The unequal effects of austerity measures between income-groups on the access to healthcare: a quasi-experimental approach.

BACKGROUND: The Great Recession, starting in 2008, was characterized by an overall reduction in living standards. This pushed several governments across Europe to restrict expenditures, also in the area of healthcare. These austerity measures are known to have affected access to healthcare, probably unevenly among social groups. This study examines the unequal effects of retrenchment in healthcare expenditures on access to medical care for different income groups across European countries. METHOD: Using data of two waves (2008 and 2014) of the European Union Statistics of Income and Living Conditions survey (EU-SILC), a difference-in-differences (DD) approach was used to analyse the overall change in unmet medical needs over time within and between countries. By adding another interaction, the differences in the effects between income quintiles (difference-in-difference-in-differences: DDD) were estimated. To do so, comparisons between two pairs of a treatment and a control case were made: Iceland versus Sweden, and Ireland versus the United Kingdom. These comparisons are made between countries with recessions equal in magnitude, but with different levels of healthcare cuts. This strategy allows isolating the effect of cuts, net of the severity of the recession. RESULTS: The DD-estimates show a higher increase of unmet medical needs during the Great Recession in the treatment cases (Iceland vs. Sweden: + 3.24 pp.; Ireland vs. the United Kingdom: + 1.15 pp). The DDD-estimates show different results over the two models. In Iceland, the lowest income groups had a higher increase in unmet medical needs. This was not the case in Ireland, where middle-class groups saw their access to healthcare deteriorate more. CONCLUSION: Restrictions on health expenditures during the Great Recession caused an increase in self-reported unmet medical needs. The burden of these effects is not equally distributed; in some cases, the lower-income groups suffer most. The case of Ireland, nevertheless, shows that certain policy measures may relatively spare lower-income groups while affecting middle-class income groups more. These results bring in evidence that policies can reduce and even overshoot the general effect of income inequalities on access to healthcare.

Validation of the Psychological Empowerment Scale and Client-Centered Care Questionnaire in budget holders with disabilities.

PURPOSE: Several high-income countries install Cash-for-Care Schemes (CCSs) by granting budgets to care users. However, little quantitative evidence exist on empowerment and client-centered care levels, due to a lack of validated scales. This research aimed to validate the Psychological Empowerment Scale (PE scale) and Client-Centered Care Questionnaire (CCCQ) in budget holders with disabilities. METHODS: A survey was developed based on a literature review and experts and budget holders input. Principal Axis Factoring with direct oblimin rotation, Cronbach's Alpha, and hypotheses testing with socio-demographic and budget characteristics as independent variables, and PE scale and CCCQ as dependent, were undertaken to assess both scales' internal consistency and validity. RESULTS: A convenience sample of 224 Flemish (proxy) budget holders completed the survey. Our analysis showed a two-factor solution for both scales; for the PE scale consisting of "meaning" and "competence," and "self-determination" and "impact," for CCCQ consisting of items 1-7 (conduct by caregiver) and items 8-15 (autonomy). Cronbach's Alpha of both scales was 0.94. The majority of our hypotheses were confirmed. CONCLUSIONS: The findings show that both scales are valid and internally consistent, meaning that they can be further tested in a respondent sample of people with disabilities and in other care contexts.

In light of the current trends in the (health)care sector to stimulate empowerment and client-centered care in care users, the monitoring of this experience is important.The Psychological Empowerment Scale (PE scale) measures empowerment by means of four cognitions (meaning, competence, impact, and self-determination), while the Client-Centered Care Questionnaire (CCCQ) measures the level of client-centered care.The PE scale and CCCQ are valid and internally consistent in our sample of (proxy) budget holders with disabilities.

Dual Use of Public and Private Health Care Services in Brazil.

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose-response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Community Health Workers as a Strategy to Tackle Psychosocial Suffering Due to Physical Distancing: A Randomized Controlled Trial.

BACKGROUND: During the COVID-19 pandemic, many primary care professionals were overburdened and experienced difficulties reaching vulnerable patients and meeting the increased need for psychosocial support. This randomized controlled trial (RCT) tested whether a primary healthcare (PHC) based community health worker (CHW) intervention could tackle psychosocial suffering due to physical distancing measures in patients with limited social networks. METHODS: CHWs provided 8 weeks of tailored psychosocial support to the intervention group. Control group patients received 'care as usual'. The impact on feelings of emotional support, social isolation, social participation, anxiety and fear of COVID-19 were measured longitudinally using a face-to-face survey to determine their mean change from baseline. Self-rated change in psychosocial health at 8 weeks was determined. RESULTS: We failed to find a significant effect of the intervention on the prespecified psychosocial health measures. However, the intervention did lead to significant improvement in self-rated change in psychosocial health. CONCLUSIONS: This study confirms partially the existing evidence on the effectiveness of CHW interventions as a strategy to address mental health in PHC in a COVID context. Further research is needed to elaborate the implementation of CHWs in PHC to reach vulnerable populations during and after health crises.

A Multilevel Perspective on the Health Effect of Social Capital: Evidence for the Relative Importance of Individual Social Capital over Neighborhood Social Capital.

Employing a multilevel perspective on the health effects of social capital, this study analyzes how individual and neighborhood differences in self-rated health in Ghent (Belgium), relate to individual and collective social mechanisms, when taking demographic and socioeconomic characteristics of individuals into account. This study estimates the health effects of social trust, informal social control and disorder at the neighborhood level and social support and network size at the individual level, using indicators indebted to both the normative and resource-based approaches to social capital. Instead of the mere aggregation of individual indicators of social capital, this study uses the key informant technique as a methodologically superior measurement of neighborhood social capital, which combined with a multilevel analysis strategy, allows to disentangle the health effects of individual and neighborhood social capital. The analysis highlights the health benefits of individual social capital, i.e., individual social support and network size. The study indicates that controlling for individual demographic and socioeconomic characteristics reduces the effect of the neighborhood-level counterparts and the neighborhood characteristics social trust and neighborhood disorder have significant, but small health effects. In its effects on self-rated health, social capital operates on the individual level, rather than the neighborhood level.