17 research outputs found
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Essays on Health Insurance Impact and Coverage Related Disparities in India
No full textThis dissertation project was aimed at evaluating health disparities that exist in health insurance programs in India and whether these programs have any impact on health service utilization and outcomes for the poor. I assessed these objectives through three independent manuscripts. In the first, I did an empirical analysis studying the effect of wealth status on health insurance enrollment. I found that primarily due to the newly introduced publicly funded health insurance schemes, the health insurance enrollment rates have improved for the marginalized caste groups. However, it was not clear what factors contribute to their higher enrollment rates. I have attempted to answer this question through the second manuscript of the dissertation. With this second manuscript, I analyzed data for India’s national health insurance scheme—Rashtriya Swasthya Bima Yojana (RSBY) and decomposed the enrollment differentials between the marginalized caste groups and the higher caste group. For the third manuscript, I assessed whether the maternal and child health (MCH) services indicators and child mortality outcomes improved after the implementation of the RSBY. For this empirical analysis, I used the difference-in-differences method to compare the selected MCH indicators for the poor versus the non-poor in the pre-and-post implementation period of the RSBY. Based on the results from the manuscripts, I argue that the poor, especially from the marginalized communities in India, are dependent on government programs for healthcare access. The federal and state governments should pay attention to the healthcare financing needs of these communities in future health insurance program implementation.Release after 08/14/202
Psychometric Testing of a New Instrument to Measure Workplace Mental Health and Well-Being
No full textWorkplace well-being and mental health among the US workforce is an ongoing concern. The pandemic both highlighted and worsened this issue, particularly among healthcare workers, who more frequently experience burnout and highly stressful workplace conditions. To address these issues, the US Surgeon General’s office proposed a five-domain framework around Worker Voice and Equity in October 2022. To our knowledge, no psychometrically developed measure is available to map the framework\u27s components on a scale. We developed the Augusta Scale from the framework and administered it to Georgia Area Health Education Centers (AHEC) medical preceptors. Using this pilot data, we assessed the scale’s psychometric properties.
We psychometrically assessed the Augusta Scale under the Classical Test Theory and Item Response Theory (IRT) paradigms. The instrument’s reliability was assessed using Cronbach’s α and omega with reference value \u3e0.70. Convergent validity was checked by conducting logistic regression on the association between the total score on the Augusta Scale and a one-item emotional burnout scale measuring a similar construct. A Confirmatory Factor Analysis (CFA) was performed using the five-domain structure. Various fit indices were estimated to check the plausibility of the five-factor solution.
Domain-specific Cronbach’s α ranged from 0.71 (0.67-0.75) to 0.90 (0.87-0.92), while the overall scale α was 0.94 (0.93-0.95), suggesting strong reliability. The omega score was 0.91, confirming items measured the latent construct. Convergent validity analysis confirmed the inverse relationship between total scale score and perception of burnout. The model fit statistics revealed good fit for the model, validating the five-factor solution for the CFA. The high-order model indicated positive correlations between domains and the second-order factor “well-being.” On the IRT paradigm, the item discrimination properties mostly ranged between “Moderate” and “Very High”.
The Augusta Scale is a valid and reliable measure that can assess workplace mental health and well-being of medical workers
Equity as the new normal: a deeper dive into the economic consequences of the pandemic on systemically disadvantaged populations from The COVID IMPACT Project
No full textUsing the empirical data, this project highlights how the pre-existing socio-economic and health disparities have widened in Canada during the pandemic. It also discusses important lessons to learn from the pandemic for an equitable recovery
COVID-19 Pandemic: Did Strict Mobility Restrictions Save Lives and Healthcare Costs in Maharashtra, India?
No full textIntroduction: Maharashtra, India, remained a hotspot during the COVID-19 pandemic. After the initial complete lockdown, the state slowly relaxed restrictions. We aim to estimate the lockdown’s impact on COVID-19 cases and associated healthcare costs. Methods: Using daily case data for 84 days (9 March–31 May 2020), we modeled the epidemic’s trajectory and predicted new cases for different phases of lockdown. We fitted log-linear models to estimate the growth rate, basic (R0), daily reproduction number (Re), and case doubling time. Based on pre-restriction and Phase 1 R0, we predicted new cases for the rest of the restriction phases, and we compared them with the actual number of cases during each phase. Furthermore, using the published and gray literature, we estimated the costs and savings of implementing these restrictions for the projected period, and we performed a sensitivity analysis. Results: The estimated median R0 during the different phases was 1.14 (95% CI: 0.85, 1.45) for pre-lockdown, 1.67 (95% CI: 1.50, 1.82) for phase 1 (strict mobility restrictions), 1.24 (95% CI: 1.12, 1.35) for phase 2 (extension of phase 1 with no restrictions on agricultural and essential services), 1.12 (95% CI: 1.01, 1.23) for phase 3 (extension of phase 2 with mobility relaxations in areas with few infections), and 1.05 (95% CI: 0.99, 1.123) for phase 4 (implementation of localized lockdowns in high-case-load areas with fewer restrictions on other areas), respectively. The corresponding doubling time rate for cases (in days) was 17.78 (95% CI: 5.61, −15.19), 3.87 (95% CI: 3.15, 5.00), 10.37 (95% CI: 7.10, 19.30), 20.31 (95% CI: 10.70, 212.50), and 45.56 (95% CI: 20.50, –204.52). For the projected period, the cases could have reached 631,819 without the lockdown, as the actual reported number of cases was 64,975. From a healthcare perspective, the estimated total value of averted cases was INR 194.73 billion (USD 2.60 billion), resulting in net cost savings of 84.05%. The Incremental Cost-Effectiveness Ratio (ICER) per Quality Adjusted Life Year (QALY) for implementing the lockdown, rather than observing the natural course of the pandemic, was INR 33,812.15 (USD 450.83). Conclusion: Maharashtra’s early public health response delayed the pandemic and averted new cases and deaths during the first wave of the pandemic. However, we recommend that such restrictions be carefully used while considering the local socio-economic realities in countries like India
The link between perceived racism and healthcare utilization among older adults: a health equity analysis
No full textPatient discrimination in healthcare settings is a growing concern in the United States. In healthcare settings, discrimination based on age, gender, sexuality, race, ethnicity, socioeconomic status, geographic region, and insurance status is well-documented. Nearly one-in-five US adults have experienced discrimination at least once when visiting the health system. While the scholarship on discrimination and its association with health outcomes is well established, there remains a dearth of literature that compares this across countries. Such comparisons could provide valuable information for policy makers.
In this study, our purpose was to conduct a secondary analysis of the 2021 Commonwealth Fund International Health Policy (IHP) Survey of Older Adults—a nationally representative, self-reported, and cross-sectional survey of adults from 11 high-income countries. We examined the relationship between the perception of racial/ethnic discrimination in the health system and its association with visits to different healthcare providers and frequency of emergency room visitations.
We employed a two-part multivariable hurdle model for the healthcare provider and ER visits. The adjusted odds ratios (OR) and risk ratios (RR) were estimated for the hurdle and count part, respectively. Separate analyses were performed for the United States by including additional socioeconomic variables.
Perceived discrimination was associated with reduced odds of meeting at least one primary care provider (OR:0.82; 95%CI: 0.68,0.99). Among those who have visited at least one provider, older adults who perceive discrimination were more likely to visit different providers when compared with those who did not perceive discrimination (RR:1.06; 95%CI: 1.01,1.11). Perceived racism was associated with first (OR:1.13; 95%CI: 1.01,1.27) and frequent (RR:1.14; 95%CI: 1.01,1.29) ER visits. Similar but attenuated results were obtained for the USA sample.
Perceived racial and ethnic discrimination significantly affects health service utilization among the elderly living in high-income countries. Healthcare provider sensitization should be the cornerstone when devising related policies and interventions
Appendix A
No full textThis file is an appendix file for the manuscript titled "Wealth status and health insurance enrollment in India-An empirical analysis of National Family Health Survey-4 (2015-16)
Leave in Silence: Hospital Discharge Communication Problems in Older Adults in 11 Countries
No full textThe transition from hospital care to another point of care is a critical moment in ensuring positive patient outcomes and safety. We aimed to determine the prevalence of hospital discharge communication problems in older adults in 11 high-income countries and the associated factors.
We analyzed data from the 2021 Commonwealth Fund International Health Policy (IHP) survey of older adults. Respondents were from 11 countries high-income countries. Poor discharge communication (PDC), a composite score, was defined as participants reporting at least 2 problems in the discharge process out of a maximum of 3. A multivariate logistic regression model assessed PDC’s association with potential risk factors.
Analyses were based on 4445 respondents hospitalized for at least one night in the last two years before the survey and answered discharge-related questions. The overall rate of PDC was 19.1% overall and was the highest in Norway (31.3%) and lowest in the US (7.5%). PDC was more likely to occur in those 75 years of age or greater and living in Canada, France, Germany, Netherlands, Norway, Sweden, Switzerland, and the United Kingdom. Of the three discharge communication problems identified, the most reported problem was medicines not being discussed at discharge, representing 27.4% of all individuals. Gender, education, income, and presence of at least one chronic disease were not associated with PDC.
In our analysis of hospital discharge communication problems in 11 high-income nations, almost 1 in 5 older adults experience PDC, although there is a wide variation between nations and those age 75 or older are at particular risk. Our results suggest that hospital discharge teams and leadership should carefully examine all communication during the hospital discharge process to ensure that care gaps are minimized
Development of The Augusta Scale, a Workplace Mental Health and Well-being Survey
No full textMental health and well-being are rising concerns in the United States workforce. These concerns are more pronounced among healthcare workers. Left unaddressed, burnout is likely to negatively impact many facets of healthcare.
In October 2022, the U.S. Surgeon General released the “Framework for Workplace Mental Health and Well-Being” in response to increasing concerns. The framework includes five “Essentials” centered around Worker Voice and Equity. These Essentials include “Protection from Harm”, “Connection and Community”, “Work-Life Harmony”, “Mattering at Work”, and “Opportunity for Growth”. Our team transformed each item from the framework into survey questions (The Augusta Scale). We piloted the Augusta Scale with Georgia Area Health Education Center (AHEC) preceptors.
A total of 583 individuals completed the survey. Responses were measured on a 1-to-5 Likert scale, with possible scores ranging from 22 to 110. Reliability was assessed using Cronbach’s alpha and omega. We conducted a Confirmatory Factor Analysis to assess construct validity. We also included one burnout question and one quality of life question to assess the convergent validity of the Augusta Scale.
Total survey scores ranged from 32 to 110, with a mean score of 85.88 (SD 17.38). Individuals who were aged 60+ scored highest, followed by 50-59, 40-49, and 30-39. Males had higher total scores than females. White respondents had the highest scores, followed by Asian, Black, and Other respondents. The highest scores by profession were physicians, physician assistances, and advanced practice nurses, respectively. Subscale reliability ranged from Cronbach’s α of 0.71 to 0.94. The convergent validity analysis confirmed the inverse relationship between the total scale score and the perception of burnout.
Significant differences were detected in total well-being scores measured by the Augusta Scale across demographic variables. Our results provide specific areas of discrepancy for policymakers to address. We plan to distribute our survey at a national level
Development and validation of an Index of Social Attributes Predictive of Frailty Among Older Adults
No full textBackground: Frailty captures accumulating age-related deficits in the normal functioning of an adult. The existing frailty models include physical and behavioral attributes; however, they ignore the complex social environments that impact them. The varying environment and estimation processes further make cross-country comparisons of frailty difficult. The Commonwealth Fund’s International Health Policy (IHP) survey data on older adults allows one to compare social predictors of frailty across high-income countries.
Methods: Our objective was to develop and validate a social risk measure to predict frailty across the countries using comparable social characteristics based on Social Production Function Theory. We employed the least absolute shrinkage and selection operator (LASSO) regression to identify a small subset of predictors for our logistic model using IHP 2017 data and including country-level fixed effects. A 10-fold cross-validation was performed to identify the lambda parameter within one SE of the minimum. The model was validated using IHP 2021 data to determine discrimination and calibration. Outcomes considered for analysis were inability to perform instrumental activities, hospitalization, and number of emergency room (ER) visits.
Results: In preliminary results, 24 attributable risks, including demographic characteristics, were identified, of which 16 appeared in the final model. The validation results showed the excellent discrimination capacity of the model (AUC ranging between 0.75 and 0.80). The confusion matrix showed the accuracy of the predictions ranged between 0.70 and 0.86.
Conclusion: A novel social frailty index can predict frailty using cross-country data. The first of such efforts allows for predicting frailty and associated adverse health outcomes for older adults using comparable social indicators across 11 high-income countries
Using the Family Planning Estimation Tool (FPET) to assess national-level family planning trends and future projections for contraceptive prevalence and associated demand for HIV-infected women in sub-Saharan Africa.
No full textThe combination of low uptake of modern contraceptives, high rates of unintended pregnancies, and the pervasive HIV epidemic in Sub-Saharan Africa (SSA) poses a threat to maternal, newborn, and child health in the region. This study examined the prevalence, need, and demand satisfied by modern contraceptive methods for women who tested positive for HIV (both unmarried and married) in 10 countries in SSA. We used the Family Planning Estimation Tool (FPET) to generate national-level trends and projections from 1983 through 2030. Individual-level data from 30 DHS surveys conducted between 2004 and 2018 in 10 sub-Saharan Africa (SSA) countries were used to produce projections for 1) all women and 2) unmarried and married women who tested positive for HIV. Throughout the period, Ethiopian and Guinean women who tested positive for HIV had a higher %mCPR (utilization of modern family planning methods) vis-à-vis all women. Among women who tested positive for HIV, the highest percentage of family planning demand satisfied by modern methods was observed in Zimbabwe (85.27, CI: 76.32-91.69), Lesotho (82.75, CI: 71.80-89.86), Rwanda (80.17, CI: 70.01-87.62), Malawi (73.11, CI: 61.50-82.63), and Zambia (72.63, CI: 64.49-80.09). The highest unmet need for modern contraceptives was found in Senegal (25.38, CI:18.36-33.72), followed by Cameroon (23.59, CI:19.30-28.59) and Sierra Leone (23.16, CI:16.64-32.05). Zimbabwe had the lowest unmet need (10.61, CI:6.36-16.13) and achieved the highest change in %mCPR (49.28, SE:6.80). Among married women who tested positive for HIV, their unmet need for modern contraception will remain higher in 2030. Continuing existing policies until 2030 would result in significant coverage gain among married vis-à-vis unmarried women who tested positive for HIV. Our projections emphasize the importance of country-specific strengthening initiatives, programs, and services targeting unmarried women
