Addressing pressures on health services in Belo Horizonte, Brazil through community-based care for poor older people: a qualitative study.

Background: In low and middle-income countries, there is growing interest in managing pressures on health services through community interventions for older people. Evidence on the effects of such interventions is scarce. We draw on qualitative data to examine these effects for a specific scheme, Programa Maior Cuidado (PMC) in the Brazilian city of Belo Horizonte. Methods: Building on quantitative findings reported elsewhere, we use qualitative data to develop and test theories of change. These include data from 50 meetings with policymakers, managers and staff in 30 health centres and social assistance posts. Data collection was embedded in key informant interaction and knowledge coproduction. Data include participant and non-participant observation, focus groups and semi-structured interviews with key informants, as well as older people and carers from seven families. Findings: The data reveal three theories of change. Theory 1 is PMC maintains older people's health which reduces their need for inpatient or outpatient care. We find strong evidence to support this, through effects on use of medication, chronic disease management and risk prevention. Theory 2 is PMC promotes timely intervention by anticipating health problems, thus reducing demand for emergency and acute care. We find some evidence for this, but it was limited by limited availability of timely treatment or referral beyond PMC. Theory 3 is PMC facilitates hospital discharge. We find limited evidence for this, reflecting a lack of formal liaison between PMC and hospitals. Interpretation: Schemes like PMC have potential to reduce pressures on health service utilisation by older people, if they are well articulated with wider health services. Funding: Medical Research Council, Newton Fund and Brazilian Council of State Funding Agencies.

The relationship of perceived discrimination in healthcare and future falls among community-dwelling older persons from an English longitudinal cohort.

BACKGROUND: The objective of this study is to examine the relation between the perceived discrimination suffered by older adults aged 60 and over during a healthcare encounter and its effects on the likelihood of falling 4 and 8 years later. METHODS: To identify discrimination, we used the English Longitudinal Study of Ageing (ELSA) data collected in 2010-2011 (wave 5) that asked respondents about feeling discriminated against by doctors or at hospitals in the past year. Falls were assessed by the question: "Have you fallen down in the last two years?" in subsequent waves. We performed longitudinal analyses using the 2014-2015 (wave 7) and 2018-2019 (wave 9) follow-ups. Multivariable logistic regression was used to estimate the odds ratios of falling. RESULTS: At baseline, 707 (15.1%) of all respondents experienced healthcare discrimination. Those suffering from discrimination in health care had 64% higher chances of falling 4 years later (odds ratio: 1.637, 95% confidence interval: 1.131-2.368) compared to those who did not, adjusting for age, sex, marital status, wealth, ethnicity, education levels, self-perceived health, depressive symptoms, and difficulties with basic and/or instrumental activities of daily living (ADL/IADL) and difficulties with walking. After 8 years, the effect was not statistically significant. Older age was the only significant detrimental factor at both 4 and 8 years. CONCLUSIONS: Understanding discrimination in health care is important to enable safe and welcoming environments for the timely future use of services. These results remind us of the physical risk and the complex panorama of bio-psychosocial determinants involved in tackling discrimination over time.

Cobertura vacinal contra covid-19 em instituições de longa permanência para idosos / Cobertura vacunal contra covid-19 en instituciones de larga estancia para personas mayores / Covid-19 vaccination coverage in long-term institutions for the elderly

Objetivo: analisar a cobertura vacinal contra COVID-19 em Instituições de Longa Permanência para idosos. Método: estudo transversal com dados agregados fornecidos pela Comissão Intersetorial de Acompanhamento das Instituições de Longa Permanência da Bahia. Foram incluídas as instituições identificadas em Salvador, Bahia, Brasil, com pelo menos um residente idoso (60 ou mais anos) que responderam ao inquérito de vacinação realizado entre maio a julho de 2021. Resultados: a amostra foi composta por 83 estabelecimentos, com predomínio de instituições privadas (50,1%) e filantrópicas (32,5%). A cobertura vacinal da COVID-19 atingiu 94,7% dos idosos residentes e 75,2% dos trabalhadores. Conclusão: o estudo mostra alta cobertura vacinal em idosos residentes nestas instituições, porém, menor cobertura entre os trabalhadores. A maximização da cobertura vacinal entre os cuidadores e residentes é fundamental, devido à extrema vulnerabilidade da população idosa institucionalizada à COVID-19.

Objetivo: analizar la cobertura vacunal contra COVID-19 en Instituciones de Larga Permanencia para ancianos. Método: estudio transversal con datos agregados proporcionados por la Comisión Intersectorial de Seguimiento de las Instituciones de Larga Permanencia de Bahía. Se incluyeron las instituciones identificadas en Salvador, Bahía, Brasil, con al menos un residente de edad avanzada (60 o más años) que respondieron a la encuesta de vacunación realizada entre mayo y julio de 2021. Resultados: la muestra fue compuesta por 83 establecimientos, con predominio de instituciones privadas (50,1%) y filantrópicas (32,5%). La cobertura vacunal de COVID-19 alcanzó el 94,7% de los ancianos residentes y el 75,2% de los trabajadores. Conclusión: el estudio muestra alta cobertura vacunal en ancianos residentes en estas instituciones, sin embargo, menor cobertura entre los trabajadores. La maximización de la cobertura vacunal entre cuidadores y residentes es fundamental debido a la extrema vulnerabilidad de la población de edad avanzada institucionalizada a COVID-19.

Objective to analyze vaccination coverage against COVID-19 in long-term care institutions for the elderly. Method: cross-sectional study with aggregated data provided by the Intersectoral Monitoring Commission of Long-Term Institutions of Bahia. We included the institutions identified in Salvador, Bahia, Brazil, with at least one elderly resident (60 years or older) who responded to the vaccination survey conducted between May and July 2021. Results: the sample consisted of 83 establishments, with a predominance of private (50.1%) and philanthropic (32.5%) institutions. Vaccination coverage for COVID-19 reached 94.7% of elderly residents and 75.2% of workers. Conclusion: the study shows high vaccination coverage in elderly residents of these institutions, but lower coverage among workers. Maximizing vaccination coverage among caregivers and residents is essential, due to the extreme vulnerability of the elderly population institutionalized to COVID-19.

Age discrimination, the right to life, and COVID-19 vaccination in countries with limited resources.

This paper seeks to develop and apply a simple yardstick based on remaining life expectancy to assess whether specific health policies unfairly discriminate against people on the basis of their age. This reveals that the COVID-19 vaccine prioritization policies of several countries have discriminated against older people. Conversely, the exclusion of older people from COVID-19 vaccine testing is shown to be non-discriminatory, as is some degree of age prioritization for limited acute COVID-19 care. Age discrimination in vaccine prioritization is shown to be embedded in wider ageist attitudes in health policy, which give the lives of older people a lower social value than the lives of people at younger ages.

Discontinuation of Health Interventions Among Brazilian Older Adults During the Covid-19 Pandemic: REMOBILIZE Study.

The objective of this study was to analyze changes in access to health interventions during the pandemic among Brazilian older adults and to investigate the factors associated with social and health inequalities. We conducted an online survey with Brazilian adults aged 60 + years between May and June 2020. A multidimensional questionnaire was used to investigate access to health interventions during the pandemic and associated factors. Of 1482 participants, 56.5% reported health care before the pandemic, and 36.4% discontinued it during the pandemic. The discontinuation rate was 64.4% (95% CI 61.1-67.6). Participants with higher educational level (nine or more years of education: OR 0.34; 95% CI 0.17-0.70) and higher income (eight or more times the minimum wage: OR 0.54; 95% CI 0.36-0.81) were associated with less probability of discontinuation. Presenting multimorbidity (OR: 1.42; 95% CI 1.06-1.90) and polypharmacy (OR: 0.61; 95% CI 0.46-0.81) were associated with discontinuity in health interventions. Our study showed that structural health inequities in access to health care shaped the rates of discontinuation in health care interventions during the COVID-19 pandemic. Strategic actions should be set up to actively monitor socially vulnerable older adults and strengthen community-based services to mitigate the discontinuation of health care interventions.

The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people.

BACKGROUND: Since 2011, the Brazilian city of Belo Horizonte has been operating an innovative scheme to support care-dependent older people in disadvantaged communities: Programa Maior Cuidado (PMC - Older Person's Care Program). This paper examines two potential associations between inclusion in PMC on types of outpatient health service utilization by dependent older people. The first is that being in PMC is associated with a higher frequency of outpatient visits for physical rehabilitation. The second is that being in PMC is associated with a higher frequency of planned versus unplanned outpatient visits. METHODS: We apply a quasi-experimental design to a unique set of health administrative data recording visits to outpatient health services. We focus on comparisons of the universe of visits, transformed to ratios of planned/unplanned visits and rehabilitation/other reasons for visiting the outpatient service. First, we preprocess our sample through different matching techniques such as 'coarsened exact matching' (CEM), 'nearest neighbor' based on logit scores (NN), 'optimal pair' (OP) and 'optimal full' (OF) methods. Second, we estimate marginal effects of being in PMC on our outcomes of interest. We use Poisson regressions controlling for individual and community factors and use robust standard errors. Our results are presented as the comparative incidence ratio of PMC on rehabilitation and planned visits. RESULTS: We find significant positive incidence rates for belonging to PMC for both outcomes of interest under all matching specifications. Poisson models using CEM shows a higher incidence rate for planned visits in comparison to unplanned visits, 1.3 (95% CI 1.1-1.4), by PMC patients compared to the non-PMC controls, and a higher proportion of visits for rehabilitation, 3.4 (95% CI 1.7-6.8). Similar positive results are found across other matching methods and models. CONCLUSIONS: Our analysis reveals significant positive associations between older people included in PMC and a matched set of controls for a greater ratio of making outpatient visits that were planned, rather than unplanned. We find similar associations for the proportion of visits made for rehabilitation, as opposed to other reasons. These findings indicate that PMC influences some elements of outpatient health service utilization by dependent older people.

Safeguarding people living in vulnerable conditions in the COVID-19 era through universal health coverage and social protection.

The COVID-19 pandemic is unprecedented. The pandemic not only induced a public health crisis, but has led to severe economic, social, and educational crises. Across economies and societies, the distributional consequences of the pandemic have been uneven. Among groups living in vulnerable conditions, the pandemic substantially magnified the inequality gaps, with possible negative implications for these individuals' long-term physical, socioeconomic, and mental wellbeing. This Viewpoint proposes priority, programmatic, and policy recommendations that governments, resource partners, and relevant stakeholders should consider in formulating medium-term to long-term strategies for preventing the spread of COVID-19, addressing the virus's impacts, and decreasing health inequalities. The world is at a never more crucial moment, requiring collaboration and cooperation from all sectors to mitigate the inequality gaps and improve people's health and wellbeing with universal health coverage and social protection, in addition to implementation of the health in all policies approach.

Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic.

BACKGROUND: All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time. METHODS: Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system. FINDINGS: We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths. INTERPRETATION: Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account. FUNDING: None.

Building the capacity of community health workers to support health and social care for dependent older people in Latin America: a pilot study in Fortaleza, Brazil.

BACKGROUND: Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza. METHODS: The study evaluated participants' own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors. RESULTS: The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors. CONCLUSIONS: The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.

Integrated Care in the Community: The Case of the Programa Maior Cuidado (Older Adult Care Programme) in Belo Horizonte-Minas Gerais, BRA.

Internationally, there is a large body of scientific evidence concerning the benefits of integrating health and social care to ensure that frail older people living in the community receive the assistance they need to maintain independence. In the Brazilian city of Belo Horizonte, located in the state of Minas Gerais, an integrated care intervention has been developed: the Programa Maior Cuidado - Older Adult Care Programme (PMC). This programme represents a pioneering example in Brazil of the provision of carers for highly vulnerable older people, through integrated action between public health and social service agencies. This paper draws on the first phase of a mixed method evaluation of PMC, including data from documentary sources, focus groups, empirical observation and expert workshops, to examine the processes that led to the establishment of programme. The origins of the PMC are discussed and its operational processes, with a particular emphasis on integrated activities and the roles of different actors. The paper situates PMC within comparable international experiences of integrated provision for older people and considers how it has been affected by unique context and challenging of a middle-income country.

Problems of Data Availability and Quality for COVID-19 and Older People in Low- and Middle-Income Countries.

For all health conditions, reliable age-disaggregated data are vital for both epidemiological analysis and monitoring the relative prioritization of different age groups in policy responses. This is especially essential in the case of Coronavirus Disease-2019 (COVID-19), given the strong association between age and case fatality. This paper assesses the availability and quality of age-based data on reported COVID-19 cases and deaths for low- and middle-income countries. It finds that the availability of reliable data which permit specific analyses of older people is largely absent. The paper explores the potential of excess mortality estimates as an alternative metric of the pandemic's effects on older populations. Notwithstanding some technical challenges, this may offer a better approach, especially in countries where cause of death data are unreliable.

An emergency strategy framework for managing COVID-19 in long-term care facilities in Brazil / Uma estratégia de emergência estruturada para o manejo da COVID-19 em instituições de longa permanência no Brasil

This paper presents a novel policy framework to support government responses to COVID-19 in long-term care facilities (LTCFs) in low and middle-income countries. It focuses on issues that are of specific relevance to Brazilian policy-settings, including examples of its local implementation. The CIAT Framework combines and summarizes broad elements for an emergency strategy to address the potential effects of COVID-19. The 4 steps of the Framework entail policies to coordinate, identify, assess, and target support. Those policies can be applied immediately to mitigate the impact of the COVID-19 pandemic in LTCFs. It is, however, essential to situate these responses within a more comprehensive and permanent strategy. Intersectoral collaboration must evolve into a fully institutionalized system.

Este artigo apresenta uma nova estrutura de política para dar apoio às respostas do governo à COVID-19 em instituições de longa permanência para idosos (ILPIs) em países de baixa e média renda. Se concentra em questões que são de relevância específica às organizações que decidem sobre as políticas brasileiras, incluindo exemplos de sua implementação local. A Matriz CIAT combina e resume amplos elementos de uma estratégia de emergência para abordar os potenciais efeitos da COVID19. As 4 etapas da Matriz envolvem políticas para a coordenação, identificação, avaliação e direcionamento do apoio. Essas políticas podem ser aplicadas imediatamente para atenuar o impacto da pandemia de COVID-19 nas ILPIs. É, no entanto, essencial situar essas respostas dentro de uma estratégia mais abrangente e permanente. A colaboração intersetorial deve evoluir para um sistema totalmente institucionalizado.

Health care strategies in long-term care facilities in Bahia State, Brazil / Estratégias de atenção à saúde em instituições de longa permanência para idosos na Bahia, Bras

OBJECTIVE: To describe health care strategies for older people living in long-term care facilities (LTCFs) in Bahia state, Brazil. METHODS: This is an ecological study involving LTCFs identified in Bahia state, which were invited to participate in a survey conducted between April and June 2021. The variables of interest were LTCF characteristics, health care strategies, visits received from national public health system (SUS, in Portuguese) teams, and health care actions taken by SUS. A comparative analysis was performed between LTCFs located in the East macro-region and other parts of the state, in general and also stratified by funding type (private and non-private). RESULTS: The sample consisted of 177 LTCFs, more than half of them were located in the East macro-region, seat of the state capital. Most facilities declared themselves as non-private (68%). Less than one-third of the LTCFs had their own health teams. Although 67% of LTCFs reported some health care provided by SUS, only 49% reported clinical consultations, with even lower percentages for other SUS actions, except for vaccination (91%). The East macro-region had a lower percentage of LTCFs accompanied by a SUS team, and the highest percentage of LTCFs with supplementary health insurance. CONCLUSIONS: This study shows the limited access of LTCF residents to essential health services, due to a general neglect of this population by public health care providers. The inadequacy of public policies to support LTCFs has important consequences for the quality of care offered to residents.

OBJETIVO: Descrever as estratégias de atenção à saúde dos idosos residentes em instituições de longa permanência para idosos (ILPI) na Bahia. METODOLOGIA: Trata-se de um estudo ecológico que envolveu as ILPI identificadas na Bahia, as quais foram convidadas a participar de uma pesquisa realizada entre abril e junho de 2021. As variáveis de interesse foram: características das ILPI, estratégias de atenção à saúde, visitas recebidas das equipes do Sistema Único de Saúde (SUS) e ações assistenciais fornecidas pelo SUS. Foi realizada análise comparativa geral entre as ILPI localizadas na macrorregião Leste e as demais partes do estado, bem como análise estratificada por tipo de financiamento (privado e não privado). RESULTADOS: A amostra foi composta de 177 ILPI, mais da metade localizada na macrorregião Leste, sede da capital do estado. A maioria das instalações declarou-se não privada (68%). Menos de 1/3 das ILPI possui equipe de saúde própria. Embora 67% das ILPI tenham referido algum atendimento de saúde prestado pelo SUS, apenas 49% referiram consultas clínicas, com percentuais ainda menores para outras ações do SUS, exceto vacinação (91%). A macrorregião Leste apresentou menor percentual de ILPI acompanhadas por equipe do SUS e maior percentual de ILPI com plano de saúde suplementar. CONCLUSÕES: Este estudo mostra a limitação de acesso dos residentes de ILPI aos serviços essenciais de saúde, em razão de negligência por parte dos prestadores de serviços públicos de saúde. A inadequação das políticas públicas de apoio às ILPI tem consequências importantes para a qualidade da assistência oferecida aos residentes.

COVID-19 morbimortality in long-term care facilities in the state of Bahia, Brazil / Morbimortalidade por COVID-19 em instituições de longa permanência para idosos na Bahia, Brasil

OBJECTIVE: To describe coronavirus disease 2019 (COVID-19) morbidity and mortality in long-term care facilities (LTCFs) in the state of Bahia, Brazil. METHODS: This is an ecological study involving identified and active LTCFs in Bahia, monitored by the Intersectoral Monitoring Commission of LTCFs. Data analysis included COVID-19 incidence among older residents and workers and COVID-19 hospitalization, fatality, and mortality rates among older residents. In addition to a global analysis of data from Bahia, a stratified analysis compared (i) the East macroregion with the rest of Bahia, and (ii) private LTCFs with philanthropic ones. RESULTS: Our sample consisted of 175 LTCFs, more than half located in the East macroregion (n = 99). Most facilities declared themselves as philanthropic (n = 94) or private (n = 59). From April/2020 to June/2021, COVID-19 incidence was 30.71% among residents and 19.86% among LTCF workers. Considering older residents, mortality was 3.57% and fatality was 11.63%. Incidence was lower in the East macroregion, for older residents (relative risk [RR] = 0.77; 95% confidence interval [CI] 0.68­0.87) and LTCF workers (RR = 0.70; 95%CI 0.59­0.83). The hospitalization rate due to COVID-19 was 19.97%, being higher in private LTCFs (RR = 1.61; 95%CI 1.30­2.00). CONCLUSIONS: This study reveals that COVID-19 morbidity and mortality in LTCFs in Bahia were consistent with the wide ranges described in the literature, although case fatality was lower than expected. This demonstrates the importance of strategies to coordinate, identify, assess, and target support for LTCFs, highlighting the need for stronger public policies.

OBJETIVO: Descrever a morbimortalidade da COVID-19 em instituições de longa permanência para idosos (ILPI) no estado da Bahia, Brasil. METODOLOGIA: Este é um estudo ecológico que envolve ILPI identificadas e ativas na Bahia, monitoradas pela Comissão Intersetorial de Monitoramento das ILPI. A análise dos dados incluiu a incidência de COVID-19 entre residentes e trabalhadores e as taxas de hospitalização, letalidade e mortalidade decorrentes de COVID-19 entre residentes. Além da análise global dos dados do estado, uma análise estratificada comparou (i) a macrorregião Leste com o restante da Bahia e (ii) ILPI privadas com filantrópicas. RESULTADOS: Nossa amostra incluiu 175 ILPI, mais da metade localizada na macrorregião Leste (n = 99). A maioria declarou-se como filantrópica (n = 94) ou privada (n = 59). De abril de 2020 a junho de 2021, a incidência de COVID-19 foi de 30,71% entre residentes e de 19,86% entre trabalhadores. A mortalidade entre idosos residentes foi de 3,57% e a letalidade foi de 11,63%. A incidência foi menor na macrorregião Leste, para idosos residentes (risco relativo ­ RR = 0,77; intervalo de confiança ­ IC95% 0,68­0,87) e trabalhadores (RR = 0,70; IC95% 0,59­0,83). A taxa de hospitalização por COVID-19 foi de 19,97%, sendo maior em ILPI privadas (RR = 1,61; IC95% 1,30­2,00). CONCLUSÕES: Este estudo revela que a morbimortalidade da COVID-19 em ILPI da Bahia foi consistente com as amplas faixas descritas pela literatura, ainda que a letalidade tenha sido menor que o esperado. Isso demonstra a importância de estratégias para coordenar, identificar, avaliar e direcionar o suporte a ILPI, ressaltando-se a necessidade de políticas públicas mais fortes para esse setor.

Survey of doctors' perception of professional values.

BACKGROUND: New challenges in the medical field of the third millennium emphasise the "humanization of medicine" leading to a redefinition of doctors' values, limits and roles. The study aims to assess whether there are different personality dimensions of physicians in relation to their perception of professional values and public expectations. METHODS: A questionnaire on the perception of professional values and the opinion on work in the medical field, work relationships and public expectations was administered to 374 doctors attending Continuing Medical Education courses. RESULTS: Two personality dimensions were identified: the first dimension (which we termed "Performance Attainment") is associated preeminently with values of competence, advocacy, confidentiality, spirit of enquiry, integrity, responsibility and commitment; the second dimension (which we called "Personal Involvement") focuses on concern and compassion. The doctors that have more difficulty accepting judgements on their activity are those who think that "Performance attainment" is less important (ß = 6.01; p-value = 0.007). Instead, the doctors who believe "public expectation of the health system" is not high enough, tend to think that "Performance Attainment" is more important (ß = -6.08; p-value = 0.024). The less importance is given to the values of "Personal Involvement", the less is the doctor's perception of having a leading role in respect to other health professionals (ß = -2.37; p-value = 0.018). CONCLUSIONS: Our results demonstrate that there are two different attitudes in terms of recognition and selection of the essential values to better practice the medical profession. Whether the doctors attach more importance to one dimension or the other, they do not differ in our analysis for how they answered the questions about relationships with patients, colleagues or family commitments in the questionnaire, even if they work in different areas. This suggests that in our research there is no single personal attitude that characterizes "a good doctor".

Pensions, consumption and health: evidence from rural South Africa.

BACKGROUND: Increasing numbers of older people in sub-Saharan Africa are gaining access to pension benefits and it is often claimed that these benefits promote healthy forms of consumption, which contribute to significant improvements in their health status. However, evidence to support these claims is limited. METHODS: The paper uses data for 2701 people aged 60 or over who participated in a population-based study in rural north-eastern South Africa. It analyses effects of receiving a pension on reported food scarcity, body mass index and patterns of consumption. RESULTS: The paper finds that living in a pension household is associated with a reduced risk of reported food scarcity and with higher levels of consumption of food and drink. The paper does not find that living in a pension household is associated with a higher prevalence of current smoking nor current alcohol consumption. However, the paper still finds that tobacco and alcohol make up over 40% of reported food and drink consumption, and that the correlation between reported food scarcity and body mass index status is imperfect. CONCLUSIONS: The paper does not show significant associations between pension receipt and the selected risk factors. However, the context of prevalent obesity and high shares of household spending allocated to tobacco and alcohol call into question widely-made claims that pensions enhance healthy consumption among older people in low and middle-income countries.