Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019.

BACKGROUND: Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS: We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS: A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION: Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING: UK National Institute for Health and Care Research.

Analyzing the relationship between socioeconomic deprivation and outpatient Medicare Part D fluoroquinolone claim rates in Texas.

Introduction: Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription rates are particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers' fluoroquinolone claim rates among beneficiaries 65 years and older in Texas. Methods: This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber's gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and SDI) and fluoroquinolone claim rates per 1,000 beneficiaries. Results: A total of 11,996 providers were included. SDI (IRR 0.98, 95% CI 0.97-0.99) and male providers (IRR 0.96, 95% CI 0.94-0.99) were inversely associated with claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95% CI 1.00-1.09), and practices with a high proportion of male (IRR 1.12, 95% CI 1.10-1.14), Black (IRR 1.05, 95% CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95% CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates. Conclusion: Lower fluoroquinolone claim rates were observed among Texas Medicare providers in metropolitan areas with higher SDI. Conversely, higher rates were observed in rural areas with higher SDI. More studies are needed to understand the underlying causes of this variation and develop effective stewardship interventions.

Trajectories of Disability and Long-Term Care Utilization After Acute Health Events.

Hip fractures, strokes, and heart attacks are common acute health events that can lead to long-term disability, care utilization, and unmet needs. However, such impacts, especially in the long term, are not fully understood. Using data from the Health and Retirement Study, 1992-2018, this study examines the long-term trajectories of individuals suffering such health shocks, comparing with individuals not experiencing health shocks. Hip fracture, stroke, and heart attack are confirmed to have severe implications for disability. In most cases of stroke and heart attack, informal caregivers provide the daily support needed by survivors, whereas following hip fracture, nursing home care is more relevant. These health shocks put individuals on worse trajectories of disability, care utilization, and unmet needs. There is no long-term recovery or convergence with individuals who do not suffer shocks. Unmet need is prevalent, even pre-shock and among individuals who do not experience health shocks, emphasizing the importance of preventative care measures. These findings support policy action to ensure hospitalized individuals, especially those aged 50 and above, receive rehabilitative services and other post-acute care. Furthermore, hospitalization is an event that requires the detection and addressing of unmet care needs beyond the short run.

Costs of incident non-hip osteoporosis-related fractures in postmenopausal women from a payer perspective.

Osteoporosis-related fractures lead to high morbidity, mortality, and healthcare costs among post-menopausal women. This study showed that incident non-hip osteoporosis-related fractures are frequent among women aged 50 + in Portugal, leading to excessive healthcare costs of €74 million per year, in a conservative scenario. PURPOSE: This study aimed to estimate the costs of incident non-hip osteoporosis-related fractures among postmenopausal women living in Portugal from a payer perspective. METHODS: The study includes women ≥ 50 years old who participated in the baseline assessment (2011-2013) and the first follow-up wave (2013-2015) of the Epidemiology of Chronic Diseases cohort, a Portuguese community-based longitudinal prospective study (n = 2,762). Incident non-hip osteoporosis-related fractures were defined as any self-reported low impact non-hip fractures since baseline. Healthcare resource utilization during the year following fracture was obtained from an informal panel of experts. The amounts of resources used were multiplied by the national tariffs practiced in the National Health Service (NHS) to obtain the cost per patient in the year following a wrist, vertebral, or other site fracture, which was subsequently multiplied by the estimated annual number of incident fractures to obtain the total annual cost of incident non-hip osteoporosis-related fractures among postmenopausal women. RESULTS: Each year approximately 5,000 wrist, 3,500 vertebral, and 39,000 other-site osteoporosis-related fractures occur in women aged 50 + in Portugal. Healthcare costs per patient in the year following fracture vary from €2,709.52 for vertebral fractures to €3,096.35 for other fractures. Non-hip incident osteoporosis-related fractures among 50 + women cost approximately €74 million per year. Among all healthcare services, physiotherapy represents the bulk of costs. CONCLUSIONS: This study pinpoints the relevance of preventing non-hip osteoporosis-related fractures, as these cost about €74 million per year in direct healthcare costs, a substantial impact on the budget of the Portuguese NHS.

Companies' Responses to a Tax on Sugar-Sweetened Beverages: Implications for Research Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019".

The paper by Forde et al, newly published in this journal, sheds light on how sugar-sweetened beverages (SSBs) companies may react to the introduction of a SSB tax. This commentary goes over the paper's main findings and drafts implications for research on the impacts of SSB taxes. First and foremost, future research needs to assess the actual impacts of SSB taxes on companies' actions, especially reformulation. Second, cross-country research, comparing large companies with similar beverage portfolios, could bring insights about the impacts of external factors, including different SSB taxes, on companies' decisions. Third, SSB companies' actions are potential confounders in empirical studies looking into the impacts of SSB taxes on prices, demand, or other outcomes. Researchers need to be aware of and discuss such aspects thoroughly in their studies, as the implications for the interpretation of results are evident.

A Web-Based Self-help Intervention for Coping With the Loss of a Partner: Protocol for Randomized Controlled Trials in 3 Countries.

BACKGROUND: The death of a partner is a critical life event in later life, which requires grief work as well as the development of a new perspective for the future. Cognitive behavioral web-based self-help interventions for coping with prolonged grief have established their efficacy in decreasing symptoms of grief, depression, and loneliness. However, no study has tested the efficacy for reducing grief after losses occurring less than 6 months ago and the role of self-tailoring of the content. OBJECTIVE: This study aims to evaluate the clinical efficacy and acceptance of a web-based self-help intervention to support the grief process of older adults who have lost their partner. It will compare the outcomes, adherence, and working alliance in a standardized format with those in a self-tailored delivery format and investigate the effects of age, time since loss, and severity of grief at baseline as predictors. Focus groups to understand user experience and a cost-effectiveness analysis will complement the study. METHODS: The study includes 3 different randomized control trials. The trial in Switzerland comprises a waitlist control group and 2 active arms consisting of 2 delivery formats, standardized and self-tailored. In the Netherlands and in Portugal, the trials follow a 2-arm design that will be, respectively, complemented with focus groups on technology acceptance and cost-effectiveness analysis. The main target group will consist of adults aged >60 years from the general population in Switzerland (n≥85), the Netherlands (n≥40), and Portugal (n≥80) who lost their partner and seek help for coping with grief symptoms, psychological distress, and adaptation problems in daily life. The trials will test the intervention's clinical efficacy for reducing grief (primary outcome) and depression symptoms and loneliness (secondary outcomes) after the intervention. Measurements will take place at baseline (week 0), after the intervention (week 10), and at follow-up (week 20). RESULTS: The trials started in March 2022 and are expected to end in December 2022 or when the needed sample size is achieved. The first results are expected by January 2023. CONCLUSIONS: The trials will provide insights into the efficacy and acceptance of a web-based self-help intervention among older adults who have recently lost a partner. Results will extend the knowledge on the role of self-tailoring, working alliance, and satisfaction in the effects of the intervention. Finally, the study will suggest adaptations to improve the acceptance of web-based self-help interventions for older mourners and explore the cost-effectiveness of this intervention. Limitations include a self-selective sample and the lack of cross-cultural comparisons. TRIAL REGISTRATION: Switzerland: ClinicalTrials.gov NCT05280041; https://clinicaltrials.gov/ct2/show/NCT05280041; Portugal: ClinicalTrials.gov NCT05156346; https://clinicaltrials.gov/ct2/show/NCT05156346. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37827.

Can Intersectoral Interventions Reduce Substance Use in Adolescence? Evidence From a Multicentre Randomized Controlled Study.

Objectives: We measure the impacts of an intersectoral intervention tackling adolescent substance use implemented between 2017 and 2019 in a tri-border region of Brazil, Paraguay, and Argentina. Methods: The intervention involved 23 institutions from different sectors and 880 adolescents, equally split between randomly selected treatment and control classes across institutions. Treatment group students were involved in the co-development of activities to tackle substance use within their institutions. Both treatment and control group students benefited from the activities developed and implemented from the second year of the intervention. We use difference-in-differences models to measure the impacts of participation in the co-development of the activities on alcohol, tobacco, and cannabis consumption. Results: Adolescents involved in the co-development of activities are 8 pp less likely to consume tobacco and cannabis, and 13 pp less likely to consume alcohol (p < 0.01), compared to those who only participate in the activities. Among cannabis users, frequent consumption is also reduced by the intervention. Peer frequency of consumption is strongly associated with individual consumption. Conclusion: Co-development of activities by the subjects themselves can be key to decreasing substance use in this very crucial stage of life, especially if the institutions and the implementers are familiar with the area and subjects of the intervention.

Formal home care use and spousal health outcomes.

This study explores the relationship between formal home care provided by paid professionals and spousal health outcomes. We use data from the Survey of Health, Ageing, and Retirement in Europe, a panel of older adults living in several European countries. We match new formal home care users to non-users to eliminate baseline (t-1) differences between couples who decide to seek formal home care in t and those who do not. After considering several potentially confounding changes between baseline and t, and looking closer at specific subgroups, we conclude that in the short run, use of formal home care is unlikely to affect spousal physical or mental health.

Effects of self-employment on hospitalizations: instrumental variables analysis of social security data.

The importance of self-employment and small businesses raises questions about their health effects and public policy implications, which can only be addressed with suitable data. We explore the relationship between self-employment and health by drawing on comprehensive longitudinal administrative data to explore variation in individual work status and by applying novel instrumental variables. We focus on an objective outcome-hospital admissions-that is not subject to recall or other biases that may affect previous studies. Our main findings, based on a sample of about 6,500 individuals followed monthly from 2005 to 2011 and who switch between self-employment and wage work along that period, suggest that self-employment has a positive effect on health as it reduces the likelihood of hospital admission by at least half.

Brown sugar, how come you taste so good? The impact of a soda tax on prices and consumption.

Increasing obesity-related problems and rising healthcare expenditures have led governments in developed countries to consider the introduction of soda taxes. We study a recent such tax, implemented in Portugal in February 2017 -one of the first soda taxes worldwide that increases with sugar content (0.08 euros per liter for drinks with less than 80 g of sugar per liter, and 0.16 euros per liter for drinks with 80 g or more sugar per liter, plus VAT). We use extremely detailed panel data from one of the two largest retailers in the country, covering the period between February 2015 and January 2018. We take advantage of the tax breakdown by sugar levels to examine how soda prices and quantities purchased reacted. For identification, we rely on difference-in-differences models with various vectors of fixed effects, comparing each group of products to water. For drinks with more than 80 g of sugar per liter, results indicate almost full price pass-through to the consumer. For drinks with less than 80 g of sugar per liter, price pass-through surpassed 100%. Regarding consumption, our findings suggest stockpiling behavior in the quarter when the tax was approved and before it was actually implemented. In the implementation period, there are no significant changes in quantities purchased for most beverages vis-à-vis water, with the exception of soda drinks with comparatively low levels of sugar. This suggests that benefits of the soda tax in terms of reducing sugar intake are mainly due to reformulation, as producers reduced the sugar content of some drinks to fall below the 80 g per liter threshold.

Measuring State Medicaid Home Care Participation and Intensity Using Latent Variables.

Population aging and policies to redirect long-term care toward home- and community-based services have led to increases in Medicaid home care spending in most states. Changes in state Medicaid home care policy generosity may result from changes in the number of persons served (i.e., Participation) and/or changes in quantities of services covered (i.e., Intensity). This study measures state Medicaid home care Participation and Intensity comprehensively using latent variables, and uses those latent variables to describe changes in Medicaid home care policy generosity over time and across states. Yearly state-level data from the Medicaid Statistical Information System (1999-2012) are analyzed using exploratory and confirmatory factor analyses. Between 1999 and 2012, 29 states expanded both Participation and Intensity, whereas six states reduced both. In the remaining states, a trade-off occurred. Distinguishing between Medicaid home care Participation and Intensity deserves attention, as expansions along these two dimensions represent potentially different implications for beneficiaries.

Selfie Aging Index: An Index for the Self-assessment of Healthy and Active Aging.

INTRODUCTION: Governments across Europe want to promote healthy and active aging, as a matter of both public health and economic sustainability. Designing policies focused on the most vulnerable groups requires information at the individual level. However, a measure of healthy and active aging at the individual level does not yet exist. OBJECTIVES: This paper develops the Selfie Aging Index (SAI), an individual-level index of healthy and active aging. The SAI is developed thinking about a tool that would allow each person to take a selfie of her aging status. Therefore, it is based entirely on self-assessed indicators. This paper also illustrates how the SAI may look like in practice. METHODS: The SAI is based on the Biopsychosocial Assessment Model (MAB), a tool for the multidimensional assessment of older adults along three domains: biological, psychological, and social. Indicators are selected and their weights determined based on an ordered probit model that relates the MAB indicators to self-assessed health, which proxies healthy and active aging. The ordered probit model predicts the SAI based on the estimated parameters. Finally, predictions are rescaled to the 0-1 interval. Data for the SAI development come from the Study of the Aging Profiles of the Portuguese Population and the Survey of Health, Aging, and Retirement in Europe. RESULTS: The selected indicators are BMI, having difficulties moving around indoors and performing the activities of daily living, feeling depressed, feeling nervous, lacking energy, time awareness score, marital status, having someone to confide in, education, type of job, exercise, and smoking status. The model also determines their weights. CONCLUSION: Results shed light on various factors that contribute significantly to healthy and active aging. Two examples are mental health and exercise, which deserve more attention from individuals themselves, health-care professionals, and public health policy. The SAI has the potential to put the individual at the center of the healthy and active aging discussion, contribute to patient empowerment, and promote patient-centered care. It can become a useful instrument to monitor healthy and active aging for different actors, including individuals themselves, health-care professionals, and policy makers.