Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study.

INTRODUCTION: Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association. METHODS: Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately. RESULTS: The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization. CONCLUSIONS: Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Testing the Effect of a Smartphone App on Hospital Admissions and Sedentary Behavior in Cardiac Rehabilitation Participants: ToDo-CR Randomized Controlled Trial.

BACKGROUND: People with coronary heart disease are at an increased risk of morbidity and mortality even if they attend cardiac rehabilitation. High sedentary behavior levels potentially contribute to this morbidity. Smartphone apps may be feasible to facilitate sedentary behavior reductions and lead to reduced health care use. OBJECTIVE: We aimed to test the effect of a sedentary behavior change smartphone app (Vire app and ToDo-CR program) as an adjunct to cardiac rehabilitation on hospital admissions and emergency department (ED) presentations over 12 months. METHODS: A multicenter, randomized controlled trial was conducted with 120 participants recruited from 3 cardiac rehabilitation programs. Participants were randomized 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and ToDo-CR program (intervention) or usual care (control). The primary outcome was nonelective hospital admissions and ED presentations over 12 months. Secondary outcomes including accelerometer-measured sedentary behavior, BMI, waist circumference, and quality of life were recorded at baseline and 6 and 12 months. Logistic regression models were used to analyze the primary outcome, and linear mixed-effects models were used to analyze secondary outcomes. Data on intervention and hospital admission costs were collected, and the incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS: Participants were, on average, aged 62 (SD 10) years, and the majority were male (93/120, 77.5%). The intervention group were more likely to experience all-cause (odds ratio [OR] 1.54, 95% CI 0.58-4.10; P=.39) and cardiac-related (OR 3.26, 95% CI 0.84-12.55; P=.09) hospital admissions and ED presentations (OR 2.07, 95% CI 0.89-4.77; P=.09) than the control group. Despite this, cardiac-related hospital admission costs were lower in the intervention group over 12 months (Aus $252.40 vs Aus $859.38; P=.24; a currency exchange rate of Aus $1=US $0.69 is applicable). There were no significant between-group differences in sedentary behavior minutes per day over 12 months, although the intervention group completed 22 minutes less than the control group (95% CI -22.80 to 66.69; P=.33; Cohen d=0.21). The intervention group had a lower BMI (ß=1.62; P=.05), waist circumference (ß=5.81; P=.01), waist-to-hip ratio (ß=.03, P=.03), and quality of life (ß=3.30; P=.05) than the control group. The intervention was more effective but more costly in reducing sedentary behavior (ICER Aus $351.77) and anxiety (ICER Aus $10,987.71) at 12 months. The intervention was also more effective yet costly in increasing quality of life (ICER Aus $93,395.50) at 12 months. CONCLUSIONS: The Vire app and ToDo-CR program was not an outcome-effective or cost-effective solution to reduce all-cause hospital admissions or ED presentations in cardiac rehabilitation compared with usual care. Smartphone apps that target sedentary behavior alone may not be an effective solution for cardiac rehabilitation participants to reduce hospital admissions and sedentary behavior. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001223123; https://australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619001223123. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-040479.

Catastrophic health expenditure and its association with socioeconomic status in China: evidence from the 2011-2018 China Health and Retirement Longitudinal Study.

BACKGROUND: An increase in healthcare utilization in response to universal health coverage may leave massive economic burden on individuals and households. Identifying catastrophic health expenditure helps us understand such burden. This study aims to examine the incidence of catastrophic health expenditure at various thresholds, explore its trend over years, and investigate whether it varies across socioeconomic status (SES). METHODS: Data used in this study were from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015, and 2018. SES was measured by annual per-capita household expenditure, which was then divided into quintiles (Quintile 1 (Q1): the poorest - Quintile 5 (Q5): the wealthiest). Catastrophic health expenditure was measured at both a fixed threshold (40%) and a set of variable thresholds, where the thresholds for other quintiles were estimated by multiplying 40% by the ratio of average food expenditure in certain quintile to that in the index quintile. Multilevel mixed-effects logistic regression models were used to analyze the determinants of catastrophic health expenditure at various thresholds. RESULTS: A total of 6,953 households were included in our study. The incidence of catastrophic health expenditure varied across the thresholds set. At a fixed threshold, 10.90%, 9.46%, 13.23%, or 24.75% of households incurred catastrophic health expenditure in 2011, 2013, 2015, and 2018, respectively, which were generally lower than those at variable thresholds. Catastrophic health expenditure often decreased from 2011 to 2013, and an increasing trend occurred afterwards. Compared to households in Q5, those in lower quintiles were more likely to suffer catastrophic health expenditure, irrespective of the thresholds set. Similarly, having chronic diseases and healthcare utilization increased the odds of catastrophic health expenditure. CONCLUSIONS: The financial protection against catastrophic health expenditure shocks remains a challenge in China, especially for the low-SES and those with chronic diseases. Concerted efforts are needed to further expand health insurance coverage across breadth, depth, and height, optimize health financing mechanism, redesign cost-sharing arrangements and provider payment methods, and develop more efficient expenditure control strategies.

Does the presence of health insurance and health facilities improve access to healthcare for major morbidities among Indigenous communities and older widows in India? Evidence from India Human Development Surveys I and II.

In this paper, we examine whether access to treatment for major morbidity conditions is determined by the social class of the person who needs treatment. Secondly, we assess whether health insurance coverage and the presence of a PHC have any significant impact on the utilisation of health services, either public or private, for treatment and, more importantly, whether the presence of health insurance and PHC modify the treatment use behaviour for the two excluded communities of interest namely Indigenous communities and older widows using data from two rounds (2005 and 2012) of the nationally representative India Human Development Survey (IHDS). We estimated a multilevel mixed effects model with treatment for major morbidity as the outcome variable and social groups, older widows, the presence of a PHC and the survey wave as the main explanatory variables. The results confirmed access to treatment for major morbidity was affected by social class with Indigenous communities and older widows less likely to access treatment. Health insurance coverage did not have an effect that was large enough to induce a positive change in the likelihood of accessing treatment. The presence of a functional PHC increased the likelihood of treatment for all social groups except Indigenous communities. This is not surprising as Indigenous communities generally live in locations where the terrain is more challenging and decentralised healthcare up to the PHC might not work as effectively as it does for others. The social class to which one belongs has a significant impact on the ability of a person to access healthcare. Efforts to address inequity needs to take this into account and design interventions that are decentralised and planned with the involvement of local communities to be effective. Merely addressing one or two barriers to access in an isolated fashion will not lead to equitable access.

Informal sector employment and the health outcomes of older workers in India.

A large proportion of the older population in India constitutes an undeniable share of workforce after the retirement age. This stresses the need to understand the implications of working at older ages on health outcomes. The main objective of this study is to examine the variations in health outcomes by formal/informal sector of employment of older workers using the first wave of the Longitudinal Ageing Study in India. Using binary logistic regression models, the results of this study affirm that type of work does play a significant role in determining health outcomes even after controlling socio-economic, demographic, life-style behaviour, childhood health and work characteristics. The risk of Poor Cognitive Functioning (PCF) is high among informal workers, while formal workers suffer greatly from Chronic Health Conditions (CHC) and Functional Limitations (FL). Moreover, the risk of PCF and/or FL among formal workers increases with the increase in risk of CHC. Therefore, the present research study underscores the relevance of policies focusing on providing health and healthcare benefits by respective economic activity and socio-economic position of older workers.

Engaging participants with research findings: A rights-informed approach.

BACKGROUND: Sharing research findings with participants is recognized as an ethical imperative for the research community. However, most discourse on this topic in mainstream public health takes a paternalistic approach, with researchers retaining the power to choose if, when, and how research findings are shared. METHODS: Fieldwork took place from August 2018 to January 2019 and again from August 2019 to December 2019 among two communities in the south Indian state of Kerala. We integrated participant engagement with study findings into the research protocol, using various collaborative strategies identified during the design stage, forming partnerships with participants and determining appropriate forms of dissemination for different participant groups during fieldwork. RESULTS: Findings from previous research projects undertaken with these communities by other researchers had not been shared with them. This was interpreted by the communities as researchers not being interested in making a difference to their situation. In the current study, building reciprocal relationships that minimized power disparities, and providing outputs in tailored formats that promoted active engagement were key factors that enabled participants to engage with results. This engagement added value by enabling us to co-develop study recommendations. This process also enabled the community to have ownership of the results and use them to advocate for health system change to improve access to health care. CONCLUSION: Research should be transformative for participating communities. Participants have a right to know the results of the research they participate in since their knowledge provides the research data which can in turn promote community change. Operationalising this requires researchers to build partnerships with participants and their communities from the outset. The role of participants must be reimagined, and adequate resources should be built into the research process. This is both socially responsible and ethical, but also improves the impact and legitimacy of research for the participants and the communities that they represent. PATIENT OR PUBLIC CONTRIBUTION: Participants of our research contributed to the design of various aspects of the engagement processes including the venue, the formats used for engagement, interpretation of the findings and recommendations from our research.

Prevalence Rates of Depression and Anxiety among Young Rural and Urban Australians: A Systematic Review and Meta-Analysis.

Globally, depression and anxiety are major public health concerns with onset during adolescence. While rural Australia experiences overall lower health outcomes, variation in mental health prevalence rates between rural and urban Australia is unclear. The aim of this paper was to estimate the pooled prevalence rates for depression and anxiety among young Australians aged between 10 and 24 years. Selected studies from a systematic literature search were assessed for risk of bias. Random effects model using DerSimonian and Laird method with Freeman-Tukey Double Arcsine Transformation was fitted. Sensitivity analyses were performed. Prevalence estimates were stratified by region and disorder. The overall pooled prevalence of depression and anxiety was 25.3% (95% CI, 19.9-31.0%). In subgroup analysis, anxiety prevalence was 29.9% (95% CI, 21.6-39.0%); depression: 21.3% (95% CI, 14.9-28.5%); and depression or anxiety: 27.2% (95% CI, 20.3-34.6%). Depression and anxiety prevalence were higher in urban 26.1% (95% CI, 17.3-35.9%) compared to rural areas 24.9% (95% CI, 17.5-33%), although the difference was not statistically significant. The heterogeneity was high with an I2 score of 95.8%. There is need for further research on healthcare access, mental health literacy and help-seeking attitude in Australia.

Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol.

BACKGROUND: Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months. METHODS: This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research. DISCUSSION: Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.

Public health insurance and maternal health care utilization in india: evidence from the 2005-2012 mothers' cohort data.

BACKGROUND: The introduction of Janani Suraksha Yojana (JSY) in India, a conditional cash transfer program which incentivized women to deliver at institutions, resulted in a significant increase in institutional births. Another major health policy reform, which could have affected maternal and child health care (MCH) utilization, was the public health insurance scheme (RSBY) launched in 2008. However, there is a noticeable lack of studies that examine how RSBY had impacted on MCH utilization in India. We used data from a cohort of mothers whose delivery had been captured in both the 2005 and 2011/12 rounds of the Indian Human Development Survey (IHDS) to study the impact of health insurance (in particular, the public insurance scheme versus private insurance) on MCH access. We also investigated whether maternal empowerment was a significant correlate that affects MCH utilization. METHODS: We used the multilevel mixed-effects ordered logistic regression model to account for the clustered nature of our data. We derived indexes for women's empowerment using Principal component analysis (PCA) technique applied to various indicators of women's autonomy and socio-economic status. RESULTS: Our results indicated that the odds of mothers' MCH utilization levels vary by district, community and mother over time. The effect of the public insurance scheme (RSBY) on MCH utilization was not as strong as privately available insurance. However, health insurance was only significant in models that did not control for household and mother level predictors. Our findings indicated that maternal empowerment indicators - in particular, maternal ability to go out of the house and complete chores and economic empowerment-were associated with higher utilization of MCH services. Among control variables, maternal age and education were significant correlates that increase MCH service utilization over time. Household wealth quintile was another significant factor with mothers belonging to upper quintiles more likely to access and utilize MCH services. CONCLUSIONS: Change in women's and societal attitude towards maternal care may have played a significant role in increasing MCH utilization over the study period. There might be a need to increase the coverage of the public insurance scheme given the finding that it was less effective in increasing MCH utilization. Importantly, policies that aim to improve health services for women need to take maternal autonomy and empowerment into consideration.

Improving birth preparedness and complication readiness in rural India through an integrated microfinance and health literacy programme: evidence from a quasi-experimental study.

OBJECTIVE: Recently, a novel community health programme-the integrated microfinance and health literacy (IMFHL) programme was implemented through microfinance-based women's only self-help groups (SHGs) in India to promote birth preparedness and complication readiness (BPCR) to improve maternal health. The study evaluated the impact of the IMFHL programme on BPCR practice by women in one of India's poorest states-Uttar Pradesh-adjusting for the community, household and individual variables. The paper also examined for any diffusion of knowledge of BPCR from SHG members receiving the health literacy intervention to non-members in programme villages. DESIGN: Quasi-experimental study using cross-sectional survey data. SETTINGS: Secondary survey data from the IMFHL programme were used. PARTICIPANTS: Survey data were collected from 17 244 women in households with SHG member and non-member households in rural India. PRIMARY OUTCOMES: Multivariable logistic regression was used to estimate main and adjusted IMFHL programme effects on maternal BPCR practice in their last pregnancy. RESULTS: Membership in SHGs alone is positively associated with BPCR practice, with 17% higher odds (OR=1.17, 95% CI 1.07 to 1.29, p<0.01) of these women practising BPCR compared with women in villages without the programmes. Furthermore, the odds of practising complete BPCR increase to almost 50% (OR=1.48, 95% CI 1.35 to 1.63, p<0.01) when a maternal health literacy component is added to the SHGs. A diffusion effect was found for BPCR practice from SHG members to non-members when the health literacy component was integrated into the SHG model. CONCLUSIONS: The results suggest that SHG membership exerts a positive impact on planned health behaviour and a diffusion effect of BPCR practice from members to non-members when SHGs are enriched with a health literacy component. The study provides evidence to guide the implementation of community health programmes seeking to promote BPCR practise in low resource settings.

Beyond personal factors: Multilevel determinants of childhood stunting in Indonesia.

BACKGROUND: Stunting is still a major public health problem in low- and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict- and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model. METHODS: We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household- and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict- and province-level characteristics on the probability of children being stunted. RESULTS: Our findings showed that the odds of childhood stunting vary significantly not only by individual child- and household-level characteristics but also by province- and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene. CONCLUSIONS: Stunting is associated with not only child-level characteristics but also family- and community-level characteristics. Hence, interventions to reduce stunting should also take into account family and community characteristics to achieve effective outcomes.

Does behavioral intervention affect intention to quit? : A quasi-experimental study from primary healthcare settings in India.

INTRODUCTION: Tobacco is the leading cause of death and disease in India. This study examines the effect of training intervention in behavioral counseling on intention to quit tobacco in primary healthcare settings in India. The intervention included training to improve behavioral counseling practices of primary care physicians (PCPs) based on the 5As approach to increase patients' motivation to quit tobacco. METHODS: A quasi-experimental design was used for the study. The intervention consists of training of primary care physicians in the behavioral intervention in tobacco cessation. The intervention was conducted in twelve districts of two states in India (Rajasthan and Odisha) in 2016-2017. Four districts were randomly sampled for the study. A total of 1314 participants (intervention and control) were recruited for the study in the baseline and end-line surveys, respectively. Intention to quit in 30 days was the primary outcome measure. Difference-in-difference (DiD) logistic regression models were used separately for smokers and smokeless tobacco users to estimate the odds of intention to quit. Analysis was done in STATA Version 14. RESULTS: The intervention and time variable had a significantly positive influence on the intention to quit tobacco among smokers. Smokers in the intervention districts had higher odds of intention to quit (OR=9.82; 95% CI: 1.67-57.72) compared to smokers in the control districts. Smokeless tobacco (SLT) users had higher odds of intention to quit (OR=3.06; 95% CI: 1.35-6.98) in the end-line survey compared to baseline survey. CONCLUSIONS: Our findings indicate that building capacity in behavioral intervention in primary care settings can help increase the intention to quit among smokers. The observed difference in intention to quit between smokers and SLT users suggests the need of tailored counseling interventions for SLT users. There is a need for further research to design and evaluate training and behavioral interventions for SLT and dual (smoking and SLT) users in primary care settings in low- and middle-income countries.

The knowledge of danger signs of obstetric complications among women in rural India: evaluating an integrated microfinance and health literacy program.

BACKGROUND: Maternal mortality can be prevented in low-income settings through early health care seeking during maternity complications. While health system reforms in India prioritised institutional deliveries, inadequate antenatal and postnatal services limit the knowledge of danger signs of obstetric complications to women, which delays the recognition of complications and seeking appropriate health care. Recently, a novel rapidly scalable community-based program combining maternal health literacy delivery through microfinance-based women-only self-help groups (SHG) was implemented in rural India. This study evaluates the impact of the integrated microfinance and health literacy (IMFHL) program on the knowledge of maternal danger signs in marginalised women from one of India's most populated and poorer states - Uttar Pradesh. Additionally, the study evaluates the presence of a diffusion effect of the knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. METHODS: Secondary data from the IMFHL program comprising 17,232 women from SHG and non-member households in rural Uttar Pradesh was included. Multivariate logistic regression models were used to identify the program's effects on the knowledge of maternal danger signs adjusting for a comprehensive range of confounders at the individual, household, and community level. RESULTS: SHG member women receiving health literacy were 27% more likely to know all danger signs as compared with SHG members only. Moreover, the results showed that the SHG network facilitates diffusion of knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. The study found that the magnitude of the program impact on outcome remained stable even after controlling for other confounding effects suggesting that the health message delivered through the program reaches all women uniformly irrespective of their socioeconomic and health system characteristics. CONCLUSIONS: The findings can guide community health programs and policy that seek to impact maternal health outcomes in low resource settings by demonstrating the differential impact of SHG alone and SHG plus health literacy on maternal danger sign knowledge.

A smartphone app for sedentary behaviour change in cardiac rehabilitation and the effect on hospital admissions: the ToDo-CR randomised controlled trial study protocol.

INTRODUCTION: Cardiac rehabilitation (CR) is recommended for secondary prevention of cardiovascular disease and reducing the risk of repeat cardiac events. Physical activity is a core component of CR; however, studies show that participants remain largely sedentary. Sedentary behaviour is an independent risk factor for all-cause mortality. Strategies to encourage sedentary behaviour change are needed. This study will explore the effectiveness and costs of a smartphone application (Vire) and an individualised online behaviour change program (ToDo-CR) in reducing sedentary behaviour, all-cause hospital admissions and emergency department visits over 12 months after commencing CR. METHODS AND ANALYSIS: A multicentre, assessor-blind parallel randomised controlled trial will be conducted with 144 participants (18+ years). Participants will be recruited from three phase-II CR centres. They will be assessed on admission to CR and randomly assigned (1:1) to one of two groups: CR plus the ToDo-CR 6-month programme or usual care CR. Both groups will be re-assessed at 6 months and 12 months for the primary outcome of all-cause hospital admissions and presentations to the emergency department. Accelerometer-measured changes in sedentary behaviour and physical activity will also be assessed. Logistic regression models will be used for the primary outcome of hospital admissions and emergency department visits. Methods for repeated measures analysis will be used for all other outcomes. A cost-effectiveness analysis will be conducted to evaluate the effects of the intervention on the rates of hospital admissions and emergency department visits within the 12 months post commencing CR. ETHICS AND DISSEMINATION: This study received ethical approval from the Australian Capital Territory Health (2019.ETH.00162), Calvary Public Hospital Bruce (20-2019) and the University of Canberra (HREC-2325) Human Research Ethics Committees (HREC). Results will be disseminated through peer-reviewed academic journals. Results will be made available to participants on request. TRIAL REGISTRATION NUMBER: ACTRN12619001223123.

A multilevel mixed effects analysis of informal carers health in Australia: the role of community participation, social support and trust at small area level.

BACKGROUND: Informal carers suffer from worse health outcomes than non-carers due to their caregiving role. Yet, in a society carers health is as important as that of their care recipients. This study investigated the self-assessed mental and general health outcomes of informal carers in Australia. It evaluated the influence of carers' personal social capital- a logically linked sequence of their social behaviour such as community participation, social support and trust in others- on their health outcomes. The study estimated the magnitude of small area level variation at Statistical Area Level 1 (SA1) along with individual level variation in carers' health outcomes. METHODS: The study used a multilevel mixed effects cross-sectional design using data from the Household Income and Labour Dynamics of Australia survey, wave 14. It included Australians aged 15 years and older that were surveyed in the year 2014. The sample consisted of 12,767 individuals and 5004 SA1s. The outcome measures included- mental health, general health and physical functioning, domains of the Short Form 36 Questionnaire, a widely used multi-dimensional measure of health-related quality of life. RESULTS: Informal carers suffered from poor mental (Beta = - 0.587, p = 0.003) and general health (Beta = - 0.670, p = 0.001) outcomes compared to non-carers in Australia. These health outcomes exhibited significant variation acrossSA1s in Australia, with 12-13% variation in general and mental health. However, within small local areas, differences at the individual level, accounted for most of the variation in outcomes. Moreover, levels of community participation, personal social connection and trust, as perceived by individuals in the communities, had a positive influence on both mental and general health of carers and non-carers, and were more beneficial for carers compared to non-carers. CONCLUSION: It seems that the positive influence of social capital for carers helps them in coping with the negative impact of their caregiving duty on health outcomes. Findings suggested that some targeted community support programs for carers to build on their personal social cohesion and trust in their community could help in improving their poor health profiles. Moreover, improved informal carers' health may help the health system in better managing their resources.

Participation in microfinance based Self Help Groups in India: Who becomes a member and for how long?

INTRODUCTION: Microfinance is a widely promoted developmental initiative to provide poor women with affordable financial services for poverty alleviation. One popular adaption in South Asia is the Self-Help Group (SHG) model that India adopted in 2011 as part of a federal poverty alleviation program and as a secondary approach of integrating health literacy services for rural women. However, the evidence is limited on who joins and continues in SHG programs. This paper examines the determinants of membership and staying members (outcomes) in an integrated microfinance and health literacy program from one of India's poorest and most populated states, Uttar Pradesh across a range of explanatory variables related to economic, socio-demographic and area-level characteristics. METHOD: Using secondary survey data from the Uttar Pradesh Community Mobilization project comprising of 15,300 women from SHGs and Non-SHG households in rural India, we performed multivariate logistic and hurdle negative binomial regression analyses to model SHG membership and duration. RESULTS: While in general poor women are more likely to be SHG members based on an income threshold limit (government-sponsored BPL cards), women from poorest households are more likely to become members, but less likely to stay members, when further classified using asset-based wealth quintiles. Additionally, poorer households compared to the marginally poor are less likely to become SHG members when borrowing for any reason, including health reasons. Only women from moderately poor households are more likely to continue as members if borrowing for health and non-income-generating reasons. The study found that an increasing number of previous pregnancies is associated with a higher membership likelihood in contrast to another study from India reporting a negative association. CONCLUSION: The study supports the view that microfinance programs need to examine their inclusion and retention strategies in favour of poorest household using multidimensional indicators that can capture poverty in its myriad forms.

"Everything is provided free, but they are still hesitant to access healthcare services": why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare?

BACKGROUND: Inequity in access to healthcare services is a constant concern. While advances in healthcare have progressed in the last several decades, thereby significantly improving the prevention and treatment of disease, these benefits have not been shared equally. Excluded communities such as Indigenous communities typically face a lack of access to healthcare services that others do not. This study seeks to understand why the indigenous communities in Attapadi continue to experience poor access to healthcare in spite of both financial protection and adequate coverage of health services. METHODS: Ethnographic fieldwork was carried out among the various stakeholders living in Attapadi. A total of 47 in-depth interviews and 6 focus group discussions were conducted amongst the indigenous community, the healthcare providers and key informants. The data was coded utilising a reflexive and inductive approach leading to the development of the key categories and themes. RESULTS: The health system provided a comprehensive financial protection package in addition to a host of healthcare facilities for the indigenous communities to avail services. In spite of this, they resisted attempts by the health system to improve their access. The failure to provide culturally respectful care, the discrimination of the community at healthcare facilities, the centralisation of the delivery of services as well as the lack of power on the part of the indigenous community to negotiate with the health system for services that were less disruptive for their lives were identified as the barriers to improving healthcare access. The existing power differentials between the community and the health system stakeholders also ensured that meaningful involvement of the community in the local health system did not occur. CONCLUSION: Improving access to health care for indigenous communities would require UHC interventions to be culturally safe, locally relevant and promote active involvement of the community at all stages of the intervention. Continuing structural power imbalances that affect access to resources and prevent meaningful involvement of indigenous communities also need to be addressed.

A longitudinal analysis of mental and general health status of informal carers in Australia.

BACKGROUND: The study investigated the self-assessed mental and general health status of informal carers in Australia. It evaluated the influence of carer's health behaviours, namely physical activity, smoking and drinking status, along with their social connectedness and workforce engagement on their health status. METHODS: The study used a retrospective longitudinal design using data from the Household Income and Labour Dynamics of Australia survey, waves 5-15 (2005-2015). It included individuals aged 15 years and older from Australian households surveyed over a period of 11 years. The sample consisted of 23,251 individuals. The outcome measures included: mental health, general health and physical functioning domains of the Short Form 36 Questionnaire, a widely used multi-dimensional measure of health-related quality of life. Using fixed effects regression and following individuals over time, the analysis took care of the issue of individuals self-selecting themselves as carers due to some predisposing factors such as age, poor health, socioeconomic status and sedentary behaviour. RESULTS: There were statistically significant carer-noncarer status differences in mental (Beta = - 0.587, p = 0.003) and general health (Beta = - 0.670, p = 0.001) outcomes. Aging had a modifying impact on carers' mental and general health outcomes. Older carers coped better with their caregiving responsibilities than younger ones. Moreover, while physical activities had a positive influence on both mental and general health for non-carers, with more activities generating better health outcomes, it only had a modifying impact on carers' mental health. Furthermore, the study found that moderate levels of social drinking had beneficial modifying impact on carers' mental and general health. CONCLUSION: This study added value to the literature on informal carers' mental and general health in Australia by identifying some of the protective and risk factors. The study found the modifying effects of carers' age, health behaviours such as physical activity, smoking and drinking status on their health. Finally, the study identified an apparent beneficial link between moderate levels of social drinking and carer health that needs to be further explored with more targeted future research.

Maternal autonomy and birth registration in India: Who gets counted?

This paper examines the effect of maternal socio-economic status in the household, such as their autonomy, ability, freedom and bargaining power, on child birth registration in India using the nationally representative India Human Development Survey-II (IHDS-II), 2011-12. We have estimated a multilevel mixed effects model which accounts for the hierarchical structure of the data and allows us to examine the effects of unobserved 'district' and 'community' characteristics along with individual child level characteristics on probability of birth registration. The results show that between-districts and between individuals differences share a considerably high and an almost equal proportion of the variations in probability of birth registration in India. At individual child level, mother's socio-economic status such as her ability to move around independently and her exposure to outside world, significantly raise the probability of birth registration. More importantly, the marginal effects of the maternal autonomy indicators: mother's ability to move around freely and her control over resources, on birth registration vary across districts in India. Other variables such as institutional birth, mother's antenatal care seeking behaviour, caste, religion, household wealth and parental education are significant determinants of birth registration.