Are there gender based differences in participation and time spent in physical activity in Albania? Evidence from 2017-18 demographic and health survey.

BACKGROUND: Since 1990, Albania has embraced the market economy and globalization. Prosperity and modernization have also brought significant lifestyle changes toward unhealthy behaviours, doubling the mortality from non-communicable diseases (NCDs). While Physical Activity (PA) can mitigate the NCDs burden, participation is low in Albania. To date, research on PA determinants that could meaningfully inform policy is lacking. To fill this gap, this study examines the PA behaviour among Albanian adults. Specifically, we assess the decisions to participate, and the time spent in PA. METHODS: Using the 2017-2018 Albania Demographic and Health Survey data and a double-hurdle regression model, we simultaneously assess the influence of demographic, socioeconomic and lifestyle factors on the likelihood of participating (extensive margin) and the time spent (intensive margin) in PA. To understand gender differences regarding PA decisions, we run separate models for men and women. RESULTS: Results show significant variations in the likelihood of participation and the time spent in PA, by household economic status, administrative regions, occupation, and education. We find that likelihood of participation in PA increases with household wealth, but conditional on participation, affluent Albanians spent less time in PA. Education and employment status also have opposite effects on participation and time spent margins. Results show notable gender-based differences in PA behaviour (either for participation or time spent) related to education, age, family structure (marital status and the number of young children), regions, occupation, and lifestyle factors. CONCLUSIONS: Insights in understanding the PA behaviour of Albanian adults allow policymakers to identify socio-demographic groups most in need of intervention effort. To effectively support PA among Albanians, policymakers should target males and females differently and address gender-specific needs accordingly.

Pain-related health care costs for long-term care residents.

BACKGROUND: We tested for differences in direct health care costs among long-term care (LTC) residents age 65 and older with clinically significant pain (CSP) and with no pain or non-daily mild pain (NP/NDMP). We are not aware of any other large scale investigation that examined the cost of pain in LTC environments. METHODS: Population-based administrative health data from Saskatchewan, Canada for 2004 to 2015 were used to compare direct health care costs for CSP and NP/NDMP groups up to one year after admission to LTC. Total accumulated costs for hospitalization, physician services, LTC, and prescription drugs were calculated in 2015 Canadian dollars. Group differences were tested using generalized linear models with generalized estimating equations. RESULTS: Amongst 24,870 LTC residents, 8289 (33.3%) were censored due to death or discharge in the 365-day study observation period. Of the 16,581 (66.7%) observed residents, 5683 (34.3%) had CSP at admission. Residents (66.3% female) had a mean age of 85 years (SD = 7.4). The mean annual total direct health care cost per resident was higher among the CSP group (CAD $8063) than the NP/NDMP group (CAD $6455). This difference was found even after including LTC costs, and for each cost component (i.e., CSP residents had higher hospitalization, physician, and prescription drug costs). Similar results were obtained after controlling for demographics, comorbidities, physical and cognitive impairment, prior health care costs, and facility characteristics. CONCLUSION: The higher costs incurred by CSP residents compared to NP/NDMP residents are likely underestimated because pain problems are often missed in residents with dementia, who comprise a large portion of the LTC population. Improved pain care can reduce such costs and improve quality of life.

The case for gender considerate tobacco control policies in Albania.

Background: Tobacco use is a serious health concern in Albania. While the prevalence of tobacco smoking has traditionally been higher for men, the increasing prevalence of smoking for women is becoming a concern. The 2007 Tobacco Control policy mandated smoke-free indoor spaces, banned various forms of tobacco advertising, required written health warnings on packaging and levied excise taxes on cigarette sales. Since smoking behavior varies among different demographic groups, each group's response to a uniform policy will differ, blunting the effectiveness of these efforts as a result. This study examines various socioeconomic, demographic and behavioral factors affecting both the likelihood and frequency of smoking in Albanian households in order to provide insights on targeting various populations more effectively. Methods: The study utilizes data from Albanian 2008-09 and 2017-18 Demographic and Health Surveys consisting of adults aged 15-49 years. The outcome variable includes respondents' current tobacco smoking behaviour and its frequency. The exposure variables include respondents' sociodemographic and lifestyle characteristics. We use a two-level random intercept model with the two-stage residual inclusion estimation method to determine the association between outcome and exposure variables. By including a time variable, we capture the change in smoking behavior during the 2009-2018 period. We also extend the analysis by assessing the differential influence of gender on the likelihood of smoking, both by income quintiles and education. Results: The results suggest that the likelihood of smoking decreased by 23% in 2017-18 compared to 2008-09, after controlling for various socioeconomic and demographic factors. Tobacco smoking is also found to be linked to alcohol consumption, with binge drinkers 59% more likely to smoke tobacco compared to moderate drinkers. We also found significant inter-quintile and inter-educational differences in smoking practices within each gender category. While the likelihood of tobacco smoking decreases with increasing wealth and educational attainment among men, the opposite (for wealth) or more involved (for educational attainment) patterns are true among women. Conclusions: To further enhance the effectiveness of the current Tobacco Control policy, the Government of Albania should target various demographic groups (such as poor males, rich and educated females) in a differentiated fashion.

Utilization of Health Care Resources by Long-term Care Residents as a Function of Pain Status.

OBJECTIVE: We estimated the association between the presence of pain and health care utilization among older adults residing in long-term care (LTC) facilities. MATERIALS AND METHODS: Using administrative health data maintained by the Saskatchewan ministry of health and time-to-event analyses with multivariable frailty models, we tested for differences in health care use (hospitalization, physician and specialist visits, and prescription drug dispensations) as a function of pain status among LTC residents after admission to an LTC. Specifically, we contrasted LTC residents with daily pain or less than daily pain but with moderate or severe intensity (ie, clinically significant pain group; CSP) to residents with no pain or nondaily mild pain (NP/NDMP group). RESULTS: Our cohort consisted of 24,870 Saskatchewan LTC residents between 2004 and 2015 with an average age of 85 years (63.2% female; 63.0% in urban facilities). Roughly one third had CSP at their LTC admission date. Health care use after admission to LTC was strongly associated with pain status, even after adjusting for residents' demographic and facility characteristics, prior comorbidities and health care utilization 1 year before the study index date. In any given quarter, compared with NP/NDMP residents, those with CSP had an increased risk of hospitalization, specialist visit, follow-up general practitioner visit, and onset of polypharmacy (ie, 3 or more medication classes). DISCUSSION: To our knowledge, this is the first large-scale project to examine the utilization of health care resources as a function of pain status among LTC facility residents. Improved pain management in LTC facilities could lead to reduced health care use.

Factors affecting tobacco smoking in Ethiopia: evidence from the demographic and health surveys.

BACKGROUND: Tobacco smoking is growing at an alarming rate in the developing world and sub-Saharan Africa. Although Ethiopia has a relatively low rate in the region, it is not immune to the tobacco epidemic. The government of Ethiopia passed an anti-tobacco bill in 2015 that includes measures governing tobacco consumption, advertising, packaging, and labeling. To effectively address the challenge of tobacco control, the government should consider a number of aspects of tobacco production and consumption, such as local production in rural areas, as well as the complementarity nature of tobacco and khat use. METHODS: Using the World Bank's Demographic and Health Surveys (2011 and 2016), this paper analyzes the key determinants of tobacco smoking in Ethiopia, emphasizing possible differences in various social contexts, across regions. More specifically, we assess the association between khat use and tobacco smoking while controlling for various observed individual-level, household-level, and community-level covariates. Using GPS data, we are able to capture the neighboring effects of smoking behavior in community clusters bordering other administrative regions as well as differences in smoking patterns between lowland and highland residents. We utilize a multilevel modeling framework and use a two-stage residual inclusion estimation method that accounts for the endogeneity of khat and tobacco use. RESULTS: The results suggest that chewing khat and geographic regions are statistically significant determinants of tobacco smoking even after controlling for various socioeconomic and demographic factors. Altitude information analysis suggests that people living in lowlands are more likely to smoke compared to those living in highland areas. Additional analysis including interactions between regions and khat use indicate wide inter-regional variations in tobacco smoking by khat users. We also extend our analysis by interacting khat use with religious adherence. Results indicate a wide variation in tobacco smoking by khat chewers across different religious groups. CONCLUSIONS: To effectively control tobacco smoking of the diverse communities in Ethiopia, policymakers should consider a multi-pronged policy approach that combines various policy tools that account for regional variation, the local social contexts, as well as the complementary nature of smoking and khat chewing practices.

Regional Gradients in Institutional Cesarean Delivery Rates: Evidence from Five Countries in Asia.

BACKGROUND: Although the influence of the type of institutional setting on the risk of cesarean birth is well documented, less is known about the regional variations in institution-specific cesarean rates within countries. Our purpose was to examine regional variations in cesarean rates across public and private facilities in five Asian countries with a sizeable private sector: Bangladesh, India, Indonesia, Pakistan, and the Philippines. METHODS: Demographic Health Survey data and a hierarchical model were used to assess regional variations in the mode of delivery while controlling for a wide range of socioeconomic, demographic, and maternal risk factors. RESULTS: The risk of cesarean birth was greater in a private facility than in a government hospital by 36-48 percent in India and Indonesia and by 130 percent in Bangladesh. Regional gradients in cesarean birth were found to be steeper for deliveries in private facilities than in government hospitals in India, Indonesia, and the Philippines. The residents of India's high-use states were 55 percent more likely to undergo a cesarean delivery in a government hospital and 83 percent more likely in a private facility than their counterparts in the medium-use states. Similarly, compared to the residents of the Philippines's medium-use provinces, giving birth in a government facility increased the likelihood of a cesarean delivery by 84 percent and by 173 percent in a private facility. CONCLUSIONS: Large regional variations in cesarean rates suggest the need for more informed clinical decision making with respect to the selection of cases for cesarean delivery and the establishment of well-developed guidelines and standards at the provincial or state levels.

Mix of Maternity Care Providers in Canada.

OBJECTIVE: To identify the factors influencing women's choice of maternity care providers in Canada. METHOD: Using the Maternity Experience Survey and a multinomial logit model, this paper examined the influence of various socio-economic and demographic factors on the mix of maternity care providers, while controlling for maternal risk profiles. Additionally, provinces were interacted with maternal age to assess the extent to which regional variations in mix of maternity care providers is influenced by pregnant women's needs. RESULTS: Besides maternal risk factors, province of prenatal care and the place of residence were found to be statistically significant determinants of choice of maternity care providers. Analysis involving interaction terms indicated wide regional variations in the mix of providers by maternal age. CONCLUSIONS: The results suggest a wide provincial variation in the mix of maternity care providers. New provincial government initiatives are needed to enhance the supply and capacity of care providers.

The impact of the global economic crisis on HIV and AIDS programmes directed at women and children in Zambia.

This investigation sought to ascertain the extent to which the global economic crisis of 2008-2009 affected the delivery of HIV/AIDS-related services directed at pregnant and lactating mothers, children living with HIV and children orphaned through HIV in Zambia. Using a combined macroeconomic analysis and a multiple case study approach, the authors found that from mid-2008 to mid-2009 the Zambian economy was indeed buffeted by the global economic crisis. During that period the case study subjects experienced challenges with respect to the funding, delivery and effectiveness of services that were clearly attributable, directly or indirectly, to the global economic crisis. The source of funding most often compromised was external private flows. The services most often compromised were non-medical services (such as the delivery of assistance to orphans and counselling to HIV-positive mothers) while the more strictly medical services (such as antiretroviral therapy) were protected from funding cuts and service interruptions. Impairments to service effectiveness were experienced relatively equally by (HIV-positive) pregnant women and lactating mothers and children orphaned through HIV. Children living with AIDS were least affected because of the primacy of ARV therapy in their care.

Socioeconomic status and children's health: evidence from a low-income country.

There has been a growing empirical literature on the relationship between household socioeconomic status (SES) and children's health, and in particular, whether this SES gradient is constant or varies in strength across different life stages. Much of this literature focuses on the developed countries and less evidence has been presented for developing countries. Using Vietnam's rich National Health Survey (2001-02) and appropriate multilevel modeling this study empirically assesses the SES gradient in health and whether it varies in strength across different life stages of children aged 15 and younger (N = 45,448). The results for the interaction terms between the natural logarithm of household consumption and age groups indicate no evidence of a steeper health gradient for older children. However, health-consumption gradients are found to be sensitive to the functional form of the regression model as well as the model specification. The results for the interaction terms between consumption expenditure quintiles and age groups indicate that gradients vary in strength across ages. Not only are children from the poorest households worse off, compared to those from the richest households, but this relative disadvantage is greater among the 0-3 year olds. The inclusion of parental health status in the regression model weakens the gradients for all age groups as does the inclusion of household sources of drinking water. However, poorer children are still relatively worse off, specially the 0-3 year olds. This suggests that absolute deprivation may help explain the relative health disadvantage of younger children. Better measures of poverty alleviation are hence needed to improve children's health in a low-income country such as Vietnam.

Determinants of prenatal care use: evidence from 32 low-income countries across Asia, Sub-Saharan Africa and Latin America.

While much has been written on the determinants of prenatal care attendance in low-income countries, comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating the decisions to use prenatal care and the frequency of use. Using the Demographic and Health Surveys data for 32 low-income countries (across Asia, Sub-Saharan Africa and Latin America) and appropriate two-part and multilevel models, this article empirically assesses the influence of a wide array of observed individual-, household- and community-level characteristics on a woman's decision to use prenatal care and the frequency of that use, while controlling for unobserved community level factors. The results suggest that, though both the decision to use care and the number of prenatal visits are influenced by a range of observed individual-, household- and community-level characteristics, the influence of these determinants vary in magnitude for prenatal care attendance and the frequency of prenatal visits. Despite remarkable consistency among regions in the association of individual, household and community indicators with prenatal care utilization, the estimated coefficients of the risk factors vary greatly across the three world regions. The strong influence of household wealth, education and regional poverty on the use of prenatal care suggests that safe motherhood programmes should be linked with the objectives of social development programmes such as poverty reduction, enhancing the status of women and increasing primary and secondary school enrolment rate among girls. Finally, the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to use prenatal care and have fewer visits suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy.

Does the type of provider and the place of residence matter in the utilization of prenatal ultrasonography? Evidence from Canada.

BACKGROUND: There has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography. OBJECTIVE: The objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles. METHODS: The study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces. RESULTS: The results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland. CONCLUSION: After controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.

What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries.

Prenatal and delivery care are critical both for maternal and newborn health. Using the Demographic and Health Surveys (DHS) data for thirty-two low-income countries across Asia, sub-Saharan Africa and Latin America, and employing a two-level random-intercept model, this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual-, household- and community-level characteristics on a woman's decision to give birth at a health facility or at home. The results show that prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions, with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility. These variations are more pronounced for Sub-Saharan Africa. The influence of the number of prenatal visits, maternal age and education, parity level, and economic status of the birthing women on the place of delivery is found to vary across the three geographical regions. The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households. The strong influence of number of visits, household wealth, education and regional poverty on the site of delivery setting suggests that policies aimed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction, enhancing the status of women, and increasing primary and secondary school enrollment rate among girls.