Cultural context index: A geospatial measure of social determinants of health in the United States.

Minority populations will continue to grow in the United States. Such pluralism necessitates iterative, geospatial measurements of cultural contexts. Our objective in this study was to create a measure of social determinants of health in geographic areas with varying ethnic, linguistic, and religious diversity in the United States. We extracted geographic information systems data based on community characteristics that have known associations with population health disparities from 2015 to 2019. We used principal component analysis to construct a Cultural Context Index (CCI). We created the CCI for 73,682 census tracts across 50 states and five inhabited territories. We identified hot and cold spots that are the highest and lowest CCI quintile, respectively. Hot spots census tracts were mostly located in metropolitan areas (84.8%), in the Southern census region (41.5%), and also had larger Black and Hispanic populations. The census tracts with the greatest need for culturally competent health care also had the sickest populations. Census tracts with a CCI rank of 5 ('greatest need') had higher prevalences of self-reported poor physical health (17.2%) and poor mental health (17.4%), compared to either the general population (13.9% and 14.5%) or to CCI rank of 1 ('lowest need') (11.9% and 10.8%). The CCI can pinpoint census tracts with a need for culturally competent health care and inform supply-side policy planning as healthcare and social service providers will inevitably come in contact with consumers from different backgrounds.

Understanding policy change for obesity prevention: learning from sugar-sweetened beverages taxes in Mexico and Chile.

This article examines the policy change process that resulted in the current sugar-sweetened beverages taxes in Mexico and Chile, using the Kaleidoscope Model for Policy Change, a framework developed for nutrition and food policy change analysis. We used a qualitative study design, including 24 key informant (KI) interviews (16 researchers, 5 civil society representatives and 3 food/beverage industry representatives), encompassing global and in-country perspectives. The analysis shows concurrence with the Kaleidoscope Model, highlighting commonalities in the policy change process. These included the importance of focusing events and coalitions for agenda-setting. Both top-down executive leadership and bottom-up pressure from civil society coalitions were important for the policy adoption as were flexible framing of the tax, and taking advantage of windows of opportunity. In both countries, the tax resulted from national, revenue-seeking fiscal reforms and in sub-optimal tax rates, as a result of the industry influence. KIs also discussed emerging evaluation results, highlighting differences in interpretation concerning the magnitude of change from the tax, and shared potential modifications to the current policies. This analysis contributes to a greater understanding of the policy change process focused on obesity prevention, using an innovative theoretical framework developed specifically for food and nutrition policy.

Incentives to change: effects of performance-based financing on health workers in Zambia.

BACKGROUND: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. METHODS: Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. RESULTS: Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. CONCLUSIONS: In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?

BACKGROUND: There is a growing recognition of China's role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China's engagement as a donor with that of more traditional global health donors. METHODS: Using newly released data from AidData on China's development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000-2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China's activities to projects from traditional donors using data from the OECD's Development Assistance Committee (DAC) Creditor Reporting System. RESULTS: Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China's contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries. CONCLUSIONS: China is an important global health donor to Africa but contrasts with traditional DAC donors through China's focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China's approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Worldwide reported use of IV tissue plasminogen activator for acute ischemic stroke.

BACKGROUND AND PURPOSE: Intravenous tissue plasminogen activator is the most effective treatment for acute ischemic stroke, and its use may therefore serve as an indicator of the available level of acute stroke care. The greatest burden of stroke is in low- and middle-income countries, but the extent to which intravenous tissue plasminogen activator is used in these countries is unreported. SUMMARY OF REVIEW: A systematic review was performed searching each country name AND 'stroke' OR 'tissue plasminogen activator' OR 'thrombolysis' using PubMed, Embase, Global Health, African Index Medicus, and abstracts published in the International Journal of Stroke (Jan. 1, 1996-Oct. 1, 2012). The reported use of intravenous tissue plasminogen activator was then analyzed according to country-level income status, total expenditure on health per capita, and mortality and disability-adjusted life years due to stroke. There were 118,780 citations reviewed. Of 214 countries and independent territories, 64 (30%) reported use of intravenous tissue plasminogen activator for acute ischemic stroke in the medical literature: 3% (1/36) low-income, 19% (10/54) lower-middle-income, 33% (18/54) upper-middle-income, and 50% (35/70) high-income-countries (test for trend, P < 0.001). When considering country-level determinants of reported intravenous tissue plasminogen activator use for acute ischemic stroke, total healthcare expenditure per capita (odds ratio 3.3 per 1000 international dollar increase, 95% confidence interval 1.4-9.9, P = 0.02) and reported mortality rate from cerebrovascular disease (odds ratio 1.02, 95% confidence interval 0.99-1.06, P = 0.02) were significant, but reported disability-adjusted life years from cerebrovascular diseases and gross national income per capita were not (P > 0.05). Of the 10 countries with the highest disability-adjusted life years due to stroke, only one reported intravenous tissue plasminogen activator use. CONCLUSIONS: By reported use, intravenous tissue plasminogen activator for acute ischemic stroke is available to some patients in approximately one-third of countries. Access to advanced acute stroke care is most limited where the greatest burden of cerebrovascular disease is reported.