronic health records (EHRs) derived from 7 health systems across New York City between 2010-2019 were analyzed. Suicidality was identified as any ICD-9/10 diagnosis of suicide attempt, suicidal ideation, or self-harm injury. SUDs were identified as any opioid, cannabis, cocaine, hallucinogen, inhalant, sedative/hypnotic/anxiolytic, amphetamine, or other substance abuse or dependence. Quasi-Poisson regression adjusted for age, gender, and chronic diseases was used to model associations between OUD exposure and the frequency of encounters and estimate the relative risk (RR) of significant covariates.ResultsA total of 6977 adults with suicidality and any comorbid SUD were selected, including 2203 (31.6%) with a diagnosis of OUD and 4774 (68.4%) without a diagnosis of OUD. Most patients were male (54.8%) and aged between 25-64 years (79.3%). Many (61.3%) had over 3 chronic diseases, including depression (80.8%), hypertension (60.6%), anemia (43.0%), and hyperlipidemia (41.9%). Compared to patients with other SUDs, those with OUD had higher odds of self-harm injury [OR: 1.26 (95% CI: 1.13-1.41)], depressive disorders [1.47 (1.29-1.67)], anxiety disorders [1.65 (1.48-1.84)], psychotic disorders [1.23 (1.11-1.37)], personality disorders [1.30 (1.16-1.48)], and post-traumatic stress disorder [1.37 (1.20-1.57)]. Patients with OUD were more likely to utilize all-cause outpatient (RR: 1.16), emergency department (ED) (RR: 1.43), and inpatient (RR: 1.60) services (p&lt;0.001). Among OUD patients, males were less likely to have outpatient visits (RR: 0.79) and inpatient hospitalizations (RR: 0.88), and older age was protective against ED admissions (RR range: 0.62-0.71). Additionally, individuals with OUD were more likely than those with other SUDs to have SUD-related encounters, as well as suicide-related ED admissions and inpatient hospitalizations (p&lt;0.0001). Those who had more mental health outpatient visits were less likely to have suicide-related ED admissions (RR: 0.85), however this association was weaker among younger or male patients with comorbid OUD.ConclusionsAmong suicidal adults with comorbid SUDs, those with a diagnosis of OUD were more likely to utilize mental health services and have psychiatric comorbidity. Males and older adults were less likely to utilize services.Disclosure of InterestNone Declared

Patterns of Health Services Utilization During Pregnancy, Delivery, and Postpartum Period: Evidence from Pakistan Maternal Mortality Survey

Utilization of health services is a multidimensional behavioural phenomenon, particularly when it comes to pregnancy and delivery concerns. The importance of maternal health care services in reducing maternal mortality and morbidity has received a significant recognition. Most of the maternal deaths can be prevented if women have access to basic antenatal, delivery and postnatal care. However, uptake of maternal health care services is very low even in the areas where they are extensively available. The aim of this study is to assess the pattern and identify underlying factors on maternal health care utilization in Pakistan. Data is taken from Pakistan Maternal Mortality Survey (PMMS) 2019. Logistic regression was performed and adjusted odd ratios were calculated by using three dependent variables – Ideal Antenatal Care (IANC), birth assisted by Skilled Birth Attendant (SBA), and Postnatal Care (PNC). Impact of biological and socio-demographic variables were computed, and findings revealed that with the increase in age, education and household wealth, women are more likely to have better opportunities to use ANC, SBA and PNC. The focus of policy considerations should be on the provision of high-quality services as well as on educating women about the value of receiving such services during pregnancy and the postpartum period through education and awareness campaigns. Moreover, skilled staff and voluntary health workers can be recruited to make future agendas in reducing maternal mortality and morbidity more successful.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents.

Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents. Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit. A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001). These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Beyond Purdah: Understanding the Barriers Indian Muslim Women Face in Accessing and Utilizing Maternal Health Services

Several analysts have found that the utilization rates of maternal health services, such as antenatal care visits, skilled birth attendants and institutional deliveries are lower among Muslim women relative to women of other religious groups in India. Some have attributed this to the religiosity of Muslim women, among other social determinants such as income, education, class, and parity. These authors highlight that religious practices such as purdah play a significant role in shaping Muslim women’s reluctance to access maternal services. They report that Muslim women prefer not to access facilities with male providers, and that they lack decision making autonomy regarding their reproductive health. In this article, I will uncover the limitations underlying their arguments. I present an alternate argument: Muslim women’s utilization patterns of maternal health services may be better explained by systemic factors such as financial barriers, the historical mistrust of government health services, health communication disparities, and discrimination against Muslim women by healthcare professionals. This article argues for public health researchers to adopt a sociopolitical lens in explaining and contextualizing the barriers women belonging to excluded, minoritized, or marginalized caste and religious groups in India face in accessing maternal care.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem

BackgroundA growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance.MethodsA cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days.ResultsThere were differences between Jewish and Arab patients’ social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty.ConclusionThe study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Responding to Ontario's Overdose Crisis in the Context of the COVID-19 Pandemic.

The COVID-19 pandemic has exacerbated the overdose crisis in Canada. Using data from ICES and the Office of the Chief Coroner of Ontario, the authors characterized changing patterns of medication use and health services utilization during the pandemic. This analysis suggests that responses to the overdose crisis must confront the rapidly changing unregulated drug supply with a tailored response that addresses varied population needs, expands accessible treatment and harm reduction services and responds to the missed opportunities for engagement and support within various healthcare settings.

Leading causes of excess mortality in Mexico during the COVID-19 pandemic 2020–2021: A death certificates study in a middle-income country

SummaryBackgroundThe death toll after SARS-CoV-2 emergence includes deaths directly or indirectly associated with COVID-19. Mexico reported 325,415 excess deaths, 34.4% of them not directly related to COVID-19 in 2020. In this work, we aimed to analyse temporal changes in the distribution of the leading causes of mortality produced by COVID-19 pandemic in Mexico to understand excess mortality not directly related to the virus infection.MethodsWe did a longitudinal retrospective study of the leading causes of mortality and their variation with respect to cause-specific expected deaths in Mexico from January 2020 through December 2021 using death certificate information. We fitted a Poisson regression model to predict cause-specific mortality during the pandemic period, based on the 2015–2019 registered mortality. We estimated excess deaths as a weekly difference between expected and observed deaths and added up for the entire period. We expressed all-cause and cause-specific excess mortality as a percentage change with respect to predicted deaths by our model.FindingsCOVID-19 was the leading cause of death in 2020–2021 (439,582 deaths). All-cause total excess mortality was 600,590 deaths (38⋅2% [95% CI: 36·0 to 40·4] over expected). The largest increases in cause-specific mortality, occurred in diabetes (36·8% over expected), respiratory infections (33·3%), ischaemic heart diseases (32·5%) and hypertensive diseases (25·0%). The cause-groups that experienced significant decreases with respect to the expected pre-pandemic mortality were infectious and parasitic diseases (-20·8%), skin diseases (-17·5%), non-traffic related accidents (-16·7%) and malignant neoplasm (-5·3%).InterpretationMortality from COVID-19 became the first cause of death in 2020–2021, the increase in other causes of death may be explained by changes in the health service utilization patterns caused by hospital conversion or fear of the population using them. Cause-misclassification cannot be ruled out.FundingThis study was funded by Conacyt.