A Mixed-Methods Study of Social Determinants and Self-care in Adults With Heart Failure.

BACKGROUND: The burden of heart failure (HF) is unequally distributed among population groups. Few study authors have described social determinants of health (SDoH) enabling/impeding self-care. AIM: The aim of this study was to explore the relationship between SDoH and self-care in patients with HF. METHODS: Using a convergent mixed-methods design, we assessed SDoH and self-care in 104 patients with HF using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) and the Self-Care of HF Index v7.2 with self-care maintenance, symptom perception, and self-care management scales. Multiple regression was used to assess the relationship between SDoH and self-care. One-on-one in-depth interviews were conducted in patients with poor (standardized score ≤ 60, n = 17) or excellent (standardized score ≥ 80, n = 20) self-care maintenance. Quantitative and qualitative results were integrated. RESULTS: Participants were predominantly male (57.7%), with a mean age of 62.4 ± 11.6 years, with health insurance (91.4%) and some college education (62%). Half were White (50%), many were married (43%), and most reported adequate income (53%). The money and resources core domain of PRAPARE significantly predicted self-care maintenance ( P = .019), and symptom perception ( P = .049) trended significantly after adjusting for other PRAPARE core domains (personal characteristics, family and home, and social and emotional health) and comorbidity. Participants discussed social connectedness, health insurance coverage, individual upbringing, and personal experiences as facilitators of self-care behavior. CONCLUSION: Several SDoH influence HF self-care. Patient-specific interventions that address the broader effects of these factors may promote self-care in patients with HF.

Postpartum Contraceptive use and Rapid Repeat Pregnancy Among Women who use Substances.

BACKGROUND: Postpartum contraception is especially important for women who use alcohol and other substances, given the risk of possible rapid repeat pregnancy and prenatal substance exposure. However, little is known about postpartum contraceptive use among women with substance use histories. OBJECTIVE: To characterize postpartum contraceptive initiation, 24-month continuation, and rapid repeat pregnancy among women who used substances during pregnancy. METHODS: This is a secondary analysis of 161 pregnant women who enrolled in a randomized clinical trial to treat substance use in pregnancy and completed at least one follow-up assessment. Women were eligible if they were less than 28 weeks gestation and reported alcohol or illicit drug use within the past 30 days. Participants were recruited from two hospital-based OB/GYN clinics between 2006 and 2010, and completed assessments at delivery and 3-, 12-, and 24-months postpartum. RESULTS: Past 30-day use of any substance (not including tobacco) was 52.4%, 58.3%, and 59.8% at 3-, 12-, and 24-month follow-up, respectively. Marijuana was the most commonly reported illicit substance (as high as 48.1%). Rates of any contraceptive use were 71.3%, 66.7% and 65.3% at 3-, 12-, and 24-month follow-up, respectively; DepoProvera and condoms were the most common methods. Rapid repeat pregnancy occurred in 28% of participants by 24-month follow-up. Conclusions/Importance: Postpartum contraceptive use among substance using women was at or near 70%, which is comparable to other samples of postpartum women. Innovative efforts are needed to promote effective contraceptive use among postpartum women in general and among those who use substances in particular.

Economic evaluation of a behavioral intervention versus brief advice for substance use treatment in pregnant women: results from a randomized controlled trial.

BACKGROUND: Substance use in pregnancy is associated with severe maternal and fetal morbidities and substantial economic costs. However, few studies have evaluated the cost-effectiveness of substance use treatment programs in pregnant women. The purpose of this study was to evaluate the economic impact of a behavioral intervention that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) for treatment of substance use in pregnancy, in comparison with brief advice. METHODS: We conducted an economic evaluation alongside a clinical trial by collecting data on resource utilization and performing a cost minimization analysis as MET-CBT and brief advice had similar effects on clinical outcomes (e.g., alcohol and drug use and birth outcomes). Costs were estimated from the health care system's perspective and included intervention costs, hospital facility costs, physician fees, and costs of psychotropic medications from the date of intake assessment until 3-month postpartum. We compared effects of MET-CBT on costs with those of brief advice using Wilcoxon rank sum tests. RESULTS: Although the integrated MET-CBT therapy had higher intervention cost than brief advice (median = $1297/participant versus $303/participant, p < 0.01), costs of care during the prenatal period, delivery, and postpartum period, as well as for psychotropic medications, were comparable between the two groups (all p values ≥ 0.55). There was no statistically significant difference in overall cost of care (median total cost = $26,993/participant for MET-CBT versus $27,831/participant for brief advice, p = 0.90). CONCLUSIONS: The MET-CBT therapy and brief advice resulted in similar clinical outcomes and overall medical costs. Further research incorporating non-medical costs, targeting women with more severe substance use disorders, and evaluating the impact of MET-CBT on participants' quality of life will provide additional insights. TRIAL REGISTRATION: ClinicalTrials.gov NCT00227903 . Registered 27 September 2005.

Responses to donor proliferation in Ghana's health sector: a qualitative case study.

OBJECTIVE: To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana's health sector between 1995 and 2012. METHODS: We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials - e.g. reports and media articles - collected during interviews and through online research. FINDINGS: Ghana's response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country's change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance. CONCLUSION: In 1995-2012, the country's central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana's need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government's transaction costs, it also increased the donors' coordination costs and reduced the government's negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.

From conceptual pluralism to practical agreement on policy: global responsibility for global health.

BACKGROUND: As the human cost of the global economic crisis becomes apparent the ongoing discussions surrounding the post-2015 global development framework continue at a frenzied pace. Given the scale and scope of increased globalization moving forward in a post-Millennium Development Goals era, to protect and realize health equity for all people, has never been more challenging or more important. The unprecedented nature of global interdependence underscores the importance of proposing policy solutions that advance realizing global responsibility for global health. DISCUSSION: This article argues for advancing global responsibility for global health through the creation of a Global Fund for Health. It suggests harnessing the power of the exceptional response to the combined epidemics of AIDS, TB and Malaria, embodied in the Global Fund to Fight AIDS, Tuberculosis and Malaria, to realize an expanded, reconceptualized Global Fund for Health. However this proposal creates both an analytical quandary embedded in conceptual pluralism and a practical dilemma for the scope and raison d'etre of a new Global Fund for Health. To address these issues we offer a logical framework for moving from conceptual pluralism in the theories supporting global responsibility for health to practical agreement on policy to realize this end. We examine how the innovations flowing from this exceptional response can be coupled with recent ideas and concepts, for example a global social protection floor, a Global Health Constitution or a Framework Convention for Global Health, that share the global responsibility logic that underpins a Global Fund for Health. CONCLUSIONS: The 2014 Lancet Commission on Global Governance for Health Report asks whether a single global health protection fund would be better for global health than the current patchwork of global and national social transfers. We concur with this suggestion and argue that there is much room for practical agreement on a Global Fund for Health that moves from the conceptual level into policies and practice that advance global health. The issues of shared responsibility and mutual accountability feature widely in the post-2015 discussions and need to be addressed in a coherent manner. Our article argues why and how a Global Fund for Health effectuates this, thus advancing global responsibility for global health.

The global and domestic politics of health policy in emerging nations.

In recent years, several emerging nations with burgeoning economies and in transition to democracy have pursued health policy innovations. As these nations have integrated into the world economy through bilateral trade and diplomacy, they have also become increasingly exposed to international pressures and norms and focused on more effective, equitable health care systems. There are several lessons learned from the case studies of Brazil, Ghana, India, China, Vietnam, and Thailand in this special issue on the global and domestic politics of health policy in emerging nations. For the countries examined, although sensitive to international preferences, domestic governments preferred to implement policy on their own and at their own pace. During the policy-making and implementation process, international and domestic actors played different roles in health policy making vis-à-vis other reform actors -- at times the state played an intermediary role. In several countries, civil society also played a central role in designing and implementing policy at all levels of government. International institutions also have a number of mechanisms and strategies in their tool box to influence a country's domestic health governance, and they use them, particularly in the context of an uncertain state or internal discordance within the state.

Women's political participation and health: a health capability study in rural India.

Understanding the relationship between women's political participation and health has eluded researchers and cannot be adequately studied using traditional epidemiological or social scientific methodologies. We employed a health capability framework to understand dimensions of health agency to illuminate how local political economies affect health. Exploiting a cluster-randomized controlled trial of a community-based behavior change management intervention in northern India, we conducted a qualitative study with semistructured, in-depth focus groups in both intervention and nonintervention villages. We presented scenarios to each group regarding the limitations and motivations involved in women's political participation and health. Thematic analysis focused on four domains of health agency -- participation, autonomy, self-efficacy, and health systems -- relevant for understanding the relationship between political participation and health. Elder women demonstrated the greatest sense of self-efficacy and as a group cited the largest number of successful health advocacy efforts. Participation in an associated community-based neonatal intervention had varying effects, showing some differences in self-efficacy, but only rare improvements in participation, autonomy, or health system functioning. Better understanding of cultural norms surrounding autonomy, the local infrastructure and health system, and male and female perceptions of political participation and self-efficacy are needed to improve women's health agency. For a community-based participatory health intervention to improve health capability effectively, explicit strategies focused on health agency should be as central as health indicators.

Governing for the Common Good.

The proper object of global health governance (GHG) should be the common good, ensuring that all people have the opportunity to flourish. A well-organized global society that promotes the common good is to everyone's advantage. Enabling people to flourish includes enabling their ability to be healthy. Thus, we must assess health governance by its effectiveness in enhancing health capabilities. Current GHG fails to support human flourishing, diminishes health capabilities and thus does not serve the common good. The provincial globalism theory of health governance proposes a Global Health Constitution and an accompanying Global Institute of Health and Medicine that together propose to transform health governance. Multiple lines of empirical research suggest that these institutions would be effective, offering the most promising path to a healthier, more just world.

Cost-effectiveness of interventions to prevent HIV and STDs among women: a randomized controlled trial.

Injection drug use is a leading transmission route of HIV and STDs, and disease prevention among drug users is an important public health concern. This study assesses cost-effectiveness of behavioral interventions for reducing HIV and STDs infections among injection drug-using women. Cost-effectiveness analysis was conducted from societal and provider perspectives for randomized trial data and Bernoullian model estimates of infections averted for three increasingly intensive interventions: (1) NIDA's standard intervention (SI); (2) SI plus a well woman exam (WWE); and (3) SI, WWE, plus four educational sessions (4ES). Trial results indicate that 4ES was cost-effective relative to WWE, which was dominated by SI, for most diseases. Model estimates, however, suggest that WWE was cost-effective relative to SI and dominated 4ES for all diseases. Trial and model results agree that WWE is cost-effective relative to SI per hepatitis C infection averted ($109 308 for in trial, $6 016 in model) and per gonorrhea infection averted ($9 461 in trial, $14 044 in model). In sensitivity analysis, trial results are sensitive to 5 % change in WWE effectiveness relative to SI for hepatitis C and HIV. In the model, WWE remained cost-effective or cost-saving relative to SI for HIV prevention across a range of assumptions. WWE is cost-effective relative to SI for preventing hepatitis C and gonorrhea. WWE may have similar effects as the costlier 4ES.

Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: a critical and systematic review of empirical research.

Economic evaluations are an important tool to improve our understanding of the costs and effects of health care services and to create sustainable health care systems. This article critically assesses empirical evidence from economic evaluations of pharmaco- and behavioral therapies for smoking cessation. A comprehensive literature review of PubMed and the British National Health Service Economic Evaluation Database was conducted. The search identified 15 articles on nicotine-based pharmacotherapies, 12 articles on nonnicotine based pharmacotherapies, no articles on selegiline, and 10 articles on brief counseling for smoking cessation treatment. Results show that both pharmaco- and behavioral therapies for smoking cessation are cost-effective or even cost-saving. The review highlights several shortcomings in methodology and a lack of standardization of current economic evaluations. Efforts to improve methodology will help make future studies more comparable and increase the evidence base so that such evaluations can be more useful to public health practitioners and policy makers.

Impact of health insurance on health care treatment and cost in Vietnam: a health capability approach to financial protection.

We applied an alternative conceptual framework for analyzing health insurance and financial protection grounded in the health capability paradigm. Through an original survey of 706 households in Dai Dong, Vietnam, we examined the impact of Vietnamese health insurance schemes on inpatient and outpatient health care access, costs, and health outcomes using bivariate and multivariable regression analyses. Insured respondents had lower outpatient and inpatient treatment costs and longer hospital stays but fewer days of missed work or school than the uninsured. Insurance reform reduced household vulnerability to high health care costs through direct reduction of medical costs and indirect reduction of income lost to illness. However, from a normative perspective, out-of-pocket costs are still too high, and accessibility issues persist; a comprehensive insurance package and additional health system reforms are needed.

Patterns and factors associated with intensive use of ED services: implications for allocating resources.

AIM: This study aims to better understand the patterns and factors associated with the use of emergency department (ED) services on high-volume and intensive (defined by high volume and high-patient severity) days to improve resource allocation and reduce ED overcrowding. METHODS: This study created a new index of "intensive use" based on the volume and severity of illness and a 3-part categorization (normal volume, high volume, intensive use) to measure stress in the ED environment. This retrospective, cross-sectional study collected data from hospital clinical and financial records of all patients seen in 2001 at an urban academic hospital ED. RESULTS: Multiple logistic regression models identified factors associated with high volume and intensive use. Factors associated with intensive days included being in a motor vehicle crash; having a gun or stab wound; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. Factors associated with high-volume days included falling from 0 to 10 ft; being in a motor vehicle crash; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. CONCLUSION: These findings offer inputs for reallocating resources and altering staffing models to more efficiently provide high-quality ED services and prevent overcrowding.

Global health justice and governance.

While there is a growing body of work on moral issues and global governance in the fields of global justice and international relations, little work has connected principles of global health justice with those of global health governance for a theory of global health. Such a theory would enable analysis and evaluation of the current global health system and would ethically and empirically ground proposals for reforming it to more closely align with moral values. Global health governance has been framed as an issue of national security, human security, human rights, and global public goods. The global health governance literature is essentially untethered to a theorized framework to illuminate or evaluate governance. This article ties global health justice and ethics to principles for governing the global health realm, developing a theoretical framework for global and domestic institutions and actors.

Shared health governance.

Health and Social Justice (Ruger 2009a ) developed the "health capability paradigm," a conception of justice and health in domestic societies. This idea undergirds an alternative framework of social cooperation called "shared health governance" (SHG). SHG puts forth a set of moral responsibilities, motivational aspirations, and institutional arrangements, and apportions roles for implementation in striving for health justice. This article develops further the SHG framework and explains its importance and implications for governing health domestically.

Micro-costing in health and medicine: a critical appraisal.

BACKGROUND: Concerns about rising health care costs require rigorous economic study to inform clinical and policy decision-making. Micro-costing is a cost estimation methodology employing detailed resource utilization and unit cost data to generate precise estimates of economic costs. Micro-costing studies have not been critically appraised. METHODS: Critical appraisal of micro-costing studies in English. Studies fully or predominantly employing micro-costing were appraised for methodological and reporting quality through economic evaluation guidelines (Evers, Drummond, Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Fukuda and Imanaka checklists). Following the Panel on Cost Effectiveness in Health and Medicine, micro-costing studies were defined as involving "direct enumeration and costing out of every input consumed in the treatment of a particular patient." RESULTS: Full or predominant micro-costing studies included  neoplasms (18.5%), infectious and parasitic diseases (17.9%), and diseases of circulatory systems (10.8%) as the  most studied diseases. 36.9% were in the United States and 34.9% were in Europe. 33.8% did not report analytic perspective, 32.8% did not report price year, 3.6% did not inflation adjust cost data, and 44.1% did not specify inflation adjustment. 86.2% did not separately report unit costs and resource utilization quantity, 14.9 and 19.5% did not provide sufficient detail to assess appropriateness of measured physical units or valued costs. CONCLUSIONS: Micro-costing studies vary widely in methodological and reporting quality, highlighting the need to standardize methods and reporting of micro-costing studies and develop tools for their evaluation.

Health capability: conceptualization and operationalization.

Current theoretical approaches to bioethics and public health ethics propose varied justifications as the basis for health care and public health, yet none captures a fundamental reality: people seek good health and the ability to pursue it. Existing models do not effectively address these twin goals. The approach I espouse captures both of these orientations through a concept here called health capability. Conceptually, health capability illuminates the conditions that affect health and one's ability to make health choices. By respecting the health consequences individuals face and their health agency, health capability offers promise for finding a balance between paternalism and autonomy. I offer a conceptual model of health capability and present a health capability profile to identify and address health capability gaps.