ABSTRACT
Increasing evidence has shown that AGEs can impair insulin sensitivity and affect glucose homeostasis. Owing to the heterogeneity of AGEs, it is still unclear which one has the strongest potential to disrupt glucose metabolism. Our study explored the effects of different types of AGEs on hepatic glucose metabolism. Three typical AGEs representing different formation pathways, namely AGEs from a glucose and lysine reaction mixture, methylglyoxal-modified BSA (MGO-BSA) and carboxymethyl lysine (CML), were chosen to treat HepG2 cells. The results indicate that only CML and MGO-BSA could disturb glucose metabolism, and MGO-BSA was the most active in promoting insulin resistance, as manifested by the inactivation of insulin receptor substrate-1 and decreased phosphorylation of AKT. Moreover, mice fed with an MGO-BSA-enriched diet showed increased blood glucose as well as impaired glucose tolerance. The present study revealed the distinctive effects of various AGEs on glucose metabolism and suggested that AGEs with high molecular weight might exert a higher pathogenic effect than small AGEs.
Subject(s)
Glucose , Insulin Resistance , Mice , Animals , Glucose/metabolism , Glycation End Products, Advanced/metabolism , Lysine/metabolism , Magnesium Oxide , Pyruvaldehyde/metabolism , Liver/metabolismABSTRACT
BACKGROUND: The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) "grease the wheels" payments if users offered to pay to get better services, and (3) "sand the wheels" payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user's outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. METHODS: We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users' outcomes. RESULTS: Payments that are the result of cultural norms are associated with better outcomes. On the contrary, "sand the wheel" payments are associated with worse outcomes. We find no association between making "grease the wheels" payments and outcomes. CONCLUSIONS: This is the first paper which evaluates association between three different categories of informal payments with a wide range of users' outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, "grease the wheels," and "sand the wheels" since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).
Subject(s)
Health Expenditures/statistics & numerical data , Health Facilities/economics , Motivation , Quality of Health Care/economics , Federal Government , Health Care Surveys , Health Facilities/standards , Humans , Personal SatisfactionABSTRACT
SCOPE: Increased consumption of modern processed foods rich in AGEs is drawing worldwide concerns because they are related with rising diabetes prevalence. This study aimed to investigate if pterostilbene (PTE) regulates glucose metabolism and insulin signaling, as well as its potential mechanism in the context of AGEs exposure. METHODS AND RESULTS: In vitro, Lo2 and HepG2 cells are treated with vehicle, AGEs with or without PTE. AGEs exposure directly impair insulin action as evidenced by assays of insulin-stimulated glucose uptake, consumption, and output. However, PTE efficiently rescue the AGE-induced phenotypes in both cell lines, and enhance IRS-1/PI3K/AKT insulin signaling in a dose-dependent manner. In vivo, C57BL6 mice are fed with regular, high AGEs diet and high AGEs plus PTE. PTE administration effectively improves hyperglycemia, glucose tolerance, and impaired hepatic insulin signaling induced by AGEs, consistent with the in vitro experiments. Moreover, PTE reduce AGEs accumulation in liver and serum. RNA-seq data indicate that PTE counteracts several AGEs-induced dysfunctions including diabetes related process, glucose metabolic process, immune response, and so on. CONCLUSION: PTE treatment prominently reduced AGEs accumulation and alleviated AGEs-associated diabetes symptoms. PTE could be used as a promising glucose-sensitizing agent for nutritional intervention.
Subject(s)
Glycation End Products, Advanced/toxicity , Hepatocytes/drug effects , Insulin Resistance , Stilbenes/pharmacology , Acetates/pharmacology , Animals , Benzopyrans/pharmacology , Cell Survival/drug effects , Gene Expression Regulation/drug effects , Glucose/metabolism , Glycation End Products, Advanced/blood , Glycation End Products, Advanced/metabolism , Hep G2 Cells , Hepatocytes/metabolism , Humans , Hyperglycemia/drug therapy , Hyperglycemia/etiology , Insulin/metabolism , Male , Mice, Inbred C57BL , Proto-Oncogene Proteins c-akt/agonists , Proto-Oncogene Proteins c-akt/metabolismABSTRACT
Chronic kidney disease, also referred to as end-stage renal disease (ESRD), is a prevalent and chronic condition for which treatment is necessary as a means of survival once affected individuals reach the fifth and final stage of the disease. Dialysis is a form of maintenance treatment that aids with kidney functioning once a normal kidney is damaged. There are two main types of dialysis: hemodialysis (HD) and peritoneal dialysis (PD). Each form of treatment is discussed between the patient and nephrologist and is largely dependent upon the following factors: medical condition, ability to administer treatment, supports, geographical location, access to necessary equipment/supplies, personal wishes, etc. For Indigenous Peoples who reside on remote Canadian First Nation communities, relocation is often recommended due to geographical location and limited access to both health care professionals and necessary equipment/supplies (i.e., quality of water, access to electricity/plumbing, etc.). Consequently, the objective of this paper is to determine the psychosocial and somatic effects for Indigenous Peoples with ESRD if they have to relocate from remote First Nation communities to an urban centre. A review of the literature suggests that relocation to urban centres has negative implications that are worth noting: cultural isolation, alienation from family and friends, somatic issues, psychosocial issues, loss of independence and role adjustment. As a result of relocation, it is evident that the impact is profound in terms of an individuals' mental, emotional, physical and spiritual well-being. Ensuring that adequate social support and education are available to patients and families would aid in alleviating stressors associated with managing chronic kidney disease.
Subject(s)
Kidney Failure, Chronic , Renal Insufficiency, Chronic , Canada , Humans , Indigenous Peoples , Kidney Failure, Chronic/therapy , Renal Dialysis , Renal Insufficiency, Chronic/therapyABSTRACT
OBJECTIVES: We study the influence of height on labour market outcomes using micro-data from a recent survey that cover 27 post-communist countries. Specifically, we focus on the influence of height on three dimensions of labour market outcome: (1) likelihood of employment, (2) occupational sorting, and (3) earnings. METHODS: We use micro-data from 2016 Life-In-Transition survey (LITS) which was jointly conducted by the European Bank for Reconstruction and Development and the World Bank. We run several types of regression to show how height influences (1) likelihood of employment, (2) occupational sorting, and (3) earnings. RESULTS: When controlling for a comprehensive set of covariates, for each 10 cm increase in height, the probability of getting a job increases by 1% points for males and by 3 for females. Equally, for each 10 cm increase in height, the probability of getting a job increases by 2% points in urban areas and rural areas. Our findings demonstrate that taller women and men are more likely: (a) being an employer rather than an employee; (b) to be employed in higher-paid and more prestigious sectors of finance, insurance, and real estate; (c) to be employed in private enterprises. Finally, when occupational sorting and socio-demographics are controlled for, a 10 cm increase in height results in a 5% increase in earning for men, and a 12% increase in earnings for women. CONCLUSIONS: Using a diverse sample of 27 post-communist countries, we found that taller individuals have better labour market outcomes in terms of employment, occupational sorting, and earnings.
Subject(s)
Body Height , Communism/statistics & numerical data , Employment/statistics & numerical data , Income/statistics & numerical data , Adult , Age Factors , Aged , Female , Humans , Male , Middle Aged , Regression Analysis , Sex Factors , Young AdultABSTRACT
OBJECTIVES: To evaluate the effect of height on life satisfaction. METHODS: We use data from a recent multi-country survey that was conducted in 27 nations. RESULTS: Our main finding is that height does have a strong positive effect on life satisfaction. These findings remain positive and significant when we use a comprehensive set of well-known covariates of life-satisfaction at both the individual and country levels. These findings also remain robust to alternative statistical specifications. CONCLUSIONS: From a theoretical standpoint, our findings suggest that height is important in explaining life-satisfaction independent of other well-known determinants. From a methodological standpoint, the findings of this study highlight the need to explicitly control for the effect of heights in studies on subjective well-being, happiness, and life-satisfaction.
Subject(s)
Body Height , Personal Satisfaction , Quality of Life , Adult , Aged , Aged, 80 and over , Asia, Central , Europe , Female , Humans , Male , Middle Aged , Young AdultABSTRACT
Mercury (Hg) is generally considered as a toxic metal; yet the biological outcomes of Hg-containing compounds are highly dependent upon their chemical forms. We hypothesize that mercury sulfide (HgS) is different from HgCl2 and methylmercury (MeHg) in producing intestinal Hg absorption and disruption of gut microbiome. To test this hypothesis, mice were given orally with HgS (α-HgS, 30â¯mg/kg), Zuotai (ß-HgS, 30â¯mg/kg), HgCl2 (33.6â¯mg/kg, equivalent Hg as HgS), or MeHg (3.1â¯mg/kg, 1/10 Hg as HgS) for 7â¯days. Accumulation of Hg in the duodenum and ileum after HgCl2 (30-40 fold) and MeHg (10-15 fold) was higher than HgS and Zuotai (~2-fold). HgCl2 and MeHg decreased intestinal intake peptide transporter-1 and Ost-ß, and increased ileal bile acid binding protein and equilibrative nucleoside transporter-1. The efflux transporters ATP-binding cassette sub-family C member-4 (Abcc4), Abcg2, Abcg5/8, and Abcb1b were increased by HgCl2 and to a lesser extent by MeHg, while HgS and Zuotai had minimal effects. Bacterial DNA was extracted and subjected to 16S rDNA sequencing. Operational taxonomic unit (OTU) results showed that among the 10 phyla, HgS increased Firmicutes, Proteobacteria, while HgCl2 increased Bacteroidetes, Cyanobacteria and decreased Firmicutes; among the 79 families, HgS increased Rikenellaceae, Lactobacillaceae, Helicobacteraceae, and decreased Prevotellaceae, while HgCl2 increased Odoribacteraceae, Porphyromonadaceae, and decreased Lactobacillaceae; among the 232 genus/species, HgS and Zuotai affected gut microbiome quite differently from HgCl2 and MeHg. qPCR analysis with 16S rRNA confirmed sequencing results. Thus, chemical forms of mercury are a major determinant for intestinal Hg accumulation, alterations in transporters and disruption of microbiome.
Subject(s)
Gastrointestinal Microbiome/drug effects , Intestinal Absorption/drug effects , Mercuric Chloride/toxicity , Mercury Compounds/pharmacokinetics , Animals , Duodenum/metabolism , Gastrointestinal Microbiome/genetics , Ileum/metabolism , Ileum/pathology , Male , Membrane Transport Proteins/drug effects , Membrane Transport Proteins/metabolism , Mercury Compounds/toxicity , Mice , RNA, Ribosomal, 16S/genetics , Real-Time Polymerase Chain ReactionABSTRACT
BACKGROUDS: Formaldehyde (FA) is an important chemicals that can induce sick house syndrome and may be an incentive of childhood leukemia, however the exact mechanism is unclear. Oxidative stress may be an underlying reason of cancer occurring, while diverse antioxidants can protect the bone marrow cells (BMCs) from damaged. Peroxiredoxinâ ¡ (Prxâ ¡) is an important member of the peroxiredoxin family, can remove reactive oxygen species (ROS), and is closely related with the occurrence of tumor. The present study aimed to detect a possible relationship between Prxâ ¡ gene and FA-induced bone marrow toxicity. METHODS: The BMCs were taken out from BALB/c mice, then exposed to control and different doses of FA (50, 100, 200⯵mol/L). The cell viability, ROS level and expressions of Prxâ ¡ gene were examined. Afterwards, we used a small interfering RNA (siRNA) to inhibit the expression of Prxâ ¡ gene, and chose 100⯵mol/L FA for exposure dose, to examine the cell viability, ROS level, cell cycle, apoptotic rate, expressions of Prxâ ¡ gene in BMCs. RESULTS: After a 24â¯h exposure to different doses of FA, the cell viability, expressions of Prxâ ¡ gene were decreased with the increasing of FA concentration, while the ROS level was increased. Inhibiting Prxâ ¡ gene's expression could enhance above FA-induced events. Additionally, siRNA targeting of Prxâ ¡could aggravate cell cycle arrest to inhibit cell's growth and development, as well as increase apoptotic rates induced by FA. CONCLUSION: These results demonstrated that Prxâ ¡ gene was involved in FA-induced bone marrow toxicity, and siRNA targeting of Prxâ ¡could enhance this toxic process.
Subject(s)
Bone Marrow Cells/drug effects , Formaldehyde/toxicity , Peroxiredoxins/genetics , Animals , Bone Marrow Cells/metabolism , Cell Proliferation/drug effects , Cell Survival/drug effects , Male , Mice, Inbred BALB C , Oxidative Stress , Peroxiredoxins/antagonists & inhibitors , Peroxiredoxins/metabolism , RNA, Small Interfering , Reactive Oxygen Species/metabolismABSTRACT
The International Agency for Research on Cancer has classified formaldehyde (FA) as a leukemogen to humans in 2012; however, the underlying mechanism remains unclear. Phosphatase and tensin homologue deleted on chromosome 10 (PTEN) is a tumorsuppressor gene and can negatively regulate the phosphoinositide 3kinase (PI3K)/protein kinase B (Akt) signal transduction pathway, which is associated with cell proliferation, apoptosis and carcinogenesis. To determine the association between FA and the PTEN/PI3K/Akt signal transduction pathway, flow cytometry, reverse transcriptionquantitative polymerase chain reaction, western blotting and immunohistochemical analysis were conducted. Bone marrow cells were obtained from BALB/c mice, divided into the control (untreated cells) and FA groups, which were treated with various doses of FA (50, 100 and 200 µmol/l). Following treatment with FA for 24 h, cell viability, the cell cycle, apoptosis, and the expression of PTEN, PI3K and Akt, as well as the protein expression of Bcell lymphoma 2 (Bcl2), Bcl2associated X (Bax), and Caspases3 and 9 were examined. Furthermore, 10 µmol/PI3K inhibitor (LY294002) was applied to inhibit the PTEN/PI3K/Akt signal transduction pathway and 100 µmol/l FA was selected for treatment; alteration in the cell cycle were analyzed. The results demonstrated that FA could suppress cell viability, and downregulate PTEN and Bcl2; the expression of PI3K, Akt, Bax, and Caspases3 and 9 were upregulated. Additionally, FA was reported to induce cell cycle arrest at the G0/G1 phase and apoptosis. Following the application of LY294002 to inhibit the PTEN/PI3K/Akt signal transduction pathway, the numbers of cells arrested in the G0/G1 phase were significantly increased in the PI3K inhibitor group compared with the control (P<0.01); however, no significant change in the number of G0/G1 cells compared with FA group was observed (P>0.05). The results of the present study suggested that the PTEN/PI3K/Akt signal transduction pathway served an important role in the process of FAinduced apoptosis, which may be associated with regulating the cell cycle; thus, cell proliferation may be affected.
Subject(s)
Bone Marrow Cells/drug effects , Formaldehyde/toxicity , Neoplasm Proteins/genetics , Neoplasms/genetics , Animals , Apoptosis/drug effects , Bone Marrow Cells/pathology , Cell Cycle Checkpoints/drug effects , Cell Proliferation/drug effects , Cell Survival/drug effects , Chromones/pharmacology , Formaldehyde/pharmacology , Gene Expression Regulation, Neoplastic/drug effects , Humans , Mice , Morpholines/pharmacology , Neoplasms/chemically induced , Neoplasms/pathology , PTEN Phosphohydrolase/genetics , Phosphatidylinositol 3-Kinases/genetics , Proto-Oncogene Proteins c-akt/genetics , Signal Transduction/drug effectsABSTRACT
We compare the transmission channels through which the 2008 global financial crisis affected health. We find that postponing or skipping visits to the doctor after falling ill and stopping buying regular medication had the strongest negative effects on health, followed by a reduced consumption of staple foods, utilities being cut, being forced to move, and having to sell assets. In comparison, experiencing cuts in TV, phone, and internet services, as well as delaying payments for utilities had relatively weaker negative impacts. In contrast, having a household head or household member lose a job also had negative effects on health status, although this effect was relatively lower. Finally, a reduced flow of remittances had the weakest negative effect.
Subject(s)
Economic Recession , Internationality , Population Health , Humans , Interviews as Topic , Qualitative Research , Surveys and QuestionnairesABSTRACT
In this study, we examine the effects of having a healthy weight in form of a healthy body mass index (BMI) on life satisfaction using the data from a diverse sample of 27 post-communist transitional countries. We find that a healthy BMI significantly raises life satisfaction, while an increase in BMI reduces life satisfaction. We also find that the positive effect of a healthy BMI on life satisfaction substantially diminishes as the political and economic situation improves. Equally, the positive effect of healthy BMI on life satisfaction is considerably lower for those who exhibit higher levels of institutional trust and express trust in government, parliament, and political parties. Classic regression models such as ordinary least squares (OLS) and ordered probit significantly underestimate the true effect of healthy BMI on life satisfaction. Such results suggest that unobserved confounders, measurement error, or their interplay appear to be the main source (s) of bias that eventually lead to a significant underestimation of the true effect of BMI on life satisfaction through classic regression models.
Subject(s)
Body Weight/physiology , Personal Satisfaction , Adult , Aged , Asia , Europe, Eastern , Female , Health Policy , Humans , Male , Middle Aged , Obesity , Regression AnalysisABSTRACT
We study the factors that influence willingness to pay to improve public health care in 29 post-communist countries, Eastern and Southern Europe, and Eurasia using 2 up-to-date cross-sectional surveys conducted in 2010 and 2016 (N = 34 768). Three hypotheses received full degree of support through empirical analysis: increase in satisfaction with health care, university education, and higher level of wealth positively associated with willingness to pay in all regions. In comparison, having a higher level social trust and adhering to left-leaning ideological position strengthens support for public health care in Southern Europe and Eurasia only, while having a higher level of institutional trust strengthens support for public health care in Eastern Europe and Eurasia only.
Subject(s)
Healthcare Financing , Quality Improvement/economics , Taxes , Adolescent , Adult , Aged , Consumer Behavior/economics , Cross-Sectional Studies , Delivery of Health Care/economics , Europe, Eastern , Health Status , Humans , Male , Middle Aged , Politics , Surveys and Questionnaires , Trust , USSR , Young AdultABSTRACT
The purpose of this study is to provide policy implications by estimating the individual and community level determinants of preventive health-care utilization in China based upon data from the China Health and Nutrition Survey. Two different frameworks, a human capital model and a psychological-behavioral model, are tested using a multilevel logit estimation. The results demonstrate different patterns for medical and nonmedical preventive activities. There is a strong correlation between having medical insurance and utilizing preventive health services. For the usage of medical-related preventive health care (MP), age, gender, education, urban residence, and medical insurance are strong predictors. High income did not provide much of an increase in the usage level of MP, but the lack of income was a huge obstacle for low-income people to overcome. Community variation in number of facilities accounted for about one third of the total variation in the utilization of MP. The utilization of MP in China remains dependent upon the individual's social-economic conditions.
ABSTRACT
This study assesses the effects of maternal healthcare on child survival by using nonrandomized data from a cross-sectional survey in Azerbaijan. Using 2SLS and simultaneous equation bivariate probit models, we estimate the effects of delivering in healthcare facility on probability of child survival taking into account self-selection into the treatment. For women who delivered at healthcare facilities, the probability of child survival increases by approximately 18%. Furthermore, if every woman had the opportunity to deliver in healthcare facility, then the probability of child survival in Azerbaijan as a whole would have increased by approximately 16%.
Subject(s)
Infant Mortality , Maternal Health Services/statistics & numerical data , Probability , Azerbaijan/epidemiology , Delivery, Obstetric/statistics & numerical data , Female , Health Facilities/statistics & numerical data , Humans , Infant , PregnancyABSTRACT
This paper evaluates the effectiveness of prenatal healthcare in Azerbaijan on improving child birthweight using the 2006 Azerbaijan Demographic and Health Survey, a nationally representative survey of reproductive aged women. Two measures of prenatal health utilization are used to measure healthcare input-the number of prenatal visits and the quality index of health care. Endogeneity in prenatal healthcare utilization is controlled by 2SLS regression. Selection bias of probability of child being weighed is controlled by a binomial probit regression. We found that prenatal healthcare does improve child birthweight. The results of the 2SLS suggest that an additional prenatal visit increases birthweight by about 26g, or approximately 0.8% of the raw mean of birthweight in the country. Likewise, a unit increase in quality of prenatal healthcare increases birthweight by 21g or by approximately 1.3% of the birthweight. In general, the magnitude of prenatal care impact in Azerbaijan is comparable with that in other countries.
Subject(s)
Birth Weight , Health Surveys , Prenatal Care/statistics & numerical data , Quality of Health Care/statistics & numerical data , Adolescent , Adult , Azerbaijan , Body Mass Index , Female , Health Policy , Humans , Male , Maternal Welfare , Middle Aged , Prenatal Care/methods , Reference Values , Regression Analysis , Time Factors , Young AdultABSTRACT
In the mid-1990s, the responsibilities to design, implement, and evaluate social welfare programs were transferred from federal to local jurisdictions in many countries of North America and Europe through devolution processes. Devolution has caused the need for a technique to measure and compare the performances of social welfare programs across multiple jurisdictions. This paper utilizes Data Envelopment Analysis (DEA) for a comparison of poverty reduction performances of jurisdictional social welfare programs across Canadian provinces. From the theoretical perspective, findings of this paper demonstrates that DEA is a promising method to evaluate, compare, and benchmark poverty reduction performance across multiple jurisdictions using multiple inputs and outputs. This paper demonstrates that DEA generates easy to comprehend composite rankings of provincial performances, identifies appropriate benchmarks for each inefficient province, and estimates sources and amounts of improvement needed to make the provinces efficient. From a practical perspective the empirical results presented in this paper indicate that Newfoundland, Prince Edwards Island, and Alberta achieve better efficiency in poverty reduction than other provinces. Policy makers and social administrators of the ineffective provinces across Canada may find benefit in selecting one of the effective provinces as a benchmark for improving their own performance based on similar size and structure of population, size of the budget for social programs, and traditions with administering particular types of social programs.
Subject(s)
Poverty/prevention & control , Program Evaluation/methods , Social Welfare/trends , Canada , Efficiency, Organizational/statistics & numerical data , Humans , Statistics, NonparametricABSTRACT
This study examines the demographic, economic, social, and geographic factors that help explain maternity health care utilization in Tajikistan, a low-income transitional country in Central Asia, based on a newly available nationally representative living standard survey. Two regression models, namely, a binomial logit model and a zero-inflated negative binomial (ZINB) model are estimated. The estimations of the two models show strikingly consistent results--the year of last childbirth, educational attainment, and the availability of public infrastructure are important predictors of maternity health care utilization. The results also signify an urgent need to overturn the current negative trend in maternity health care utilization. The findings also suggest that many determinants of maternity health care are outside the direct sphere of health care policies, indicating the need of cross-sectional policies in addressing maternity health care utilization, for example, policies and strategies that include contributions from other sectors.
Subject(s)
Healthcare Disparities , Maternal Health Services/statistics & numerical data , Female , Humans , Maternal Health Services/economics , Pregnancy , Socioeconomic Factors , TajikistanABSTRACT
Since the transition from a centrally planned to a market economy, Tajikistan has witnessed a high rate of child and maternal mortality, a decline in the birth rate and a significant drop in public expenditures on health care. Against this backdrop, this paper analyses the determinants of prenatal health care utilization using Andersen's behavioural model, which has been modified to the context of Tajikistan. We applied a two-stage sequential model to data drawn from a nationally representative survey. Binary logit regression is used to predict and explain the probability of using prenatal health care services, while negative binomial regression is used to predict and explain the frequency of using these services. Findings suggest that higher educational attainment increases the utilization of prenatal care. Conversely, poverty, limited knowledge about matters related to sex, low quality of health care service, lack of public infrastructure, as well as absence of or long distance of travel to the nearest health facility, all reduce the utilization of prenatal health care. Health policy and research implications are presented and discussed.