Sex and gender differences in healthcare utilisation trajectories: a cohort study among Quebec workers living with chronic pain.

OBJECTIVES: Chronic pain (CP) is a poorly recognised and frequently inadequately treated condition affecting one in five adults. Reflecting on sociodemographic disparities as barriers to CP care in Canada was recently established as a federal priority. The objective of this study was to assess sex and gender differences in healthcare utilisation trajectories among workers living with CP. DESIGN: Retrospective cohort study. PARTICIPANTS: This study was conducted using the TorSaDE Cohort which links the 2007-2016 Canadian Community Health Surveys and Quebec administrative databases (longitudinal claims). Among 2955 workers living with CP, the annual number of healthcare contacts was computed during the 3 years after survey completion. OUTCOME: Group-based trajectory modelling was used to identify subgroups of individuals with similar patterns of healthcare utilisation over time (healthcare utilisation trajectories). RESULTS: Across the study population, three distinct 3-year healthcare utilisation trajectories were found: (1) low healthcare users (59.9%), (2) moderate healthcare users (33.6%) and (3) heavy healthcare users (6.4%). Sex and gender differences were found in the number of distinct trajectories and the stability of the number of healthcare contacts over time. Multivariable analysis revealed that independent of other sociodemographic characteristics and severity of health condition, sex-but not gender-was associated with the heavy healthcare utilisation longitudinal trajectory (with females showing a greater likelihood; OR 2.6, 95% CI 1.6 to 4.1). CONCLUSIONS: Our results underline the importance of assessing sex-based disparities in help-seeking behaviours, access to healthcare and resource utilisation among persons living with CP.

Analysis of the social acceptability of a humanized childbirth intervention in Senegal: A qualitative study.

BACKGROUND: In efforts to improve the quality of women's care and enhance related experiences in Senegal, the Senegalese government implemented an intervention named "humanized childbirth" in their health facilities. AIM: To analyze the social acceptability of humanized childbirth as well as its relevance given the social values in Senegal. METHODS: A multiple-case study was conducted within four health facilities in Dakar. Breastfeeding mothers (n = 20), pregnant women (n = 4), midwives (n = 8), Bajenu Gox (n = 4), members of the Health Development Committee (n = 4), and men from the community (n = 4) were interviewed individually, and a documentary analysis was done. The thematic analysis was performed using the acceptability theoretical framework. FINDINGS: The results show that most participants agreed with the idea of humanized childbirth. However, participants display varying viewpoints as to the social acceptability of various components of the intervention. While there is an overall agreement concerning the benefits of motivated and attentive health professionals focused on prevention, restoring dignity for the parturient woman, freedom to eat and drink, massages and relaxation, the same cannot be said about the freedom of choice for birth positions and companionship. DISCUSSION: The contrasting viewpoints as to the acceptability of humanized childbirth can be explained by the perception of risk and lack of experience with free birthing positions, as well as structural and cultural barriers surrounding the notion of companionship. CONCLUSION: Education and awareness of the benefits of free birthing positions and companionship would be required among Senegalese women to enable a cultural shift in maternity wards in Senegal.

Rethinking development interventions through the lens of decoloniality in sub-Saharan Africa: The case of global health.

There has been much talk about decolonizing global health lately. The movement, which has arisen in various communities around the world, suggests an interesting critique of the Western dominant model of representations. Building upon the 'decolonial thinking' movement from the perspective of Francophone African philosophers, we comment on its potential for inspiring the field of global healthinterventions. Using existing literature and personal reflections, we reflect on two widely known illustrations of global health interventions implemented in sub-Saharan Africa - distribution of contraceptives and dissemination of Ebola virus prevention and treatment devices - featuring different temporal backdrops. We show how these solutions have most often targeted the superficial dimensions of global health problems, sidestepping the structures and mental models that shape the actions and reactions of African populations. Lastly, we question the ways through which the decolonial approach might indeed offer a credible positioning for rethinking global health interventions.

Trajectory Modelling Techniques Useful to Epidemiological Research: A Comparative Narrative Review of Approaches.

Trajectory modelling techniques have been developed to determine subgroups within a given population and are increasingly used to better understand intra- and inter-individual variability in health outcome patterns over time. The objectives of this narrative review are to explore various trajectory modelling approaches useful to epidemiological research and give an overview of their applications and differences. Guidance for reporting on the results of trajectory modelling is also covered. Trajectory modelling techniques reviewed include latent class modelling approaches, ie, growth mixture modelling (GMM), group-based trajectory modelling (GBTM), latent class analysis (LCA), and latent transition analysis (LTA). A parallel is drawn to other individual-centered statistical approaches such as cluster analysis (CA) and sequence analysis (SA). Depending on the research question and type of data, a number of approaches can be used for trajectory modelling of health outcomes measured in longitudinal studies. However, the various terms to designate latent class modelling approaches (GMM, GBTM, LTA, LCA) are used inconsistently and often interchangeably in the available scientific literature. Improved consistency in the terminology and reporting guidelines have the potential to increase researchers' efficiency when it comes to choosing the most appropriate technique that best suits their research questions.

Meeting the challenges posed by per diem in development projects in southern countries: a scoping review.

PURPOSE: This study presents the results of a review whose goal is to generate knowledge on the possible levers of action concerning per diem practices in southern countries in order to propose reforms to the existing schemes. METHODOLOGY: A synthesis of available knowledge was performed using scoping review methodology: a literature search was conducted using several databases (Medline, Cinahl, Embase, PubMed, Google Scholar, ProQuest) and grey literature. A total of 26 documents were included in the review. Furthermore, interviews were conducted with the authors of the selected articles to determine whether the proposed recommendations had been implemented and to identify any outcomes. RESULTS: For the most part, the results of this review are recommendations supporting per diem reform. In terms of strategy, the recommendations call for a redefinition of per diems by limiting their appeal. Issued recommendations include reducing daily allowance rates, paying per diem only in exchange for actual work, increasing control mechanisms or harmonizing rates across organizations. In terms of operations, the recommendations call for the implementation of concrete actions to reduce instances of abuse, including not paying advances or introducing reasonable flat-rate per diem. That said, the authors contacted stated that few per diem reforms had been implemented as a result of the issued recommendations. CONCLUSION: The results of the study clearly identify possible levers of action. Such levers could make up the groundwork for further reflection on context and country-specific reforms that are carried out using a dynamic, participatory and consensual approach.

Conducting gender-based analysis of existing databases when self-reported gender data are unavailable: the GENDER Index in a working population.

OBJECTIVES: Growing attention has been given to considering sex and gender in health research. However, this remains a challenge in the context of retrospective studies where self-reported gender measures are often unavailable. This study aimed to create and validate a composite gender index using data from the Canadian Community Health Survey (CCHS). METHODS: According to scientific literature and expert opinion, the GENDER Index was built using several variables available in the CCHS and deemed to be gender-related (e.g., occupation, receiving child support, number of working hours). Among workers aged 18-50 years who had no missing data for our variables of interest (n = 29,470 participants), propensity scores were derived from a logistic regression model that included gender-related variables as covariates and where biological sex served as the dependent variable. Construct validity of propensity scores (GENDER Index scores) were then examined. RESULTS: When looking at the distribution of the GENDER Index scores in males and females, they appeared related but partly independent. Differences in the proportion of females appeared between groups categorized according to the GENDER Index scores tertiles (p < 0.0001). Construct validity was also examined through associations between the GENDER Index scores and gender-related variables identified a priori such as choosing/avoiding certain foods because of weight concerns (p < 0.0001), caring for children as the most important thing contributing to stress (p = 0.0309), and ability to handle unexpected/difficult problems (p = 0.0375). CONCLUSION: The GENDER Index could be useful to enhance the capacity of researchers using CCHS data to conduct gender-based analysis among populations of workers.

[Innovations to improve access to care for vulnerable people in OECD countries.] / Innovations pour l'amélioration de l'accès aux soins des personnes vulnérables dans les pays de l'OCDE.

INTRODUCTION: This study presents results of a systematic review aimed at mapping and understanding which elements are essential to the success of innovations for the improvement of the healthcare access for vulnerable groups. METHOD: A mixed systematic literature review was conducted and several databases were studied (Medline, Cinahl, Embase, Social Work, SocIndex). All OECD countries were covered in 10-year period (2005-2015). In total, 26 articles were deemed relevant and were included in the review. RESULTS: The thematic synthesis reveals several categories of innovation such as navigation services, outreach services and clinics offering adapted care. It also highlights key characteristics which contributed to the success of these innovations and improved patient satisfaction, such as social proximity, mastery of context on the part of the worker, interorganizational and interdisciplinary collaboration, respectful care and, finally, sustainability of funding. CONCLUSION: One of the main lessons learned from this review is that providing health services in a compassionate way is a determinant for access to care among vulnerable groups.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

The impact of free healthcare on women's capability: A qualitative study in rural Burkina Faso.

In March 2006, the government of Burkina Faso implemented an 80% subsidy for emergency obstetric and neonatal care (EmONC). To complement this subsidy, an NGO decided to cover the remaining 20% in two districts of the country, making EmONC completely free for women there. In addition, the NGO instituted fee exemptions for children under five years of age in those two districts. We conducted a qualitative study in 2011 to examine the impact of these free healthcare interventions on women's capability. We conducted semi-structured interviews with 40 women, 16 members of health centre management committees, and eight healthcare workers in three health districts, as well as a documentary analysis. Results showed free healthcare helped reinforce women's capability to make health decisions by eliminating the need for them to negotiate access to household resources, which in turn helped shorten delays in health services use. Other effects were also observed, such as increased self-esteem among the women and greater respect within their marital relationship. However, cultural barriers remained, limiting women's capability to achieve certain things they valued, such as contraception. In conclusion, this study's results illustrate the transformative effect that eliminating fees for obstetric care can have on women's capability to make health decisions and their social position. Furthermore, if women's capability is to be strengthened, the results impel us to go beyond health and to organize social and economic policies to reinforce their positions in other spheres of social life.

Building a middle-range theory of free public healthcare seeking in sub-Saharan Africa: a realist review.

Realist reviews are a new form of knowledge synthesis aimed at providing middle-range theories (MRTs) that specify how interventions work, for which populations, and under what circumstances. This approach opens the 'black box' of an intervention by showing how it triggers mechanisms in specific contexts to produce outcomes. We conducted a realist review of health user fee exemption policies (UFEPs) in sub-Saharan Africa (SSA). This article presents how we developed both the intervention theory (IT) of UFEPs and a MRT of free public healthcare seeking in SSA, building on Sen's capability approach. Over the course of this iterative process, we explored theoretical writings on healthcare access, services use, and healthcare seeking behaviour. We also analysed empirical studies on UFEPs and healthcare access in free care contexts. According to the IT, free care at the point of delivery is a resource allowing users to make choices about their use of public healthcare services, choices previously not generally available to them. Users' ability to choose to seek free care is influenced by structural, local, and individual conversion factors. We tested this IT on 69 empirical studies selected on the basis of their scientific rigor and relevance to the theory. From that analysis, we formulated a MRT on seeking free public healthcare in SSA. It highlights three key mechanisms in users' choice to seek free public healthcare: trust, risk awareness and acceptability. Contextual elements that influence both users' ability and choice to seek free care include: availability of and control over resources at the individual level; characteristics of users' and providers' communities at the local level; and health system organization, governance and policies at the structural level.

[Health system revenue collection in Burkina Faso from 1980 to 2012]. / Les modalités de collecte du financement de la santé au Burkina Faso de 1980 à 2012.

As a step towards universal health coverage, African countries need to develop funding systems that are effective, equitable, and tailored to national circumstances. To support policy makers in Burkina Faso, we present a review of research on interventions related to user fees, prepayment plans, and user fee subsidies. We compiled a narrative summary of articles published in scientific journals between 1980 and 2012. In all, 64 articles were selected. A thematic analysis was performed. User fees are a barrier to access to care; they curtail the use of health services and exclude the worst-off. People prefer prepayment plans in which each household pays an annual premium. However, the insurance premium remains a barrier to membership. Insurance does not benefit the poor but increases the use of health services by the insured. The subsidy for facility-based deliveries was not sufficiently well planned and difficulties have been observed in its implementation. While it helps reduce costs and improves access to care, it has not reduced inequalities. Community-based and participatory interventions have been useful for identifying the worst-off in order to exempt them from user fees. While prepayment is being promoted internationally as a financing model for universal health coverage, the evidence in favour of this system in Burkina Faso is still very limited. Further studies, more representative of the national context, must be conducted on this option, while at the same time, continuing efforts must be made to identify solutions for the poor who are unable to pay.