Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings.

The delivery of high-quality antenatal care is a perennial global concern for improving maternal and neonatal outcomes. Antenatal care is currently provided mainly on a one-to-one basis, but growing evidence has emerged to support the effectiveness of group antenatal care. Providing care in a small group gives expectant mothers the opportunity to have discussions with their peers about certain issues and concerns that are unique to them and to form a support system that will improve the quality and utilization of antenatal care services. The aim of this article is to promote group antenatal care as a means to increase utilization of healthcare.

Many Kinds of Poverty: Three Dimensions of Economic Hardship, Their Combinations, and Children's Behavior Problems.

Income poverty, material deprivation, and subjective financial stress are three distinct dimensions of economic hardship. The majority of the theoretical and empirical literature on the effects of economic hardship on children has treated material deprivation and subjective financial stress as only mediators of the effects of income poverty, not considering the independent effects of each dimension or the effects of their combinations. Using nationally representative, longitudinal data from the Millennium Cohort Study on more than 18,000 families in the United Kingdom, we propose seven distinct experiences of economic hardship, based on the possible combinations of income poverty, material deprivation, and subjective financial stress. We use mixed- and fixed-effects linear regression models to identify whether these different economic hardship combinations are differentially associated with children's behavior problems between ages 3 and 7. We find that all economic hardship combinations, including those without income poverty, are associated with higher levels of children's behavior problems. The combination of material deprivation and subjective financial stress and the combination of all three dimensions of economic hardship are associated with the highest levels of behavior problems. Based on these findings, we argue that income poverty is an important but insufficient measure of economic hardship for children and that theory and research on the effects of economic hardship on children should consider the multidimensional nature of economic stressors for families.

Spatial distribution of Robson 10-group classification system and poverty in southern and southeastern Brazil.

OBJECTIVE: To assess the spatial distribution of the Robson 10-group classification system (TGCS) and poverty in southeastern and southern regions of Brazil in 2016. METHODS: An ecologic study based on public data from the Brazilian Information System on Live Births and the Brazilian Institute of Geography and Statistics, including 1 519 289 (53.2%) of all live-born neonates in Brazil between January and December 2016. Statistical analysis used Bayesian modelling with spatial distribution following an autoregressive conditional structure, and Moran index. RESULTS: In 2016, the percentage of live-born neonates delivered by cesarean was 58.8% and 60.7% in the southeastern and southern regions, respectively. Robson groups 1 and 3, involving spontaneous labor, were related to regions with higher poverty (Moran index, 0.36 and 0.44, respectively), whereas groups 2 and 5, involving cesarean delivery, were related to poorer regions (Moran index, 0.56 and 0.45, respectively). CONCLUSION: The frequencies of each group of the Robson TGCS were heterogeneously distributed in the geographic space owing to important associations with the proportion of poverty in the different regions. Actions are needed to develop the poorest regions in order to minimize existing disparities.

Correlates of school dropout and absenteeism among adolescent girls from marginalized community in north Karnataka, south India.

Secondary education among lower caste adolescent girls living in rural Karnataka, South India, is characterized by high rates of school drop-out and absenteeism. A cross-sectional baseline survey (N=2275) was conducted in 2014 as part of a cluster-randomized control trial among adolescent girls (13-14 year) and their families from marginalized communities in two districts of north Karnataka. Bivariate and multivariate logistic regression models were used. Overall, 8.7% girls reported secondary school dropout and 8.1% reported frequent absenteeism (past month). In adjusted analyses, economic factors (household poverty; girls' work-related migration), social norms and practices (child marriage; value of girls' education), and school-related factors (poor learning environment and bullying/harassment at school) were associated with an increased odds of school dropout and absenteeism. Interventions aiming to increase secondary school retention among marginalized girls may require a multi-level approach, with synergistic components that address social, structural and economic determinants of school absenteeism and dropout.

Including health insurance in poverty measurement: The impact of Massachusetts health reform on poverty.

We develop and implement what we believe is the first conceptually valid health-inclusive poverty measure (HIPM) - a measure that includes health care or insurance in the poverty needs threshold and health insurance benefits in family resources - and we discuss its limitations. Building on the Census Bureau's Supplemental Poverty Measure, we construct a pilot HIPM for the under-65 population under ACA-like health reform in Massachusetts. This pilot demonstrates the practicality, face validity and value of a HIPM. Results suggest that public health insurance benefits and premium subsidies accounted for a substantial, one-third reduction in the health inclusive poverty rate.

Measuring Poverty in Southern India: A Comparison of Socio-Economic Scales Evaluated against Childhood Stunting.

INTRODUCTION: Socioeconomic status (SES) scales measure poverty, wealth and economic inequality in a population to guide appropriate economic and public health policies. Measurement of poverty and comparison of material deprivation across nations is a challenge. This study compared four SES scales which have been used locally and internationally and evaluated them against childhood stunting, used as an indicator of chronic deprivation, in urban southern India. METHODS: A door-to-door survey collected information on socio-demographic indicators such as education, occupation, assets, income and living conditions in a semi-urban slum area in Vellore, Tamil Nadu in southern India. A total of 7925 households were categorized by four SES scales-Kuppuswamy scale, Below Poverty Line scale (BPL), the modified Kuppuswamy scale, and the multidimensional poverty index (MDPI) and the level of agreement compared between scales. Logistic regression was used to test the association of SES scales with stunting. FINDINGS: The Kuppuswamy, BPL, MDPI and modified Kuppuswamy scales classified 7.1%, 1%, 5.5%, and 55.3% of families as low SES respectively, indicating conservative estimation of low SES by the BPL and MDPI scales in comparison with the modified Kuppuswamy scale, which had the highest sensitivity (89%). Children from low SES classified by all scales had higher odds of stunting, but the level of agreement between scales was very poor ranging from 1%-15%. CONCLUSION: There is great non-uniformity between existing SES scales and cautious interpretation of SES scales is needed in the context of social, cultural, and economic realities.

[Poverty and Health: The Living Standard Approach as a Supplementary Concept to Measure Relative Poverty. Results from the German Socio-Economic Panel (GSOEP 2011)]. / Armut und Gesundheit: Der Lebensstandardansatz als ergänzendes Messinstrument relativer Armut. Ergebnisse aus dem Sozio-ökonomischen Panel (SOEP 2011).

BACKGROUND: A common indicator of the measurement of relative poverty is the disposable income of a household. Current research introduces the living standard approach as an alternative concept for describing and measuring relative poverty. This study compares both approaches with regard to subjective health status of the German population, and provides theoretical implications for the utilisation of the income and living standard approach in health research. METHODS: Analyses are based on the German Socio-Economic Panel (GSOEP) from the year 2011 that includes 12 290 private households and 21106 survey members. Self-rated health was based on a subjective assessment of general health status. Income poverty is based on the equalised disposable income and is applied to a threshold of 60% of the median-based average income. A person will be denoted as deprived (inadequate living standard) if 3 or more out of 11 living standard items are lacking due to financial reasons. To calculate the discriminate power of both poverty indicators, descriptive analyses and stepwise logistic regression models were applied separately for men and women adjusted for age, residence, nationality, educational level, occupational status and marital status. RESULTS: The results of the stepwise regression revealed a stronger poverty-health relationship for the living standard indicator. After adjusting for all control variables and the respective poverty indicator, income poverty was statistically not significantly associated with a poor subjective health status among men (OR Men: 1.33; 95% CI: 1.00-1.77) and women (OR Women: 0.98; 95% CI: 0.78-1.22). In contrast, the association between deprivation and subjective health status was statistically significant for men (OR Men: 2.00; 95% CI: 1.57-2.52) and women (OR Women: 2.11; 95% CI: 1.76-2.64). CONCLUSIONS: The results of the present study indicate that the income and standard of living approach measure different dimensions of poverty. In comparison to the income approach, the living standard approach measures stronger shortages of wealth and is relatively robust towards gender differences. This study expands the current debate about complementary research on the association between poverty and health.

Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions.

BACKGROUND: Many low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures. METHODS: We compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system. FINDINGS: The distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the "basic needs" poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the "basic needs" poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard. CONCLUSION: In choosing poverty identification strategies for programmes seeking to enhance health equity it's necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities.

Free solar lanterns to below poverty line girls in India: a step toward achieving millennium development goals.

Development sectors like health cannot function in isolation. Intersectoral coordination between various departments helps in bringing a positive change in the health-seeking behavior of society in the long run. The decision by the Government of India to provide free solar lanterns (lamps) to the school-going girls of below poverty line families is a welcome step in this context. This initiative would help in reducing the number of school dropout girls and thus help in improving the health indicators that are directly related to women's education. Thus it is an initiative that will help in attainment of Millennium Development Goals through women's education and empowerment. Along with that, the environment-friendly approach will definitely have an impact on health of the girls by switching from kerosene/wood stoves to solar lantern light. Also this initiative would pave the path of real "intersectoral coordination" in the health sector in India that is marred with watertight functioning of various departments. There is an urgent need to popularize the scheme and involve different stakeholders like corporate houses, media, nongovernment organizations, multinational welfare agencies, and local governing bodies for ensuring the availability and utilization of solar lanterns in India.

Older adults need twice the federal poverty level to make ends meet in California.

New calculations using the Elder Economic Security Standard (TM) Index (Elder Index) for California show that both singles and couples age 65 or older who rent need more than twice the amount established by the Federal Poverty Level (FPL) Guideline to meet basic living expenses. The gap is greater for elders who own their home and are paying a mortgage than for renters. The gap between basic expenses and the FPL is smaller for owners without a mortgage, but still exists. Housing and health care are the primary drivers of the high costs. This policy brief documents that the Elder Index provides a better measure of income adequacy than the FPL for older adults because it accounts for those costs at the county level. The growing number of public and nonprofit organizations using the Elder Index will aid the quality of planning and programs that improve income security for California's rapidly growing older population.

The Canadian elder standard - pricing the cost of basic needs for the Canadian elderly.

We determined the after-tax income required to finance basic needs for Canadian elders living with different circumstances in terms of age, gender, city of residence, household size, homeowner or renter status, means of transportation, and health status. Using 2001 as our base year, we priced the typical expenses for food, shelter, medical, transportation, miscellaneous basic living items and home-based long-term care for elders living in five Canadian cities. This is the first Canadian study of basic living expenses tailored to elders instead of adults in general, prepared on an absolute rather than a relative basis. We also accounted for an individual's unique life circumstances and established the varying effect that they have on the cost of basic expenses, particularly for home care. We found that the maximum Guaranteed Income Supplement and Old Age Security benefit did not meet the cost of basic needs for an elder living in poor circumstances.

Physical, consumer, and social aspects of measuring the food environment among diverse low-income populations.

Obesity and other diet-related chronic diseases are directly related to the food environment. We describe how to better assess the food environment in specific ethnic minority settings for designing and implementing interventions, based on a review of our previous work on the food environment in American Indian reservations, Canadian First Nations reserves, the Republic of the Marshall Islands, and inner-city Baltimore. The types of food stores available within each setting and the range of healthy foods available varied greatly across these geographic regions. In all settings, proximity to food stores/supermarkets, cost, and limited availability of healthful foods were common features, which limited access to health-promoting food options. Features specific to each population should be considered in an assessment of the food environment, including physical (e.g., openness of stores, mix of types of food sources); consumer (e.g., adequacy of the food supply, seasonal factors); and social (e.g., inter-household food sharing, perceptions of food quality, language differences) aspects. The food environments common in low-income ethnic subpopulations require special focus and consideration due to the vulnerability of the populations and to specific and unique aspects of each setting.

Poverty and cumulative hospitalization in infancy and early childhood in the Quebec birth cohort: a puzzling pattern of association.

OBJECTIVE: We anticipate a negative gradient between income and hospitalization, since income is positively associated with good health. In a previous cross-sectional study, we reported an unexpected pattern of association between poverty and hospitalization for 5-month-old infants in Quebec. This study re-examines the poverty-hospitalization relationship within a longitudinal population study of the same birth cohort aged 3.5 years. METHOD: Life table analysis, multivariable proportional hazard regression, and multivariable logistic regression were performed on data from the first four waves of the Quebec Longitudinal Study of Child Development (QLSCD). Probabilities of hospitalization were estimated by poverty status. The hazard ratios (HR) (Cox-regression) for duration of poverty (frequency of insufficient income) and severity of poverty (combining frequency and level of income insufficiency) were estimated, controlling for predisposing, enabling, and need determinants of hospitalization. RESULTS: At 3.5 years, 31% of children had been hospitalized at least once. Compared with children whose families had constantly sufficient income, children with intermittent poverty exhibited higher hospitalization risks (HR = 1.30; 95%CI = 1.04-1.64) while chronically poor children exhibited comparable hospitalization hazards (HR = 0.97; 95%CI = 0.73-1.27). Hospitalization risks for children in the severest poverty group resembled that of the non-poor group (HR = 0.99; 95%CI = 0.66-1.49), while children in less severely poor families were more likely to be hospitalized (HR = 1.26; 95%CI = 0.99-1.60). CONCLUSION: Results suggest hospitalization barriers for children living in chronic and severe poverty. If these barriers exist in a universal health care system, they may originate with primary care service organization or hospital care referral procedures.

A caracterização da pobreza urbana ao longo do tempo: aplicação do modelo idade-período-coorte na estimação das tendências de privações crônica e transitória no Brasil / Characterizing urban poverty over time: the use of the Age-Period-Cohort model for estimating chronic and transient poverty trends in Brazil

Ao longo das últimas décadas, a pobreza no Brasil vem mudando seu perfil, devido, em parte, a alterações no padrão de reprodução e mortalidade da população. Da mesma forma, os desenhos de políticas sociais, especialmente de combate à pobreza, tomaram outros rumos. Nesse aspecto, a pertinência desses novos desenhos depende da natureza da condição de baixa renda, podendo ser entendida como um fenômeno permanente ou temporário e, principalmente, da tendência de mudanças nessa composição transitória-crônica (T-C). O objetivo deste trabalho é justamente analisar essa tendência, assim como o processo de incidência da pobreza urbana, em termos de mudanças ao longo do tempo e de gerações de indivíduos, projetando medidas futuras de privação na renda. Para tanto, é utilizado um modelo de idade-período-coorte (IPC) sobre a pobreza, absoluta e relativa, observada nas PNADs entre 1995 e 2003, e sobre sua composição T-C estimada. Os resultados apontam que o efeito coorte é mais expressivo do que o de período sobre a redução da pobreza recentemente, em especial de seu componente crônico. Já o componente transitório apresenta tendência de aumento ao longo do tempo.

The profile of poverty in Brazil has changed in recent decades, partially due to alterations in the reproduction and mortality standards of the population. During this same period, the designs of social policies, especially those for reducing poverty, have also undergone changes. It must be emphasized that the effectiveness of these policies depends on the type of poverty that is being dealt with. Destitution can be a permanent or temporary phenomenon, and this transient-chronic (T-C) composition may show a temporal trend. The objective of this paper is to analyze this trend as well as the temporal evolution of poverty rates in urban areas. The result may make it possible to predict future income and destitution. To this end, an Age-Period-Cohort (APC) model was applied to absolute and relative poverty measures and to the T-C composition, based on data from the PNADs between 1995 and 2003. The results indicate that the cohort-effect is more expressive than the period effect for the recent reduction in poverty rates, especially for the chronic component. In contrast, the transient component showed a relative temporal tendency to increase.

A lo largo de las últimas décadas, la pobreza en Brasil viene cambiando su perfil, debido, en parte, a modificaciones en el padrón de reproducción y mortalidad de la población. De la misma forma, los diseños de políticas sociales, especialmente de combate a la pobreza, tomaron otros rumbos. En este aspecto, la pertinencia de esos nuevos diseños depende de la naturaleza de la condición de baja renta, pudiendo ser entendida como un fenómeno permanente o temporal y, principalmente, de la tendencia de cambios en esa composición transitoria-crónica (T-C). El objetivo de este trabajo es justamente analizar esa tendencia, así como el proceso de incidencia de la pobreza urbana, en términos de modificaciones a lo largo del tiempo y de generaciones de individuos, proyectando medidas futuras de privación en la renta. Para ello es utilizado un modelo de edad-período-cohorte (IPC) sobre la pobreza, absoluta y relativa, observada en las PNADs entre 1995 y 2003, y sobre su composición T-C estimada. Los resultados apuntan que el efecto cohorte es más indicativo que el de período sobre la reducción de la pobreza recientemente, en especial de su componente crónico. Ya el componente transitorio presenta tendencia de aumento a lo largo del tiempo.