User-reported quality of care: findings from the first round of the People's Voice Survey in 14 countries.

High-quality care is essential for improving health outcomes, although many health systems struggle to maintain good quality. We use data from the People's Voice Survey-a nationally representative survey conducted in 14 high-income, middle-income, and low-income countries-to describe user-reported quality of most recent health care in the past 12 months. We described ratings for 14 measures of care competence, system competence, and user experience and assessed the relationship between visit quality factors and user recommendation of the facility. We disaggregated the data by high-need and underserved groups. The proportion of respondents rating their most recent visit as high quality ranged from 25% in Laos to 74% in the USA. The mean facility recommendation score was 7·7 out of 10. Individuals with high needs or who are underserved reported lower-quality services on average across countries. Countries with high health expenditure per capita tended to have better care ratings than countries with low health expenditure. Visit quality factors explained a high proportion of variation in facility recommendations relative to facility or demographic factors. These results show that user-reported quality is low but increases with high national health expenditure. Elevating care quality will require monitoring and improvements on multiple dimensions of care quality, especially in public systems.

Small Area Variation in the Quality of Maternal and Newborn Care in India.

Importance: In India, the district serves as the primary policy unit for implementing and allocating resources for various programs aimed at improving key developmental and health indicators. Recent evidence highlights that high-quality care for mothers and newborns is critical to reduce preventable mortality. However, the geographic variation in maternal and newborn health service quality has never been investigated. Objective: To examine the variation between smaller areas within districts in the quality of maternal and newborn care in India. Design, Setting, and Participants: This cross-sectional study assessed data from women aged 15 to 49 years on the most recent birth (singleton or multiples) in the 5 years that preceded the fifth National Family Health Survey (June 17, 2019, to April 30, 2021). Exposures: Maternal and newborn care in 36 states and union territories (UTs), 707 districts, and 28 113 clusters (small areas) in India. Main Outcomes and Measures: The composite quality score of maternal and newborn care was defined as the proportion of components of care received of the total 11 essential components of antenatal and postnatal care. Four-level logistic and linear regression was used for analyses of individual components of care and composite score, respectively. Precision-weighted prevalence of each component of care and mean composite score across districts as well as their between-small area SD were calculated. Results: The final analytic sample for the composite score was composed of 123 257 births nested in 28 113 small areas, 707 districts, and 36 states/UTs. For the composite score, 58.3% of the total geographic variance was attributable to small areas, 29.3% to states and UTs, and 12.4% to districts. Of 11 individual components of care, the small areas accounted for the largest proportion of geographic variation for 6 individual components of care (ranging from 42.3% for blood pressure taken to 73.0% for tetanus injection), and the state/UT was the largest contributor for 4 components of care (ranging from 41.7% for being weighed to 52.3% for ultrasound test taken). District-level composite score and prevalence of individual care components and their variation across small areas within the districts showed a consistently strong negative correlation (Spearman rank correlation ρ = -0.981 to -0.886). Low-quality scores and large between-small area disparities were not necessarily concentrated in aspirational districts (mean district composite score [SD within districts], 92.7% [2.1%] among aspirational districts and 93.7% [1.8%] among nonaspirational districts). Conclusions and Relevance: The findings of this cross-sectional study suggest that the policy around maternal and child health care needs to be designed more precisely to consider district mean and between-small area heterogeneity in India. This study may have implications for other low- and middle-income countries seeking to improve maternal and newborn outcomes, particularly for large countries with geographic heterogeneity.

The relative importance of macro versus micro geographical scale in explaining suicide variation in Seoul, South Korea 2014-2016.

BACKGROUND: As ecological factors are getting attention as important determinants of suicide, it is important to identify the unit at which the largest variation exists for more tailed strategy to prevent suicide. We examined the relative importance of two administrative levels for geographic variation in the suicide rate between 2014-2016 in Seoul, the capital city of Korea. METHODS: Two-level linear regression with Dongs (level 1) nested within Gus (level 2) was performed based on suicide death data aggregated at the Dong-level. We performed pooled analyses and then year-stratified analyses. Dong-level socioeconomic status and environmental characteristics were included as control variables. RESULTS: The overall age- and sex- standardized suicide rate across all Dongs decreased over time from 24.9 deaths per 100,000 in 2014 to 23.7 deaths in 2016. When Dong and Gu units were simultaneously considered in a multilevel analysis, most of the variation in suicide rate was attributed to within-Gu, between-Dong differences with a contribution of Gu-level being small and decreasing over time in year (Variance partitioning coefficient of Gu = 5.3% in 2014, <0.1% in 2015 and 2016). The number of divorce cases per 100,000 explained a large fraction of variation in suicide rate at the Dong-level. CONCLUSIONS: Findings from this study suggest that ecological micro-area unit is more important in reducing the geographic variation in the suicide rate. More diverse ecological-level data needs to be collected for targeted area-based suicide prevention policies in Korea.

Changes In Catastrophic Health Expenditures For Major Diseases After A 2013 Health Insurance Expansion In South Korea.

The South Korean National Health Insurance scheme has lacked sufficient coverage scope (services covered) and depth (costs covered) since it achieved national coverage in 1989. The government implemented two separate welfare plans (2004-08 and 2009-12) to improve the financial protection of National Health Insurance by mainly focusing on costs covered. The third plan (initiated in 2013) was the most comprehensive, addressing both scope and depth. We evaluated the impact of this benefit expansion policy for four categories of major disease (cancer, cardiac disease, cerebrovascular disease, and rare diseases) on catastrophic health expenditures, impoverishment, and unmet need. Using 2012-17 Korean Health Panel Survey data, we performed difference-in-differences analyses and triple-difference analyses to examine the differential impact of policy across income groups. The policy reduced catastrophic health expenditures among beneficiary households across almost all postpolicy years. However, there was no average effect on reducing household impoverishment or unmet need. The policy had mixed effects by income but did not generally favor low-income households. To provide stronger financial protection, the policy must address issues beyond expanding coverage, such as provider payment structure. In addition, special policy measures for low-income households need to be adopted.

Did expansion of insurance coverage for major diseases in Korea induce a positive spillover effect on dental service utilization?

Although people with serious major diseases are disproportionately likely to have poor oral health, they are also more likely to defer treatment for oral health conditions due to financial constraints. The South Korean government introduced a comprehensive benefit expansion policy covering four major disease categories in 2013: cancer, cardiac diseases, cerebrovascular diseases, and rare diseases. Meanwhile, a policy expanding benefits for dental prosthetic services for the elderly was also introduced during the same period. Using nationally representative Korean Health Panel data from 2012 to 2017, we performed a difference-in-difference (DID) analysis to examine the positive spillover effect of insurance expansion for the four major disease categories on encouraging dental service utilization (frequency of dental visits and dental out-of-pocket payments) or decreasing unmet dental needs. Additionally, a triple-difference (TD) analysis was performed to examine whether the effect of coverage expansion of dental prosthetic services on dental service utilization was larger among the beneficiaries of the expansion for the four major disease categories. Benefit expansion for the four major disease categories did not significantly affect dental service utilization among the beneficiaries (DID model) during all study years and slightly increased unmet dental needs in 2014 and 2015. However, the effect of expanded coverage for dental prosthetic services on encouraging dental service utilization was larger (TD model) among the beneficiaries of the policy for the four major disease categories than among non-beneficiaries when we defined the beneficiaries as individuals with two or more household members who had one of the four major diseases. Our results suggest a need to provide more intense coverage for those with comorbidities by embracing the concept of proportionate universalism in the coverage of dental services.

Health Technology Assessment Development in Vietnam: A Qualitative Study of Current Progress, Barriers, Facilitators, and Future Strategies.

INTRODUCTION: To make more efficient use of limited resources, Vietnam incorporated health technology assessment (HTA) into the decision-making process for the health insurance benefit package in 2014. We evaluated progress in HTA institutionalization in Vietnam based on the theoretical framework developed by the National Institute for Health and Care Excellence and the Health Intervention and Technology Assessment Program, identified negative and conducive factors for HTA development, and finally suggested policy recommendations that fit the Vietnamese context. METHODS: Semi-structured in-depth qualitative interviews were conducted between December 2017 and March and April 2018 with a purposive sample of 24 stakeholders involved in decision-making for health insurance reimbursement. We employed thematic analysis to examine themes within the data. RESULTS: Despite a variety of activities (e.g., training and advising/mentoring) and a substantial level of output (e.g., policy statements, focal points assigned, and case studies/demonstration projects), Vietnam has not yet reached the policy decision stage based on HTA with scientific integrity and active stakeholder participation. Most respondents, except some clinicians, supported the use of HTA. The lack of capacity of human resources in the government sector and academia, the limited data infrastructure, the absence of guidelines, the government's interest in immediate budget-saving, and public resistance were identified as barriers to the advancement of HTA. CONCLUSIONS: A structured data repository, guidelines based on the Vietnamese context for both policy decision-making at the central level and daily clinical decision-making at the micro-level, and integration of a participatory process into HTA are suggested as priorities for HTA institutionalization in Vietnam.

Public Preferences in Resource Allocation for Insurance Coverage of Dental Implant Service in South Korea: Citizens' Jury.

The Korean government sought to include dental implant services for the elderly in the benefits package of the national health insurance. In 2014, the Citizens' Jury was held to discuss the topic, during which thirty jurors, randomly selected from the 2665 applicants, participated in a day-long deliberation process after having an information session on the topic by a team of experts. There was a substantial shift in opinion during the deliberation session toward a more cost-conscious view. Most jurors supported limiting the coverage of dental implant to only one tooth per individual given the extent of the financial burden that will be imposed on the population. They opposed covering implant services for the front teeth, given that the implant of front teeth generally serves aesthetic purposes rather than restoring mastication function. The government's final decision in 2014 was to offer coverage up to two teeth, regardless of tooth location. This scheme based on the jury's recommendations in 2014 has been implemented without policy failure to date, which shows that the lay public can meaningfully contribute to a decision-making process regarding controversial agendas such as benefits packages for expensive health services.

Association between the type of provider and Cesarean section delivery in India: A socioeconomic analysis of the National Family Health Surveys 1999, 2006, 2016.

BACKGROUND: Prevalence of Cesarean section (C-section) is unequally distributed. Since both extremely low and high levels of C-section can not only cause adverse birth outcomes but also impose a double burden of inefficiency within maternal health care, it is important to monitor the dynamics of key factors associated with the use of C-section. OBJECTIVES: To examine the association between type of provider and C-section in India in three-time points: 1999, 2006, and 2016, and also to assess whether this association differed across maternal education and wealth level. METHODS: Data were from three waves of cross-sectional and nationally representative Indian National Health Family Survey: Wave II (1999), III (2006), and IV (2016). Target population is women aged 15 and 49 who had an institutional delivery for the most recent live birth during the three or five years preceding the survey (depending on the survey round). Multivariate logistic regression models adjusting for state cluster effect were performed to determine the association between the type of providers and C-section. Differential association between the type of providers and C-section by maternal education and wealth level was examined by stratified analyses. RESULTS: The prevalence of C-section among institutional delivery increased from 20.5% in 1999 to 24.8% in 2006 while it declined to 19.4% in 2016. The positive association between private providers and C-section became stronger over the study period (Odds Ratio (OR) = 1.39, 95% Confidence Interval (CI) 1.18-1.64 in 1999, OR = 3.71 95% CI 2.93-4.70 in 2016). The association was consistently significant across all states in 2016. The gap in C-section between public and private providers was greater among less-educated and poorer women. The ORs gradually increased from the poorest to the richest quintiles, and also from the least educated group (no formal education) to the most educated group (college graduate or above). CONCLUSIONS: Our results suggest that disparity in C-section between private and public providers has increased over the last 15 years and was higher in lower SES women. The behavior of providers needs to be closely monitored to ensure that C-section is performed only when medically justified.

Are "Obstetrically Underserved Areas" really underserved? Role of a government support program in the context of changing landscape of maternal service utilization in South Korea: A sequential mixed method approach.

OBJECTIVES: The Korean government has been providing financial support to open and operate the maternal hospital in Obstetrically Underserved Areas (OUAs) since 2011. Our study aims to assess the effectiveness of the government-support program for OUAs and to suggest future directions for it. METHODS: We performed sequential-mixed method approach. Descriptive analyses and multi-level logistic regression were performed based on the 2015 Korean National Health Insurance claim data. Data for the qualitative analysis were obtained from in-depth interviews with health providers and mothers in OUAs. RESULTS: Descriptive analyses indicated that the share of babies born in the hospitals located in the area among total babies ever born from mothers residing in the area (Delivery concentration Index: DCI) was lower in government-supported OUAs than other areas. Qualitative analyses revealed that physical distance is no longer a barrier in current OUAs. Mothers travel to neighboring big cities to seek elective preferences only available at specialized maternal hospitals rather than true medical need. Increasing one-child families changed the mother's perception of pregnancy and childbirth, making them willing to pay for more expensive services. Concern about an emergency for mothers or infants, especially of high-risk mothers was also an important factor to make mothers avoid local government-supported hospitals. Adjusted multi-level logistic regression indicated that DCIs of government-supported OUAs were higher than the ones of their counterpart areas. CONCLUSION: Our results suggest that current OUAs do not reflect reality. Identification of true OUAs where physical distance is a real barrier to the use of obstetric service and focused investment on them is necessary. In addition, more sophisticated performance indicator other than DCI needs to be developed.

Long-term trend in socioeconomic inequalities and geographic variation in the utilization of antenatal care service in India between 1998 and 2015.

OBJECTIVE: To investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in the utilization of antenatal care (ANC) services in India before and throughout the Millennium Development Goals era. DATA SOURCES/STUDY SETTING: For this temporal analysis, secondary data from the Indian National Family Health Surveys between 1998 and 2015 (Waves 2, 3, and 4) were used. STUDY DESIGN: We analyzed the trend in inequality for at least one and four ANC visits to a health care professional (ANC1+ and ANC4+, respectively) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the temporal trend and the relative contribution of communities and states to the overall variation in ANC1+ and ANC4+. DATA COLLECTION/EXTRACTION METHODS: Data on utilization of ANC services for the last birth of women aged 15-49 years during the three or five years preceding the survey (depending on the survey year) were used. PRINCIPAL FINDINGS: Educational and wealth inequality in ANC1+ and ANC4+ worsened between 1998 and 2005 and improved between 2005 and 2015 (for ANC4+, OR [95% CI] = 0.22 [0.19-0.25] in Wave 2; OR [95% CI] = 0.19 [0.17-0.22] in Wave 3; and OR [95% CI] = 0.38 [0.36-0.40] in Wave 4 for the poorest). Rural-urban inequality showed a consistent decline (for ANC4+, OR [95% CI] = 0.59 [0.54-0.64] in Wave 2; OR [95% CI] = 0.63 [0.59-0.68] in Wave 3; and OR [95% CI] = 0.82 [0.79-0.85] in Wave 4 for rural area). The relative contribution of the community to the total geographic variation in the utilization of ANC services increased more than four times during the study period. CONCLUSIONS: The use of ANC services remains disproportionately lower among women with low socioeconomic status. Efforts to directly target these women are necessary to tackle inequality in ANC utilization in India.

Changes in socio-economic patterns of energy consumption and insufficient energy intake across India from 1993-94 to 2011-12.

OBJECTIVE: To assess whether disparities in energy consumption and insufficient energy intake in India have changed over time across socio-economic status (SES). DESIGN: This cross-sectional, population-based survey study examines the relationship between several SES indicators (i.e. wealth, education, caste, occupation) and energy consumption in India at two time points almost 20 years apart. Household food intake in the last 30 d was assessed in 1993-94 and in 2011-12. Average dietary energy intake per person in the household (e.g. kilocalories) and whether the household consumed less than 80 % of the recommended energy intake (i.e. insufficient energy intake) were calculated. Linear and relative risk regression models were used to estimate the relationship between SES and average energy consumed per day per person and the relative risk of consuming an insufficient amount of energy. SETTING: Rural and urban areas across India. PARTICIPANTS: A nationally representative sample of households. RESULTS: Among rural households, there was a positive association between SES and energy intake across all four SES indicators during both survey years. Similar results were seen for energy insufficiency vis-à-vis recommended energy intake levels. Among urban households, wealth was associated with energy intake and insufficiency at both time points, but there was no educational patterning of energy insufficiency in 2011-12. CONCLUSIONS: Results suggest little overall change in the SES patterning of energy consumption and percentage of households with insufficient energy intake from 1993-94 to 2011-12 in India. Policies in India need to improve energy intake among low-SES households, particularly in rural areas.

Clinical characteristics and economic burden of tuberculous-destroyed lung in Korea: a National Health Insurance Service-National Sample Cohort-based study.

BACKGROUND: Tuberculous destroyed lung (TDL) contributes to patient mortality via acute exacerbation and combined medical comorbidities. This study characterized the clinical characteristics and economic burden of patients with TDL using large scale database, Health Insurance Review and Assessment Service (HIRA) data. METHODS: We searched the HIRA national database to identify patients diagnosed with TDL from January 01, 2011 to December 31, 2015. The clinical characteristics of the patients were collected and the 5-year claims data were analyzed. RESULTS: In total, 645,031 patients (55% male, mean age, 59.6 years) were enrolled over the 5 years. During the study period, 98.5% of the patients visited a primary care clinic and 71.1% and 93.2% visited secondary and tertiary hospitals, respectively. Patients spent a median of 5 days for inpatient services, and were admitted to the hospital a median of 0.62±1.2 times per person annually. Annual total cost per person was $1,838 and half of the total cost was expended for inpatient services. About 68.9% of the patients were prescribed respiratory medications, and $12 million was paid. Oral bronchodilators (46.5%) and methylxanthine (35.2%) were used more frequently than inhaled corticosteroids (ICSs)/long-acting ß2 agonist (LABA) combination agents (11.6%) or inhaled long-acting muscarinic antagonists (LAMAs) (7.5%). CONCLUSIONS: TDL imposes a high medical economic burden in Korea. The estimated economic costs were mainly made up of inpatient services and outpatient medication prescriptions. Interventions to prevent acute disease exacerbations and progression of comorbid conditions should be accompanied to alleviate the clinical and economic burden of TDL.

Use of high-level health facilities and catastrophic expenditure in Vietnam: can health insurance moderate this relationship?

BACKGROUND: Overcrowding of high-level health facilities is a major concern in a Vietnamese health system. This may increase an economic burden to the households since health insurance is still insufficient in providing financial risk protection. This paper sought to examine the association between the use of high-level health facilities and household-level expenditure status such as out-of-pocket (OOP), and catastrophic expenditure on health, as well as a moderating effect of health insurances in rural and urban districts of Vietnam. METHODS: Data utilized a health system community survey collected between 2015 and 2017 in two districts of Vietnam (one from rural area in northern part, and the other one from urban area in sourthern part). The world Health Organization's definition of catastrophic expenditure was used. Multivariate tobit and logistic regression were employed for catastrophic expenditure and OOP respectively. Interaction term between health insurance status and visit frequency in high-level facilities was included to investigate the moderating effect of health insurance. RESULTS: Health insurance status was associated with neither OOP health expenditure nor catastrophic expenditure occurrence, whereas visit frequency of high-level health facilities was strongly associated with both outcomes in both districts(e.g., for catastrophic expenditure, ORs are 1.77 and 1.30 in northern and southern district respecitvely. P values are < 0.001). Significant interaction between health insurance status and use of high-level facilities on catastrophic expenditure occurrence was found in Quoc Oai district (OR = 0.68, p < 0.05). CONCLUSIONS: The present study demonstrated negative financial impact of utilizing high-level facility on household financial status and weak role of health insurance in decreasing this impact. Multi-faceted approach is called for to mitigate the patient's financial burden.

Association between maternal literacy and child vaccination in Ethiopia and southeastern India and the moderating role of health workers: a multilevel regression analysis of the Young Lives study.

BACKGROUND: Child vaccination coverage in low- and middle-income countries is still far from complete, mainly among marginalized people such as children with illiterate mothers. OBJECTIVE: This study aims to examine the association between maternal literacy and immunization status of children in Ethiopia and southeastern India (Andhra Pradesh and Telangana) and test whether state-run health centers and community health workers moderate that association. METHODS: This study is based on cross-sectional data from samples of children in Ethiopia and India, collected as part of round 2 within the Young Lives study (2006). Multilevel logistic regression was conducted to estimate the association between maternal literacy and the completion of four kinds of child vaccinations. We further tested for cross-level interactions between state-run health centers or community health workers and maternal literacy. Estimates were adjusted for several individual- and household-level demographic and socioeconomic factors. RESULTS: Literate mothers were more likely to complete all four kinds of vaccinations for their children compared to illiterate mothers in Ethiopia (Odds Ratio (OR)=4.84, Confidence Interval (CI)=1.75-13.36). Presence of a health center was positively associated with completed vaccinations in India only (OR = 6.60, CI = 1.57-27.70). A cross-level interaction between community health workers and maternal literacy on the vaccination completion status of children was significant in Ethiopia only (OR = 0.29, CI = 0.09-0.96). CONCLUSIONS: Our findings suggest that increased availability of community health workers may reduce the child vaccination gap for illiterate mothers, depending on the country context.

Positive and negative social support and depressive symptoms according to economic status among adults in Korea: cross-sectional results from the Health Examinees-Gem Study.

OBJECTIVES: The interaction between positive and negative social support as well as each domain of social support and income on depressive symptom has not been much explored. We aimed to examine the associations of positive and negative social support with the risk of depressive symptoms among urban-dwelling adults in Korea, focusing on those interaction effects. DESIGN: We used the first wave of a large-scale cohort study called The Health Examinees-Gem Study. Positive and negative support scores ranged between 0 and 6; the variables were then categorised into low, medium, and high groups. A two-level random intercept linear regression model was used, where the first level is individual and the second is the community. We further tested for interactions between each domain of social supports and household income. SETTING: A survey conducted at 38 health examination centres and training hospitals in major Korean cities and metropolitan areas during 2009-2010. PARTICIPANTS: 21 208 adult men and women aged between 40 and 69 in Korea (mean age: 52.6, SD: 8.0). OUTCOME MEASURES: Depressive symptoms score measured by Epidemiologic Studies-Depression Scale, with scores ranging from 0 to 60. RESULTS: Level of positive and negative social support showed a negative and positive association with depressive symptom score with statistical significance at p<0.05, respectively. When the interaction terms among household income and social supports were examined, a negative association between level of positive social support and depressive symptom score was more pronounced as income was lower and level of negative social support was higher. Similarly, positive association between level of negative social support and depressive symptom score was more pronounced as income was lower and level of positive social support was lower. CONCLUSIONS: Our findings suggest that strategies for encouraging positive social support and discouraging negative social support for disadvantaged individuals might be effective in reducing depression in Korea.

Neighborhood-level and individual-level socioeconomic status and self-reported management of ischaemic heart disease: cross-sectional results from the Korea Health Examinees Study.

OBJECTIVE: Several studies identified neighbourhood context as a predictor of prognosis in ischaemic heart disease (IHD). The present study investigates the relationships of neighborhood-level and individual-level socioeconomic status with the odds of ongoing management of IHD, using baseline survey data from the Korea Health Examinees-Gem study. DESIGN: In this cross-sectional study, we estimated the association of the odds of self-reported ongoing management with the neighborhood-level income status and percentage of college graduates after controlling for individual-level covariates using two-level multilevel logistic regression models based on the Markov Chain Monte Carlo function. SETTING: A survey conducted at 17 large general hospitals in major Korean cities and metropolitan areas during 2005-2013. PARTICIPANTS: 2932 adult men and women. OUTCOME MEASURE: The self-reported status of management after incident angina or myocardial infarction. RESULTS: At the neighbourhood level, residence in a higher-income neighbourhood was associated with the self-reported ongoing management of IHD, after controlling for individual-level covariates [OR: 1.22, 95% credible interval (CI): 1.01 to 1.61). At the individual level, higher education was associated with the ongoing IHD management (high school graduation, OR: 1.33, 95% CI: 1.08 to 1.65); college or higher, OR: 1.63, 95% CI: 1.22 to 2.12; reference, middle school graduation or below). CONCLUSIONS: Our study suggests that policies or interventions aimed at improving the quality and availability of medical resources in low-income areas may associate with ongoing IHD management. Moreover, patient-centred education is essential for ongoing IHD management, especially when targeted to patients with IHD with a low education level.

Manifestations of socioeconomic status and its association with physical child punishment- Results from the Multi-Indicators Cluster Survey in Viet Nam, 2006-2014.

Physical child punishment is a critical public health problem that exhibits negative and long-lasting mental and physical health consequences. Yet, the predictors of physical punishment are understudied in developing countries, and disparities that exist between levels of economic status are not known well. The socioeconomic predictors of physical child punishment were investigated using three rounds of the Multiple Indicator Cluster Survey (MICS) results in a lower middle-income country, Viet Nam from 2006 to 2014. A total of 16,784 households that have answered the child punishment questionnaire from MICS data from 2006 to 2014 were included in the analysis. Descriptive statistics, univariate, and multivariate logistic regression analyses were conducted. A secular trend of disparity was investigated with and without the parents' normative values on physical punishment. Children in Viet Nam have been subject to some form of violent physical punishment by their parents or caregivers. About half of the children in the poorest households (44.7%) experienced physical child punishment while lesser percentage of children in the richer households experienced physical child punishment. Disparities existed across different wealth groups as the prevalence of physical child punishment decreased: the gap between the poorest and the richest group widened. Compared to the richest households, the poorest households were more likely to experience physical child punishment AOR 1.58 (95% CI 1.39-1.79). There is a decrease in the prevalence of physical punishment over the recent years in Viet Nam, socioeconomic disparities, in contrast, have increased, and the poorest children have a higher risk of experiencing physical child punishment. Such disparities should be considered in future research and intervention development.

Socioeconomic inequalities in the prevalence of biomarkers of cardio-metabolic disease in South Korea: Comparison of the Health Examinees Study to a nationally representative survey.

BACKGROUND/OBJECTIVES: This study aimed to examine socioeconomic inequalities in the prevalence of biomarkers of cardiovascular disease and diabetes in the newly developed large-scale genomic cohort study of Korean adults, the Health Examinees-Gem (HEXA-G), with a comparison of the nationally representative cross-sectional study, the Korea National Health and Nutrition Examination Survey (K-NHANES). SUBJECTS/METHODS: Using the HEXA-G and the K-NHANES from 2007-2012, we analyzed the age-adjusted relative risk (RR) and prevalence of enlarged waist circumference (EWC), elevated triglycerides (ET), low HDL cholesterol (LHC), elevated blood pressure (EBP) and elevated blood glucose (EBG) by income and educational groups for adults at age 40-69. RESULTS: For men, the prevalence of risk factors was similar across different income and educational groups (p>0.1), and between the K-NHANES and the HEXA-G. Among five risk factors, EBG showed the greatest discrepancy by 7 to 11 percentage points (i.e., the prevalence of 0.43 and 0.36 for college graduates, respectively, in K-NHANES and HEXA-G). For women, socioeconomic inequalities appeared for the five risk factors. Prevalence of risk factors was mostly lower in the HEXA-G than the K-NHANES, by approximately 11.0 percentage points. Especially, the discrepancy between K-NHANES and HEXA-G was largest in EBG (i.e., the prevalence of 0.31 and 0.20 for the lowest income groups, respectively). CONCLUSION: The HEXA-G shows broadly similar socioeconomic inequality in prevalence of cardio-metabolic risk factors to the nationally representative sample with more modest socioeconomic inequality among women in the HEXA-G than the K-NHANES.

Ecological and social patterns of child dietary diversity in India: a population-based study.

OBJECTIVE: Dietary diversity (DD) measures dietary variation in children. Factors at the child, community, and state levels may be associated with poor child nutritional outcomes. However, few studies have examined the role of macro-level factors on child DD. This study seeks to 1) describe the distribution of child DD in India, 2) examine the variation in DD attributable to the child, community and state levels, and 3) explore the relationship between community socioeconomic context and child DD. RESEARCH METHODS AND PROCEDURES: Using nationally representative data from children aged 6-23 months in India, multilevel models were used to determine the associations between child DD and individual- and community-level factors. RESULTS: There was substantial variation in child DD score across demographic and socioeconomic characteristics. In an age and sex-only adjusted regression model, the largest portion of variation in child DD was attributable to the child level (75%) while the portions of variance attributable to the community-level and state level were similar to each other (15% and 11%). Including individual-level socioeconomic factors explained 35.6 percent of the total variation attributed to child DD at the community level and 24.8 percent of the total variation attributed to child DD at the state level. Finally, measures of community disadvantage were associated with child DD in when added to the fully adjusted model. CONCLUSIONS: This study suggests that both individual and contextual factors are associated with child DD. These results suggest that a population-based approach combined with a targeted intervention for at-risk children may be needed to improve child DD in India.

Medical expenditure and unmet need of the pre-elderly and the elderly according to job status in Korea: Are the elderly indeed most vulnerable?

Increase in the elderly population and early retirement imposes immense economic burden on societies. Previous studies on the association between medical expenditure and working status in the elderly population have not adequately addressed reverse causality problem. In addition, the pre-elderly group has hardly been discussed in this regard. This study assessed possible causal association between employment status and medical expenditure as well as employment status and medical unmet needs in a representative sample of the Korean elderly (aged≧65) and the pre-elderly (aged ≧50 and < 65) adults from the Korea Health Panel Data (KHP). Dynamic panel Generalized Method of Moments (GMM) estimation was employed for the analysis of medical expenditure to address reverse causality, and fixed effect panel logistic regression was used for the analysis of unmet need. The results showed no significant association between job status and medical expenditure in the elderly, but a negative and significant influence on the level of medical expenditure in the pre-elderly. Unemployment was a significant determinant of lowering unmet need from lack of time while it was not associated with unmet need from financial burden in the fixed-effect panel model for both the elderly and pre-elderly groups. The pre-elderly adults were more likely to reduce necessary health service utilization due to unemployment compared to the elderly group because there is no proper financial safety net for the pre-elderly, which may cause non-adherence to treatment and therefore lead to negative health effects. The policy dialogue on safety net currently centers only on the elderly, but should be extended to the pre-elderly population.