Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

INTRODUCTION: Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. METHODS: Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. RESULTS: Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. CONCLUSIONS: Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.

The determinants of mental health inequalities between Chinese migrants and non-migrants during the Shanghai 2022 lockdown: a Blinder-Oaxaca decomposition.

BACKGROUND: The mental health inequality between migrants and non-migrants was exacerbated by the COVID-19 pandemic. Identifying key determinants of this inequality is essential in promoting health equity. METHODS: This cross-sectional study recruited Shanghai residents by purposive sampling during the city-wide lockdown (from April 29 to June 1, 2022) using an online questionnaire. Migration statuses (non-migrants, permanent migrants, and temporary migrants) were identified by migration experience and by household registration in Shanghai. Mental health symptoms (depression, anxiety, loneliness, and problematic anger) were assessed by self-report scales. The nonlinear Blinder-Oaxaca decomposition was used to quantify mental health inequality (i.e., differences in predicted probabilities between migration groups) and the contribution of expected correlates (i.e., change in predicted probability associated with variation in the correlate divided by the group difference). RESULTS: The study included 2738 participants (771 [28.2%] non-migrants; 389 [14.2%] permanent migrants; 1578 [57.6%] temporary migrants). We found inequalities in depression (7.1%) and problematic anger (7.8%) between permanent migrants and non-migrants, and inequalities in anxiety (7.3%) and loneliness (11.3%) between temporary migrants and non-migrants. When comparing permanent migrants and non-migrants, age and social capital explained 12.7% and 17.1% of the inequality in depression, and 13.3% and 21.4% of the inequality in problematic anger. Between temporary migrants and non-migrants, age and social capital also significantly contributed to anxiety inequality (23.0% and 18.2%) and loneliness inequality (26.5% and 16.3%), while monthly household income (20.4%) and loss of monthly household income (34.0%) contributed the most to anxiety inequality. CONCLUSIONS: Significant inequalities in depression and problematic anger among permanent migrants and inequalities in anxiety and loneliness among temporary migrants were observed. Strengthening social capital and economic security can aid in public health emergency preparedness and promote mental health equity among migrant populations.

Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences.

BACKGROUND: Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. METHODS: We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. RESULTS: Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap. CONCLUSIONS: Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

Decomposing socioeconomic inequality in household out of pocket health expenditures in Pakistan (2010-11-2018-19).

BACKGROUND: The increased socioeconomic inequality in catastrophic health expenditure (CHE) disproportionately affects disadvantaged populations, subjecting them to financial hardships, limiting their access to healthcare, and exacerbating their vulnerability to morbidity. OBJECTIVES: This study examines changes in socioeconomic inequality related to CHE and analyzes the contributing factors responsible for these changes in Pakistan between 2010-11 and 2018-19. METHODS: This paper extracted the data on out-of-pocket health expenditures from the National Health Accounts for 2009-10 and 2017-18. Sociodemographic information was gathered from the Household Integrated Economic Surveys of 2010-11 and 2018-19. CHE was calculated using budget share and the ability-to-pay approaches. To assess socioeconomic inequality in CHE in 2010-11 and 2018-19, both generalized and standard concentration indices were used, and Wagstaff inequality decomposition analysis was employed to explore the causes of socioeconomic inequality in each year. Further, an Oaxaca-type decomposition was applied to assess changes in socioeconomic inequality in CHE over time. RESULTS: The concentration index reveals that socioeconomic inequality in CHE decreased in 2018-19 compared to 2010-11 in Pakistan. Despite the reduction in inequality, CHE was concentrated among the poor in Pakistan in 2010-11 and 2018-19. The inequality decomposition analysis revealed that wealth status was the main cause of inequality in CHE over time. The upper wealth quantiles indicated a positive contribution, whereas lower quantiles showed a negative contribution to inequality in CHE. Furthermore, urban residence contributed to pro-rich inequality, whereas employed household heads, private healthcare provider, and inpatient healthcare utilization contributed to pro-poor inequality. A noticeable decline in socioeconomic inequality in CHE was observed between 2010 and 2018. However, inequality remained predominantly concentrated among the lower socio-economic strata. CONCLUSION: These results underscore the need to improve the outreach of subsidized healthcare and expand social safety nets.

The role of positive psychological wellbeing in walking speed differences among married and unmarried English older adults.

Objectives: Walking speed has been identified as an important indicator of functional independence and survival among older adults, with marital status being related to walking speed differences. We explored explanatory factors, with a focus on positive psychological wellbeing, in walking speed differences between married and non-married individuals in later life. Methods: We used wave 8 (2016/17) cross-sectional data from adults aged 60-79 years who participated in the English Longitudinal Study of Ageing (n = 3,743). An Oaxaca-Blinder decomposition was used to compute walking speed differences between married and unmarried individuals, and the portion of those differences that could be explained by characteristic differences in those groups, particularly wellbeing. Results: Overall, married individuals had walking speeds that were 0.073 m/s (95% confidence interval: 0.055-0.092 m/s) faster than their unmarried counterparts. This was primarily driven by differences between the married and separated/divorced group, and the widowed group. Included covariates explained roughly 89% of the overall walking speed difference. Positive psychological wellbeing consistently explained a significant portion of walking speed differences, ranging between 7% to 18% across comparisons. Conclusion: Although wealth has been previously found to partially explain walking speed differences by marital status, we found that positive psychological wellbeing also demonstrated pertinence to these differences.

Explaining gender inequalities in overweight people: a Blinder-Oaxaca decomposition analysis in northern Sweden.

BACKGROUND: Being overweight and obesity are considered serious public health concerns worldwide. At the population level, factors contributing to overweight as well as the differences in overweight between men and women in terms of prevalence or associated factors are relatively well-known. What is less known is what explains the inequalities in overweight between men and women. In this study, we examined the contribution of material, behavioural, and psychosocial factors in explaining the gender differences in overweight among adults in northern Sweden. METHODS: This study was based on the 2018 Swedish Health on Equal Terms survey, which was carried out in Sweden's four northernmost regions. The analytical sample consisted of 20,855 participants (47% men) aged 20-84 years. Overweight (including obesity) was the outcome, and the selected explanatory variables were grouped according to three theoretical perspectives: material, behavioural and psychosocial. Descriptive statistics and Blinder-Oaxaca decomposition were applied for analysing the data. RESULTS: Our study showed that the prevalence of overweight was 64% and 52% among men and women, respectively. It, therefore, revealed a gender gap in overweight people of 11.7% points with explanatory factors accounting for 39% of that gap. This gender gap in overweight people was mostly explained by behavioural variables (19.3%), followed by the materialistic variables and age accounting for 16.2% and 3.1%, respectively. Specifically, having low education, being in the lowest income quintile, alcohol drinking and snus usage contributed to explain 8.4%, 8.9%, 2.8% and 6.3% of the gender difference, respectively. CONCLUSIONS: We found a considerable gender inequality in overweight between men and women. The findings highlight that future overweight prevention initiatives would benefit from targeting the uncovered contributing factors to reduce gender inequalities in overweight people.

Socioeconomic inequality in self-rated health and its determinants: an Oaxaca blinder decomposition in Ilam, West of Iran during 2023.

AIM: To determine inequality and decompose it's in Self-Rated Health (SRH). METHOD: This population-based cross-sectional study was undertaken on the entire population of the city of Ilam, Iran, in 2023. Multi-stage stratified cluster random sampling with proportion-to-size approach was used to select the participants. Oaxaca-Blinder decomposition technique was used to show the amount of inequity in SRH and to decompose of the gap of SRH between the poor and the rich group of participants. RESULTS: 1370 persons participated in the study. The 59.38% of participants stated good SRH status and just 8.86% of participants had poor SRH status. The results of the Oaxaca-Blinder decomposition revealed a considerable gap (15.87%) in the poor status of SRH between the rich and the poor. A large proportion (89.66%) of this difference was described by explained portion of the model. The results of decomposition showed that economic status was directly responsible for explaining 27.98% of overall inequality gap between rich and poor people. Moreover, hopelessness to future (32.64%), having an underlying disease (18.34%) and difference in the education level (10.71%) were associated with an increase in inequality disfavoring the poor. CONCLUSION: For people suffering from underlying disease, it is suggested to devise policies to improve access to/and remove healthcare utilization barriers. To address hopelessness to future, it is recommended to carry out further studies to reveal factors which affect it in more details. This can help policy makers to formulate more realistic and evidence-informed policies on order to lessen the current socioeconomic inequity in SRH.

Understanding factors associated with rural-urban disparities of stunting among under-five children in Rwanda: A decomposition analysis approach.

Childhood stunting in its moderate and severe forms is a major global problem and an important indicator of child health. Rwanda has made progress in reducing the prevalence of stunting. However, the burden of stunting and its geographical disparities have precipitated the need to investigate its spatial clusters and attributable factors. Here, we assessed the determinants of under-5 stunting and mapped its prevalence to identify areas where interventions can be directed. Using three combined rounds of the nationally representative Rwanda Demographic and Health Surveys of 2010, 2015 and 2020, we employed the Blinder-Oaxaca decomposition analysis and the hotspot and cluster analyses to quantify the contributions of key determinants of stunting. Overall, there was a 7.9% and 10.3% points reduction in moderate stunting among urban and rural areas, respectively, and a 2.8% and 8.3% points reduction in severe stunting in urban and rural areas, respectively. Child age, wealth index, maternal education and the number of antenatal care visits were key determinants for the reduction of moderate and severe stunting. Over time, persistent statistically significant hotspots for moderate and severe stunting were observed in Northern and Western parts of the country. There is a need for an adaptive scaling approach when implementing national nutritional interventions by targeting high-burden regions. Stunting hotspots in Western and Northern provinces underscore the need for coordinated subnational initiatives and strategies such as empowering the rural poor, enhancing antenatal health care, and improving maternal health and education levels to sustain the gains made in reducing childhood stunting.

Rural-urban disparities in postpartum contraceptive use among women in Nigeria: a Blinder-Oaxaca decomposition analysis.

BACKGROUND: Unintended pregnancies are a global public health concern that could be prevented with appropriate access to contraceptive methods. Evidence from research has indicated that avoidance of closely space birth/pregnancy within the first year of postpartum, mitigates the risk of adverse health outcomes such as preterm birth, low birth-weight, etc. Postpartum family planning helps women to minimize closely spaced and unplanned pregnancies within the first 12 months after delivery. Less contraceptive use is often present in more socially disadvantaged groups. Studies from Nigeria have shown a persistent disparity on contraceptive use between rural and urban residents. To identify the factors explaining these inequalities is important to implement targeted interventions. This study aimed to identify the factors contributing to the rural-urban disparity in postpartum contraceptive use among women in Nigeria. METHODS: This is a cross-sectional study using the Nigerian Demographic Health Survey. In total, 28,041 postpartum Nigerian women were included. Self-reported contraceptive use was the outcome, while the selected explanatory variables were grouped according to three theoretical perspectives: materialistic, behavioural/cultural, and psychosocial variables. Descriptive statistics and Blinder-Oaxaca decomposition were used to summarize and identify the factors contributing to the rural-urban disparity in postpartum contraceptive use. RESULTS: In this study, 27% of women reported to have used contraceptives during the postpartum period. The rural-urban disparity in postpartum contraceptive use accounted for 18.2 percentage points. The findings further showed that the disparities in postpartum contraceptive use between rural-urban residence were mostly explained by materialistic variables (82%), followed by the behavioural/cultural variables and age (included as covariate) accounting for 15.6 and 3.0%, respectively. Household wealth (37%) and educational attainment (38%) had the most significant contribution to the differences in postpartum contraceptive use. Only 15% of the difference in postpartum contraceptive use remained unexplained. CONCLUSION: This study has shown important inequalities in postpartum contraceptive use between rural and urban residents in Nigeria. These differences were mainly explained by materialistic factors. These findings highlight crucial areas for the government to target in order to close the existing gap between rural and urban settings in contraceptive use in the country.

Assessing the inequality in out-of-pocket health expenditure among the chronically and non-chronically ill in Saudi Arabia: a Blinder-Oaxaca decomposition analysis.

BACKGROUND: Many high-income countries have made significant progress towards achieving universal health coverage. Nevertheless, out-of-pocket (OOP) health expenditure continues to undermine the effectiveness of the universal healthcare system. In Saudi Arabia, due to the overburdened free public health services, many people opt for alternative healthcare services, risking high OOP payments. The presence of chronic illness further exacerbates this situation. However, there is limited evidence on the extent of the gap in OOP health expenditure between the chronically and non-chronically ill and the associated drivers contributing to this gap. The aim of this study was to assess inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, between the chronically and non-chronically ill in Saudi Arabia and their associated drivers. METHODS: Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and curves. A Blinder-Oaxaca decomposition analysis was used to assess the differences in relative OOP health expenditure between the chronically and non-chronically ill. RESULTS: The results showed that the chronically ill experience a higher financial burden due to healthcare services in absolute costs and relative to their income compared to the non-chronically ill. In addition, there was higher pro-poor inequality (-0.1985) in relative OOP health expenditure among the chronically ill compared to that (-0.1195) among the non-chronically ill. There was a 2.6% gap in relative OOP health expenditure among the chronically and non-chronically ill, of which 53.8% was attributable to unexplained factors, with explained factors accounting for the 46.2% difference. Factors that significantly contributed to the overall gap (i.e. both explained and non-explained factors) included employment status, insurance status, self-rated health, and periodic check-ups. CONCLUSION: This study underscores the high financial burden due to OOP payments among the chronically ill and the existence of pro-poor inequalities. In addition, there is a significant gap in relative OOP health expenditure between the chronically and non-chronically ill, which is mainly attributable to differences in socio-economic characteristics. This indicates that the existing financial mechanisms have not been sufficient in cushioning the chronically ill and less well off in Saudi Arabia. This situation calls for health policymakers to integrate a social safety net into the health financing system and to prioritize the disadvantaged population, thereby ensuring access to health services without experiencing financial hardship.

What explains the large disparity in child stunting in the Philippines? A decomposition analysis.

OBJECTIVE: About one-third of under-five Filipino children are stunted, with significant socio-economic inequality. This study aims to quantify factors that explain the large gap in stunting between poor and non-poor Filipino children. DESIGN: Using the 2015 Philippine National Nutrition Survey, we conducted a linear probability model to examine the determinants of child stunting and then an Oaxaca-Blinder decomposition to explain the factors contributing to the gap in stunting between poor and non-poor children. SETTING: Philippines. PARTICIPANTS: 1881 children aged 6-23 months participated in this study. RESULTS: The overall stunting prevalence was 38·5 % with a significant gap between poor and non-poor (45·0 % v. 32·0 %). Maternal height, education and maternal nutrition status account for 26 %, 18 % and 17 % of stunting inequality, respectively. These are followed by quality of prenatal care (12 %), dietary diversity (12 %) and iron supplementation in children (5 %). CONCLUSIONS: Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.

Changes of inequality in functional disability of older populations in China from 2008 to 2018: a decomposition analysis.

BACKGROUND: This study aims to determine the change of inequality in functional disability of older populations in China over the period from 2008 to 2018 and decompose the contribution of the personal and environmental predictors to the change. METHODS: Data were drawn from two waves (2008 and 2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Functional disability was assessed by the basic activities of daily living (ADL) and the instrumental activities of daily living (IADL). Concentration index (CI) was calculated to measure the socioeconomic inequality in ADL and IADL. A two-level linear regression model was established to identify the individual and care environmental predictors and their contribution to the inequality of ADL and IADL, respectively. The Oaxaca-type decomposition technique was adopted to estimate the contribution of these predictors to changes of the inequality in ADL and IADL over the period from 2008 to 2018. RESULTS: Socioeconomic inequality in functional disability of older adults increased over the period from 2008 to 2018, with the CI for ADL changing from - 0.0085 to - 0.0137 and the CI for IADL changing from - 0.0164 to - 0.0276, respectively. Self-rated economic status was the single most powerful predictor of changes in the inequality, although the growing and dominant rating of older persons with fare economic status could offset the detrimental effects of other (rich or poor) ratings on the changes. The enlarged inequality was also attributable to the increasing importance of regular exercise and its distributional changes, as well as the accumulative long-term effect of farming in earlier life. They outweighed the counteracting effects of rural residency, living with chronic conditions and in an institution. CONCLUSIONS: Socioeconomic inequality in functional disability of older populations in China increased over the period from 2008 to 2018. Re-distribution of wealth remains to be a powerful instrument for addressing the inequality issue, but alone it is not enough. The detrimental accumulative effect of farming will not disappear any time soon. While rural residents are catching up with their urban counterparts, new challenges such as physical inactivity are emerging.

Socioeconomic inequality in different phenotypes of childhood obesity and its determinants in Iran: a Blinder-Oaxaca decomposition method.

BACKGROUND: Childhood obesity has become a significant public health issue worldwide. Socioeconomic status is among its key determinants. This study examined the socioeconomic inequality in different phenotypes of childhood obesity at the national level in Iran. METHODS: This national, multistage school cross-sectional study was undertaken in 2015 on 14,400 students aged 7-18 years from urban and rural areas of 30 provinces of Iran. Using principal component analysis, socioeconomic status (SES) was categorized into tertiles. SES inequality in different phenotypes of obesity (i.e., generalized obesity", "abdominal obesity", and combined obesity) was estimated using the concentration index. The determinants of this inequality were assessed by the Blinder-Oaxaca decomposition method. RESULTS: Overall, 14,274 students completed the study (response rate: 99%). The mean age was 12.28 years, 50.6% were boys, and 71.42% lived in urban areas. The prevalence of generalized obesity and abdominal obesity was 20.8% and 11.3%, respectively. The concentration index for different phenotypes of obesity was positive, indicating that inequality is more common amongst the low SES groups. High SES, being male, living in a rural, and having a positive family history of obesity were associated with general obesity. Moderate physical activity and living in a rural area were associated with abdominal obesity. In addition, living in a rural area, having a high SES, being male, and having a positive family history of obesity were associated with combined obesity. CONCLUSION: According to the present study findings, all childhood obesity phenotypes were more prevalent in Iranian children with high SES. Therefore, due to obesity and other diseases, it is essential to implement environmental changes in addition to designing macro-educational programs and prevention strategies.

Poor and non-poor gap in under-five child nutrition: a case from Nepal using Blinder-Oaxaca decomposition approach.

INTRODUCTION: Many low-and middle-income countries (LMICs) have improved health indicators in the past decades, however, there is a differential in outcomes between socioeconomic groups. Systematic analysis of drivers of child nutrition gap between non-poor and poor groups has a policy relevance in Nepal and other countries to make progress towards universal health coverage (UHC). The objective of this paper was to estimate the mean height-for-age z scores (HAZ) gap between under-five children belonging to non-poor and poor groups, divide the gap into components (endowments, coefficients and interaction), and identify the factors that contributed most to each of the component. METHODS: Information about 6277 under-five children was extracted from the most recent nationally representative Nepal Multiple Indicator Cluster Survey (MICS) 2019. HAZ was used to assess nutritional status of children. Wealth index was used to categorize children into non-poor and poor. Mean HAZ gap between groups was decomposed using Blinder-Oaxaca technique into components: endowments (group difference in levels of predictors), coefficients (group difference in effects of predictors), and interaction (group difference due to interaction between levels and effects of predictors). Detailed decomposition was carried out to identify the factors that contributed most to each component. RESULTS: There was a significant non-poor and poor gap in nutrition outcome measured in HAZ (0.447; p < 0.001) among under-five children in Nepal. The between-group mean differences in the predictors of study participants (endowments) contributed 0.210 (47%) to the gap. Similarly, the between-group differences in effects of the predictors (coefficients) contributed 0.308 (68.8%) towards the gap. The interaction contributed -0.071 (15.8%) towards minimizing the gap. The predictors/variables that contributed most towards the gap due to (i) endowments were: maternal education, province (Karnali, Sudurpaschim, Madhesh), residence (rural/urban), type of toilet facility and ethnic group (Dalit and Muslim); (ii) coefficients were: number of under-five children in family, ethnic group (Dalit and Muslim), type of toilet facility, maternal age and education. CONCLUSION: Decomposition of the child nutrition gap revealed that narrowing the inequality between wealth groups depends not only on improving the level of the predictors (endowments) in the poor group but also on reducing differential effects of the predictors (coefficients).

The gender gap in access to finance: Evidence from the COVID-19 pandemic.

Using gender as a theoretical framework, we analyse the dynamics of debt and equity financing during the COVID-19 pandemic for a cross-country sample of 8,921 private firms. We provide evidence of a slight gender bias in debt financing, with creditors favouring female entrepreneurs when dealing with cash flow problems during the COVID-19 pandemic. We find no evidence of gender bias in equity financing. The results are robust after controlling for a larger number of firm-specific characteristics and selection bias. We challenge the assumption of "gender-based discrimination" in the debt market, speculating that in the context of high uncertainty, prototypical forms of femininity may be advantageous as financial institutions seek to hedge their risk by favouring more conservative borrowers.

Demographic and socio-economic shifts partly explain the Martinican nutrition transition: an analysis of 10-year health and dietary changes (2003-2013) using decomposition models.

OBJECTIVE: The Caribbean has seen a dramatic shift in the obesity and chronic disease prevalence over the past decades, suggesting a nutrition transition. Simultaneously, Martinique has faced a demographic transition marked by significant population ageing. We aimed to differentiate the contribution of changes in health status and dietary intakes due to shifts in demographic and socio-economic characteristics (DSEC) from that due to unobserved factors. DESIGN: Two cross-sectional surveys conducted in 2003 (n 743) and 2013 (n 573) on representative samples were used. Dietary intakes were estimated by 24-h recalls. The contribution of changes in health status and dietary intakes due to shifts in observed DSEC was differentiated from that due to unobserved factors over a 10-year interval, using Oaxaca-Blinder decomposition models. SETTING: Martinique, French region in the Caribbean. PARTICIPANTS: Martinican adults (≥16 years). RESULTS: Over the study period, health status deteriorated, partly owing to shifts in DSEC, explaining 62 % of the change in the prevalence of hypertension (+13 percentage points (pp)) and 48 % of waist circumference change (+3 cm). Diet quality decreased (mean adequacy ratio -2pp and mean excess ratio + 2 pp) and energy supplied by ultra-processed food increased (+4 pp). Shifts in DSEC marginally explained some changes in dietary intakes (e.g. increased diet quality), while the changes that remained unexplained were of opposite sign, with decreased diet quality, lower fruits, tubers and fish intakes and higher energy provided by ultra-processed foods. CONCLUSION: Explained dietary changes were of opposite sign to nutrition transition conceptual framework, probably because unobserved drivers are in play, such as food price trends or supermarkets spread.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies.

BACKGROUND: The prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences. METHODS: Unbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences. RESULTS: The CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas. The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly. CONCLUSIONS: Compared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.

Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis.

BACKGROUND: Educational disparities in daily smoking begin during adolescence and can lead to educational disparities in health among adults. In particular, vocational students including apprentices have higher daily smoking rates compared to non-vocational students. This study aimed to identify the determinants of the gap in daily smoking between French apprentices and high school students aged 17 in 2008 and in 2017. METHODS: We used data from a cross-sectional repeated survey representative of all French adolescents aged 17 in 2008 and 2017. We conducted a non-linear extension of the Oaxaca-Blinder decomposition technique and included the following variables: sociodemographic and familial characteristics, parental smoking, cannabis and alcohol use, suicidal attempt, grade repetition and money received. RESULTS: Daily smoking was about two times higher among French apprentices compared to high school students in 2008. This gap did not decrease between 2008 and 2017. Differences in measured characteristics between the two groups explained this gap partly, from 28.6 to 51.2%. Cannabis and alcohol use, money received and parental smoking contributed the most to the daily smoking gap. CONCLUSIONS: Prevention programs could target cannabis and alcohol use as well as parental smoking to help decrease educational disparities in smoking status among French adolescents.

Monitoring the decomposition of wealth-related inequality in the use of regular antenatal care in Egypt (1995-2014).

BACKGROUND: Between 1995 and 2014 Egypt successfully increased the use of regular antenatal care (URAC) among women from 30.4 to 82.9%. The same period saw a decrease in the wealth-based inequality in URAC. This paper investigates the changes in the main determinants contributing to the wealth-based inequality in URAC for the 2 years of 1995 and 2014, and the determinants that underlined the declines in this inequality. METHODS: The secondary analysis was based on data from the 1995 and 2014 rounds of the Egypt Demographic and Health Survey. Logistic regression was implemented to model URAC for the 2 years and inequality was measured using the concentration index. Decomposition of the concentration index and Blinder -Oaxaca decomposition were implemented to assess the contribution of the URAC determinants to its inequality and the changes between 1995 and 2014. RESULTS: Decomposition of inequalities in URAC in 1995 and 2014 showed that social determinants were the main contributors to these inequalities. More than 90% of the inequalities were explained by the living in rural Upper Egypt, women and their husbands secondary and higher education, the household standard of living, and birth order. These same determinants were responsible for more than 76% of the decline in the inequality in URAC between 1995 and 2014. Wide spread of poverty in rural Upper Egypt was found to contribute significantly to the inequality in URAC. Women and their husbands who have secondary or higher education maintained their high odds of URAC. CONCLUSION: Since poverty in rural Upper Egypt, and inequality in education and parity are crucial social determinants of URAC inequality and its change overtime, new policies and interventions need to focus not only on the health system but on social initiatives with an equity lens to tackle the structural causes underlying these factors and their inequalities.

Decomposing the educational inequalities in the factors associated with severe acute malnutrition among under-five children in low- and middle-income countries.

BACKGROUND: Low- and Middle-Income Countries (LMIC) have remained plagued with the burden of severe acute malnutrition (SAM). The decomposition of the educational inequalities in SAM across individual, household and neighbourhood characteristics in LMIC has not been explored. This study aims to decompose educational-related inequalities in the development of SAM among under-five children in LMIC and identify the risk factors that contribute to the inequalities. METHODS: We pooled successive secondary data from the Demographic and Health Survey conducted between 2010 and 2018 in 51 LMIC. We analysed data of 532,680 under-five children nested within 55,823 neighbourhoods. Severe acute malnutrition was the outcome variable while the literacy status of mothers was the main exposure variable. The explanatory variables cut across the individual-, household- and neighbourhood-level factors of the mother-child pair. Oaxaca-Blinder decomposition method was used at p = 0.05. RESULTS: The proportion of children whose mothers were not educated ranged from 0.1% in Armenia and Kyrgyz Republic to as much as 86.1% in Niger. The overall prevalence of SAM in the group of children whose mothers had no education was 5.8% compared with 4.2% among those whose mothers were educated, this varied within each country. Fourteen countries (Cameroon(p < 0.001), Chad(p < 0.001), Comoro(p = 0.047), Burkina Faso(p < 0.001), Ethiopia(p < 0.001), India(p < 0.001), Kenya(p < 0.001), Mozambique(p = 0.012), Namibia(p = 0.001), Nigeria(p < 0.001), Pakistan(p < 0.001), Senegal(p = 0.003), Togo(p = 0.013), and Timor Leste(p < 0.001) had statistically significant pro-illiterate inequality while no country showed statistically significant pro-literate inequality. We found significant differences in SAM prevalence across child's age (p < 0.001), child's sex(p < 0.001), maternal age(p = 0.001), household wealth quintile(p = 0.001), mother's access to media(p = 0.001), birth weight(p < 0.001) and neighbourhood socioeconomic status disadvantage(p < 0.001). On the average, neighbourhood socioeconomic status disadvantage, location of residence were the most important factors in most countries. Other contributors to the explanation of educational inequalities are birth weight, maternal age and toilet type. CONCLUSIONS: SAM is prevalent in most LMIC with wide educational inequalities explained by individual, household and community-level factors. Promotion of women education should be strengthened as better education among women will close the gaps and reduce the burden of SAM generally. We recommend further studies of other determinate causes of inequalities in severe acute malnutrition in LMIC.