Barriers to access adequate maternal care in Romania, Bulgaria, and Moldova: A cross-country comparison.

BACKGROUND: Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova. METHODS: This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015-2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries. RESULTS: Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers. CONCLUSIONS: This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.

COVID-19 pandemic: health impact of staying at home, social distancing and 'lockdown' measures-a systematic review of systematic reviews.

BACKGROUND: To systematically review the evidence published in systematic reviews (SR) on the health impact of staying at home, social distancing and lockdown measures. We followed a systematic review approach, in line with PRISMA guidelines. METHODS: In October 2020, we searched the databases Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase and Web of Science, using a pre-defined search strategy. RESULTS: The literature search yielded an initial list of 2172 records. After screening of titles and abstracts, followed by full-text screening, 51 articles were retained and included in the analysis. All of them referred to the first wave of the coronavirus disease 2019 pandemic. The direct health impact that was covered in the greatest number (25) of SR related to mental health, followed by 13 SR on healthcare delivery and 12 on infection control. The predominant areas of indirect health impacts covered by the included studies relate to the economic and social impacts. Only three articles mentioned the negative impact on education. CONCLUSIONS: The focus of SR so far has been uneven, with mental health receiving the most attention. The impact of measures to contain the spread of the virus can be direct and indirect, having both intended and unintended consequences.

Female Pakistani carers' views on future formal and informal care for their older relatives in Norway.

BACKGROUND: The aging of Pakistani immigrants in Norway raises questions related to their increased need for care and help from relatives, as well as those concerning what future formal and informal care and healthcare accessibility for older immigrants may look like. The hidden nature of family caregiving means that the circumstances of carers, their views and their dilemmas related to future care are largely invisible. In this study, we explored female Pakistani carers' views of future care and healthcare accessibility for their older relatives in Norway. METHODS: Our data included interviews with family carers between the ages of 23 and 40 years old, living in Oslo, Norway. We recruited ten family carers, out of which eight were daughters and two were daughters-in-law. Interviews were conducted by the first author in Urdu or English and were recorded and transcribed verbatim. RESULTS: Our findings revealed several factors that influenced participants' perceptions about formal and informal caregiving, which can be organised into the following themes: 1) caring for family in Norway as in Pakistan, 2) worries about being 'dropped off' at a care home, 3) concerns about being cared for by outsiders, 4) questions about what other people might say and 5) adhering to society's expectations of a 'good' carer. CONCLUSION: Family carers' traditional views of filial piety do not entirely determine the use of or access to healthcare services of their older relatives. There is a need to develop culturally sensitive healthcare systems so that immigrant families and their carers have more options in choosing care in old age, which in turn will ease their families' care burden. Healthcare professionals and policymakers should not assume that immigrant families will take care of their own older members but should instead secure adequate support for older immigrants and their family carers.

Barriers to accessing adequate maternal care in Georgia: a qualitative study.

BACKGROUND: The maternal health outcomes in Georgia are linked to shortcomings in healthcare such as inequities in access to adequate maternal care. Due to the macro-level, quantitative approach applied in most previous studies, little is known about the underlying reasons that influence maternal care and care-seeking behaviour of pregnant women. METHODS: This qualitative study explores the stakeholders' perspectives on access to adequate maternal care in Georgia. Focus-group discussions are conducted with mothers who gave birth within in the past four years and in-depth interviews are conducted with decision-makers and health professionals in the field. Five access-related aspects are studied: availability, appropriateness, affordability, approachability and acceptability of maternal care. The method of direct content analysis is applied. RESULTS: Results indicate problems with maternal care standards, inequalities across population groups and drawbacks in maternal care financing. This includes gaps in clinical quality and staff skills, as well as poor communication between women and health professionals. Geographical barriers to adequate maternal care exist in rural and mountainous areas due to the weak infrastructure (poor roads and weak transportation), in addition to financial hardships. Despite improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups are financially unprotected from the high out-of-pocket payments for maternal care services. CONCLUSION: These findings imply that micro-level indicators, such as disrespectful behaviour of health professionals and affordability of care, should be taken into account when assessing maternal care provision in Georgia. It should complement the existing macro-level indicators for a comprehensive evaluation of maternal care.

A systematic review on the use of healthcare services by undocumented migrants in Europe.

BACKGROUND: Undocumented migrants face particular challenges in accessing healthcare services in many European countries. The aim of this study was to systematically review the academic literature on the utilization of healthcare services by undocumented migrants in Europe. METHODS: The databases Embase, Medline, Global Health and Cinahl Plus were searched systematically to identify quantitative, qualitative and mixed methods studies published in 2007-2017. RESULTS: A total of 908 articles were retrieved. Deletion of duplicates left 531. After screening titles, abstracts and full texts according to pre-defined inclusion and exclusion criteria, 29 articles were included in the review. Overall, quantitative studies showed an underutilization of different types of healthcare services by undocumented migrants. Qualitative studies reported that, even when care was received, it was often inadequate or insufficient, and that many undocumented migrants were unfamiliar with their entitlements and faced barriers in utilizing healthcare services. CONCLUSIONS: Although it is difficult to generalize findings from the included studies due to methodological differences, they provide further evidence that undocumented migrants in Europe face particular problems in utilizing healthcare services.

A systematic literature review on the use and outcomes of maternal and child healthcare services by undocumented migrants in Europe.

Background: Undocumented migrants, in particular pregnant women and their newborns, constitute a particularly vulnerable group of migrants. The aim of this study was to systematically review the academic literature on the use and outcomes of maternal and child healthcare by undocumented migrants in the European Union (EU) and European Free Trade Association (EFTA) countries. Methods: The databases, MEDLINE, Embase, CINAHL Plus, Global Health and Popline were searched for the period 2007 to 2017. Two independent reviewers judged the eligibility of studies. The final number of included studies was 33. Results: The results of quantitative, qualitative and mixed methods studies were analysed separately due to their differences in study design, sample size and quality. Overall, the quantitative studies found that undocumented women underutilised essential maternal and child healthcare services, and experienced worse health outcomes. Qualitative studies supported these results, indicating that undocumented migrants were hesitant to use services due to a lack of knowledge and fear of deportation. Studies included in the review covered 10 of 32 EU or EFTA countries, making a European comparison impossible. Conclusions: Despite major methodological differences between included studies, the results of this review indicate that the status of undocumented migrants exacerbates known health risks and hampers service use.

Macroeconomic implications of population ageing and selected policy responses.

Between now and 2030, every country will experience population ageing-a trend that is both pronounced and historically unprecedented. Over the past six decades, countries of the world had experienced only a slight increase in the share of people aged 60 years and older, from 8% to 10%. But in the next four decades, this group is expected to rise to 22% of the total population-a jump from 800 million to 2 billion people. Evidence suggests that cohorts entering older age now are healthier than previous ones. However, progress has been very uneven, as indicated by the wide gaps in population health (measured by life expectancy) between the worst (Sierra Leone) and best (Japan) performing countries, now standing at a difference of 36 years for life expectancy at birth and 15 years for life expectancy at age 60 years. Population ageing poses challenges for countries' economies, and the health of older populations is of concern. Older people have greater health and long-term care needs than younger people, leading to increased expenditure. They are also less likely to work if they are unhealthy, and could impose an economic burden on families and society. Like everyone else, older people need both physical and economic security, but the burden of providing these securities will be falling on a smaller portion of the population. Pension systems will be stressed and will need reassessment along with retirement policies. Health systems, which have not in the past been oriented toward the myriad health problems and long-term care needs of older people and have not sufficiently emphasised disease prevention, can respond in different ways to the new demographic reality and the associated changes in population health. Along with behavioural adaptations by individuals and businesses, the nature of such policy responses will establish whether population ageing will lead to major macroeconomic difficulties.

Measles among migrants in the European Union and the European Economic Area.

AIMS: Progress towards meeting the goal of measles elimination in the EU and the European Economic Area (EEA) by 2015 is being obstructed, as some children are either not immunized on time or never immunized. One group thought to be at increased risk of measles is migrants; however, the extent to which this is the case is poorly understood, due to a lack of data. This paper addresses this evidence gap by providing an overview of the burden of measles in migrant populations in the EU/EEA. METHODS: Data were collected through a comprehensive literature review, a country survey of EU/EEA member states and information from measles experts gathered at an infectious disease workshop. RESULTS: Our results showed incomplete data on measles in migrant populations, as national surveillance systems do not systematically record migration-specific information; however, evidence from the literature review and country survey suggested that some measles outbreaks in the EU/EEA were due to sub-optimal vaccination coverage in migrant populations. CONCLUSIONS: We conclude that it is essential that routine surveillance of measles cases and measles, mumps and rubella (MMR) vaccination coverage become strengthened, to capture migrant-specific data. These data can help to inform the provision of preventive services, which may need to reach out to vulnerable migrant populations that currently face barriers in accessing routine immunization and health services.

Regional differences in cardiovascular mortality in Kazakhstan: further evidence for the 'Russian mortality paradox'?

BACKGROUND: The role of alcohol consumption in patterns of CVD mortality in Central Asia is still largely unexplored. Previous research in Kazakhstan and Kyrgyzstan has found that ethnic Russians have higher adult mortality rates than native ethnic groups, despite their higher socio-economic status. This has been termed the 'Russian mortality paradox'. METHODS: We calculated age-standardized CVD mortality data by gender and region of Kazakhstan, based on mortality data obtained from the Ministry of Health and population data from the State Agency for Statistics. We analysed data on self-reported alcohol consumption from the nationally representative 5th National Behavior Study. RESULTS: We found substantial differences in CVD mortality rates across regions, as well as between males and females. With the exception of Almaty and Astana cities, mortality rates are highest in the country's North-Eastern regions and lowest in South-Western regions, despite the fact that North-Eastern regions have higher income levels. Patterns of self-reported alcohol consumption and alcohol sales follow a similar pattern. One explanation could be related to higher self-reported drinking prevalence among ethnic Russians who live predominantly in the country's North-Eastern regions. CONCLUSIONS: Hazardous alcohol consumption seems to be highest in Kazakhstan's North-Eastern regions, which might be related to different patterns of alcohol consumption among different ethnic groups. However, more detailed analyses are required to corroborate these assumptions. The high overall rates suggest the need for population-based measures, such as increasing taxes on alcohol, in particular spirits such as vodka, and strengthening the capacity of primary health care.

Tuberculosis among migrant populations in the European Union and the European Economic Area.

BACKGROUND: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report 'Key Infectious Diseases in Migrant Populations in the EU/EEA' commissioned by The European Centre for Disease Prevention and Control. METHODS: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. RESULTS: In 2010, of the 73,996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. CONCLUSION: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants' vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA.

Migration and health in an increasingly diverse Europe.

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

Ageing in the European Union.

The ageing of European populations presents health, long-term care, and welfare systems with new challenges. Although reports of ageing as a fundamental threat to the welfare state seem exaggerated, societies have to embrace various policy options to improve the robustness of health, long-term care, and welfare systems in Europe and to help people to stay healthy and active in old age. These policy options include prevention and health promotion, better self-care, increased coordination of care, improved management of hospital admissions and discharges, improved systems of long-term care, and new work and pension arrangements. Ageing of the health workforce is another challenge, and policies will need to be pursued that meet the particular needs of older workers (ie, those aged 50 years or older) while recruiting young practitioners.

Health and health systems in the Commonwealth of Independent States.

The countries of the Commonwealth of Independent States differ substantially in their post-Soviet economic development but face many of the same challenges to health and health systems. Life expectancies dropped steeply in the 1990s, and several countries have yet to recover the levels noted before the dissolution of the Soviet Union. Cardiovascular disease is a much bigger killer in the Commonwealth of Independent States than in western Europe because of hazardous alcohol consumption and high smoking rates in men, the breakdown of social safety nets, rising social inequality, and inadequate health services. These former Soviet countries have embarked on reforms to their health systems, often aiming to strengthen primary care, scale back hospital capacities, reform mechanisms for paying providers and pooling funds, and address the overall shortage of public funding for health. However, major challenges remain, such as frequent private out-of-pocket payments for health care and underdeveloped systems for improvement of quality of care.

An examination of Roma health insurance status in Central and Eastern Europe.

BACKGROUND: Roma in Central and Eastern Europe (CEE) face problems in accessing health care, and a lack of access to statutory health insurance schemes is a key factor. This study seeks to quantify differences in health insurance coverage between Roma and non-Roma and assess whether variations can be explained by socio-economic factors. METHODS: Secondary household survey data collected in 12 CEE countries in 2011 were analysed. A univariate analysis assessed the effect of Roma status on insurance coverage by country. Multivariate analyses were used to progressively adjust for socio-demographic factors, employment status and income. Country-specific literature was drawn on to examine the context of the findings. RESULTS: Lack of insurance coverage for Roma populations varied considerably between countries, from 2.8% without insurance in Slovakia to 67.7% in Albania. Roma were significantly less likely to have health insurance than non-Roma in all countries except Slovakia and Serbia. The greatest differences in Roma and non-Roma insurance coverage were in Montenegro, Bosnia and Herzegovina, Croatia, Bulgaria and Romania. When adjusting for employment status and income, the gap between Roma and non-Roma remained significant in Montenegro, Croatia, Bosnia and Herzegovina, Bulgaria, Romania and Moldova. CONCLUSION: Roma are significantly less likely to have insurance coverage in most CEE countries, and this gap remains when adjusting for socio-economic differences between Roma and non-Roma in many countries. Much needs to be done to address the known barriers that Roma face in accessing insurance coverage, such as tackling problems related to documentation and the receipt of social benefits.

Informal payments for health services: the experience of Bulgaria after 10 years of formal co-payments.

BACKGROUND: Informal payments were reported in Bulgaria before and after the introduction of formal co-payments for services included in the basic benefits package in 2000. The aim of our study was to establish the current scale and type of informal payments, as well as public attitudes towards these payments. METHODS: A nationally representative survey of 1003 individuals was conducted in Bulgaria in July 2010 using face-to-face interviews based on a standardized questionnaire. Respondents were selected through a multi-stage random probability method. The questionnaire included questions on total informal payments (in cash and in kind) for health services used by the respondent during the preceding 12 months. RESULTS: About 13% of users reported informal payments for outpatient visits and 33% of users reported to have paid informally for hospitalizations. The average amount paid informally for inpatient services was nearly twice higher than that for outpatient services. More than 50% of the sample had negative attitudes towards informal payments in both cash and kind, but about 27% of respondents had a positive attitude towards giving gifts in kind. Regression analysis showed that respondents with higher levels of education had more negative attitudes towards informal cash payments. Positive attitudes towards gifts in kind were more often stated by citizens of larger cities. CONCLUSION: Informal payments continue to exist in Bulgaria irrespective of the formal co-payments introduced in 2000. Although the problem has been recognized in Bulgaria, policies should aim to eliminate the underlying structural reasons for such payments.

The inability to pay for health services in Central and Eastern Europe: evidence from six countries.

BACKGROUND: Out-of-pocket payments for health services constitute a major financial burden for patients in Central and Eastern European (CEE) countries. Individuals who are unable to pay use different coping strategies (e.g. borrowing money or foregoing service utilization), which can have negative consequences on their health and social welfare. This article explores patients' inability to pay for outpatient and hospital services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. METHODS: The analysis is based on quantitative data collected in 2010 in nationally representative surveys. Two indicators of inability to pay were considered: the need to borrow money or sell assets and foregoing service utilization. Statistical analyses were applied to investigate associations between the indicators of inability to pay and individual characteristics. RESULTS: Patient payments are most common in Bulgaria, Ukraine, Romania and Lithuania and often include informal payments. Romanian and, particularly, Ukrainian patients most often face difficulties to pay for health services (with approximately 40% of Ukrainian payers borrowing money or selling assets to cover hospital payments and approximately 60% of respondents who need care foregoing services). Inability to pay mainly affects those with poor health and low incomes. CONCLUSION: Widespread patient payments constitute a major financial barrier to health service use in CEE. There is a need to formalize them where they are informal and to take measures to protect vulnerable population groups, especially those with limited possibilities to deal with payment difficulties.

Facing diversity under institutional constraints: challenging situations for community nurses when providing care to ethnic minority patients.

AIMS: To explore the challenges faced by community nurses when providing home health care to ethnic minority patients. BACKGROUND: Norway has a growing number of immigrants, including older immigrant patients. Community nurses who provide home care encounter considerable challenges when delivering services to an increasingly diverse patient population. DESIGN: A qualitative study based on a hermeneutics approach. METHODS: A qualitative study was conducted involving 19 nurses in Norwegian home health care districts, which had high proportions of minority patients. Data were collected in 2008. FINDINGS: We identified three critical aspects of the encounters between community nurses and minority patients. The first was intimate care. Nurses perceived the fear of mistakes and crossing boundaries related to the cultural and religious practices of minority patients as particularly stressful. The second was rehabilitation after stroke. The beliefs of nurses in the benefits of rapid rehabilitation conflicted with those of the minority patients and their relatives who favoured extended rest during recovery. Third, the commitment of community nurses to transparency in the care of dying patients was tested severely when they met relatives who believed in religious explanations for the destinies of patients and who wanted to conceal the true diagnosis from terminally ill patients. CONCLUSION: Community nurses encountered various challenges due to a lack of experience with highly diverse patient populations. This situation will continue to create difficulties for nurses and minority patients if management support and appropriate training measures are not provided.

Out-of-pocket payments for health care services in Bulgaria: financial burden and barrier to access.

BACKGROUND: In recent years, Bulgaria has increasingly relied on out-of-pocket payments as one of the main sources of health care financing. However, it is largely unknown whether the official patient charges, combined with informal payments, are affordable for the population. Our study aimed to explore the scale of out-of-pocket payments for health care services and their affordability. METHODS: Data were collected in two nationally representative surveys, conducted in Bulgaria in 2010 and 2011, using face-to-face interviews based on a standardized questionnaire. To select respondents, a multi-stage random probability method was used. The questionnaire included questions on the out-of-pocket payments for health care services used by the respondent during the preceding 12 months. RESULTS: In total, 75.7% (2010) and 84.0% (2011) of outpatient service users reported to have paid out-of-pocket, with 12.6% (2010) and 9.7% (2011) of users reporting informal payments. Of those who had used inpatient services, 66.5% (2010) and 63.1% (2011) reported to have made out-of-pocket payments, with 31.8% (2010) and 18.3% (2011) reporting to have paid informally. We found large inability to pay indicated by the need to borrow money and/or forego services. Regression analysis showed that the inability to pay is especially pronounced among those with poor health status and chronic diseases and those on low household incomes. CONCLUSION: The high level of both formal and informal out-of-pocket payments for health care services in Bulgaria poses a considerable burden for households and undermines access to health services for poorer parts of the population.