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1.  Acknowledgement of manuscript reviewers 2014 
Contributing reviewers
The editors of International Journal for Equity in Health would like to thank all our reviewers who have contributed to the journal in Volume 13 (2014).
doi:10.1186/s12939-015-0141-7
PMCID: PMC4336477
3.  Quality of care for the treatment for uncomplicated malaria in South-East Nigeria: how important is socioeconomic status? 
Introduction
Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups.
Methods
A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey.
Results
Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p < 0.01). Very few of those in the richest SES group used public health centres (4%) instead choosing to go to pharmacies (44%) and patent medicine dealers (52%, p < 0.001). During consultations with a healthcare provider, the poorest compared to the richest were significantly more likely to discuss symptoms with the provider, be physically examined and rely on providers for diagnosis and treatment rather than request a specific medicine. Those from the poorest SES group were however, least likely to request or to receive an antimalarial (p < 0.001). The use of artemisinin combination therapy (ACT), the recommended treatment for uncomplicated malaria, was low across all SES groups.
Conclusions
The quality of malaria treatment is sub-optimal for all febrile patients. Having greater interaction with the provider also did not translate to better quality care for the poor. The poor face a number of significant barriers to accessing quality treatment especially in relation to treatment seeking behaviour and type of treatment received. Strategies to address these inequities are fundamental to achieving universal coverage of effective malaria treatment and ensuring that the most vulnerable people are not left behind.
doi:10.1186/s12939-015-0150-6
PMCID: PMC4330641
Malaria; Inequity; Socioeconomic status; SES; Artemisinin combination therapy; Nigeria
4.  Social inequalities in patient-reported outcomes among older multimorbid patients – results of the MultiCare cohort study 
Introduction
In this article three research questions are addressed: (1) Is there an association between socioeconomic status (SES) and patient-reported outcomes in a cohort of multimorbid patients? (2) Does the association vary according to SES indicator used (income, education, occupational position)? (3) Can the association between SES and patient-reported outcomes (self-rated health, health-related quality of life and functional status) be (partly) explained by burden of disease?
Methods
Analyses are based on the MultiCare Cohort Study, a German multicentre, prospective, observational cohort study of multimorbid patients from general practice. We analysed baseline data and data from the first follow-up after 15 months (N = 2,729). To assess burden of disease we used the patients’ morbidity data from standardized general practitioner (GP) interviews based on a list of 46 groups of chronic conditions including the GP’s severity rating of each chronic condition ranging from marginal to very severe.
Results
In the cross-sectional analyses SES was significantly associated with the patient-reported outcomes at baseline. Associations with income were more consistent and stronger than with education and occupational position. Associations were partly explained (17% to 44%) by burden of disease. In the longitudinal analyses only income (but not education and occupational position) was significantly related to the patient-reported outcomes at follow-up. Associations between income and the outcomes were reduced by 18% to 27% after adjustment for burden of disease.
Conclusions
Results indicate social inequalities in self-rated health, functional status and health related quality of life among older multimorbid patients. As associations with education and occupational position were inconsistent, these inequalities were mainly due to income. Inequalities were partly explained by burden of disease. However, even among patients with a similar disease burden, those with a low income were worse off in terms of the three patient-reported outcomes under study.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-015-0142-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-015-0142-6
PMCID: PMC4322453
Socioeconomic status; Patient-reported outcomes; Multimorbid patients; Burden of disease
5.  Public health nurse educators’ conceptualisation of public health as a strategy to reduce health inequalities: a qualitative study 
Background
Nurses have long been identified as key contributors to strategies to reduce health inequalities. However, health inequalities are increasing in the UK despite policy measures put in place to reduce them. This raises questions about: convergence between policy makers’ and nurses’ understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities.
Aim
The aim of this qualitative research project is to determine public health nurse educators’ understanding of public health as a strategy to reduce health inequalities.
Method
26 semi-structured interviews were conducted with higher education institution-based public health nurse educators.
Findings
Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health.
Conclusion
Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than take population approaches.
doi:10.1186/s12939-015-0146-2
PMCID: PMC4320498  PMID: 25643629
Social justice; Inequalities in health; Public health; Socioeconomic determinants; Nursing
6.  “Best care on home ground” versus “elitist healthcare”: concerns and competing expectations for medical tourism development in Barbados 
Introduction
Many countries have demonstrated interest in expanding their medical tourism sectors because of its potential economic and health system benefits. However, medical tourism poses challenges to the equitable distribution of health resources between international and local patients and private and public medical facilities. Currently, very little is known about how medical tourism is perceived among front line workers and users of health systems in medical tourism ‘destinations’. Barbados is one such country currently seeking to expand its medical tourism sector. Barbadian nurses and health care users were consulted about the challenges and benefits posed by ongoing medical tourism development there.
Methods
Focus groups were held with two stakeholder groups in May, 2013. Nine (n = 9) citizens who use the public health system participated in the first focus group and seven (n = 7) nurses participated in the second. Each focus group ran for 1.5 hours and was digitally recorded. Following transcription, thematic analysis of the digitally coded focus group data was conducted to identify cross-cutting themes and issues.
Results
Three core concerns regarding medical tourism’s health equity impacts were raised; its potential to 1) incentivize migration of health workers from public to private facilities, 2) burden Barbados’ lone tertiary health care centre, and 3) produce different tiers of quality of care within the same health system. These concerns were informed and tempered by the existing a) health system structure that incorporates both universal public healthcare and a significant private medical sector, b) international mobility among patients and health workers, and c) Barbados’ large recreational tourism sector, which served as the main reference in discussions about medical tourism’s impacts. Incorporating these concerns and contextual influences, participants’ shared their expectations of how medical tourism should locally develop and operate.
Conclusions
By engaging with local health workers and users, we begin to unpack how potential health equity impacts of medical tourism in an emerging destination are understood by local stakeholders who are not directing sector development. This further outlines how these groups employ knowledge from their home context to ground and reconcile their hopes and concerns for the impacts posed by medical tourism.
doi:10.1186/s12939-015-0147-1
PMCID: PMC4320816  PMID: 25643761
Medical tourism; Health equity; Barbados; Focus groups; Thematic analysis; Health services; International medical travel; Caribbean; Qualitative methods
7.  Social determinants of health in the Mixtec and Zapotec community in Ventura County, California 
Introduction
There are an estimated 165,000 indigenous Mexicans living in California, including Mixtec and Zapotec immigrant farm workers. Because many of these immigrants speak only their native non-written languages, there is little information about the needs of this community. An academic-community partnership research team developed a survey to assess basic needs that are known to be social determinants of health in the Mixtec and Zapotec community in Ventura County.
Methods
In summer 2013, Spanish-Mixteco and Spanish-Zapoteco bilingual promotoras conducted surveys in Spanish, Mixteco and Zapoteco in the greater Oxnard area in Ventura County, California to assess the following basic needs: ability of adults and children to obtain health services; household needs regarding work opportunities, food, housing, transportation, safety and education; and discrimination. Independent variables included respondent characteristics such as age, gender, marital status, living part of the year in another city, and household characteristics such as Spanish spoken in the household, number of household members and number of health care providers/agencies used. Several sets of analyses examined the relationship between basic needs and independent variables.
Results
Respondents (N = 989) reported insufficient employment opportunities (74%), food for the family (59%) or housing (48%), lack of transportation (59%), and discrimination or bullying (34%). Most reported access to medical care for children (90%), but only 57% of respondents were able to get health care for themselves.
Conclusions
Many basic needs in the Mixtec and Zapotec community in Ventura County are unmet. It will require many different resources and services to address the needs of this community and to overcome longstanding inequities that are experienced by immigrant farm workers. Our findings will guide the development of future health programs and will serve as a baseline to evaluate the impact of services to improve the health conditions in this community.
doi:10.1186/s12939-015-0148-0
PMCID: PMC4320817  PMID: 25643835
Household survey; Indigenous farm workers; Community-engaged research; Promotoras; Social determinants of health
8.  Time trends in socio-economic inequalities in the lack of access to dental services among children in Spain 1987-2011 
Introduction
Adult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children’s dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987–2011.
Methods
Pooled data from eight editions of the Spanish National Health Survey for the years 1987–2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children’s household.
Results
The mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80).
Conclusion
There has been a reduction in children’s lack of access to dentists in Spain over the period 1987–2011. However, this reduction has not corrected the socioeconomic inequalities in children’s access to dentists in Spain.
doi:10.1186/s12939-015-0132-8
PMCID: PMC4316659  PMID: 25636711
Inequalities in lack of access; Dental services; Children; Spanish National Health System
9.  Promoting the inclusion of Afghan women and men in research: reflections from research and community partners involved in implementing a ‘proof of concept’ project 
Introduction
With mounting evidence that poor maternal and child health outcomes are related to the social determinants of health, researchers need to engage with vulnerable and isolated communities to gather the evidence that is essential to determine appropriate solutions. Conventional research methods may not ensure the degree and quality of participation that is necessary for meaningful study findings. Participatory methods provide reciprocal opportunities for often excluded communities to both take part in, and guide the conduct of research.
Method/design
The Having a baby in a new country research project was undertaken to provide evidence about how women and men of refugee background experience health services at the time of having a baby. This two year, multifaceted proof of concept study comprised: 1) an organisational partnership to oversee the project; 2) a community engagement framework including: female and male Afghan community researchers, community and sector stakeholder advisory groups and community consultation and engagement.
Discussion
Inclusive research strategies that address power imbalances in research, and diversity of and within communities, are necessary to obtain the evidence required to address health inequalities in vulnerable populations. Such an approach involves mindfully adapting research processes to ensure that studies have regard for the advice of community members about the issues that affect them. Researchers have much to gain by committing time and resources to engaging communities in reciprocal ways in research processes.
doi:10.1186/s12939-015-0145-3
PMCID: PMC4316798  PMID: 25637274
Health inequalities; Community engagement; Partnerships; Refugee health
10.  Unexplained health inequality – is it unfair? 
Introduction
Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health – a difference in health – is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question – whether unexplained health inequality is unfair – determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity.
Methods
We use the American sample of the 2002–03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity.
Results
Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable).
Conclusions
The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-015-0138-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-015-0138-2
PMCID: PMC4318200  PMID: 25637028
Health inequalities; Health disparities; Health inequities; Measurement; Ethics
11.  Sex and gender matter in health research: addressing health inequities in health research reporting 
Attention to the concepts of ‘sex’ and ‘gender’ is increasingly being recognized as contributing to better science through an augmented understanding of how these factors impact on health inequities and related health outcomes. However, the ongoing lack of conceptual clarity in how sex and gender constructs are used in both the design and reporting of health research studies remains problematic. Conceptual clarity among members of the health research community is central to ensuring the appropriate use of these concepts in a manner that can advance our understanding of the sex- and gender-based health implications of our research findings. During the past twenty-five years much progress has been made in reducing both sex and gender disparities in clinical research and, to a significant albeit lesser extent, in basic science research. Why, then, does there remain a lack of uptake of sex- and gender-specific reporting of health research findings in many health research journals? This question, we argue, has significant health equity implications across all pillars of health research, from biomedical and clinical research, through to health systems and population health.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-015-0144-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-015-0144-4
PMCID: PMC4320818  PMID: 25637131
Sex and gender; Health equity; Methodology; Knowledge dissemination
12.  A qualitative study on why did the poorly-educated Chinese elderly fail to attend nurse-led case manager clinic and how to facilitate their attendance 
Objectives
This study explored the views, barriers and facilitators of the poorly-educated elderly who were non-attendee of the nurse-led case manager clinic. The case managers provide assessment for diabetes complication screening and can refer patients to the appropriate multidisciplinary team in public outpatient primary care setting.
Methods
We adopted qualitative research method by individual semi-structured face to face interviews. Nineteen Chinese type 2 diabetes mellitus subjects aged ≥ 60 who failed to attend the nurse-led case manager clinic were interviewed. They all came from a socially deprived urban district in Hong Kong. Content and thematic analysis was performed.
Results
Seven men and twelve women aged 60 to 89 were interviewed. Nine of them received no formal education and ten of them attended up to primary school. The reasons for non-attendance included attitude and poor knowledge towards diabetes complication screening and confusion of the nurse-led clinic as an educational talk. Most respondents could not understand the reason for the screening of diabetic complications, the concept of multidisciplinary care and the procedure and outcomes of nurse assessment. Five respondents were unable to follow multiple appointments because they could not read. Other reasons included physical barriers and comorbidity, family and financial constraint. They either had a tight daily schedule because of the need to take care of family members, or the family members who brought them to clinic had difficulty in attending multiple appointments. Enhanced understanding of the importance and procedure of diabetes multidisciplinary management, a flexible appointment system and a single clear appointment sheet may facilitate their attendance.
Conclusion
Poorly-educated Chinese elderly with DM and their care givers faced physical, social and psychological barriers when attending the nurse-led case manager clinic. Strategies targeting on their low literacy include effective communication and education by health care professionals to arrive a shared understanding of care plan as well as a flexible appointment and schedule system.
doi:10.1186/s12939-015-0137-3
PMCID: PMC4322441  PMID: 25636857
Nurse led clinic; Primary health care; Diabetes mellitus type 2; Patient dropout; Aged
13.  Catastrophic health expenditures and its inequality in elderly households with chronic disease patients in China 
Background
Although numerous studies examine catastrophic health expenditures (CHE) worldwide, most focus on whole populations rather than specific vulnerable groups. This study analyzes the extent, associated factors and inequality of CHE in elderly household with chronic disease patients in China.
Methods
Data were obtained from a nationally representative elderly household survey—the China Health and Retirement Longitudinal Study—that was conducted by the National School of Development of Peking University in 2011. An elderly household with chronic disease patients is defined by ≥ 1 chronic disease patient who is ≥ 45 years of age. CHE was measured according to the proportion of out-of-pocket health payments to non-food household expenditures. The associated factors of CHE were estimated using ordinary least square and logistic regression modeling. CHE inequality was measured according to the concentration index (CI) and its decomposition.
Results
CHE incidence and intensity were relatively high among elderly households with chronic disease patients. The main associated factors of CHE include household size, having members > 65 years, having members with ≥ 2 chronic diseases, per capita income, and elderly household members demonstrating healthcare-seeking behaviors. Healthcare insurance did not significantly affect CHE risk. Disproportionate concentration of CHE was noted among elderly households, and poor elderly households demonstrated a higher probability of experiencing CHE. Factors such as household size, per capita income, having members > 65 years, and having members with ≥ 2 chronic diseases are major and positive contributors to CHE inequality. Some inpatient and outpatient services are negatively contributed to CHE inequality,suggesting that the unequal usage of such services reduces CHE inequality among elderly households with chronic disease patients.
Conclusion
Policy efforts should focus on improving financial protection and relieving the economic burden of disease in elderly households. The government should increase income subsidies and optimize social health insurance programs, thereby reducing CHE and alleviating CHE inequality among elderly households in China.
doi:10.1186/s12939-015-0134-6
PMCID: PMC4304672  PMID: 25599715
Catastrophic health expenditures; Inequality; Elderly households; China
14.  A tertiary approach to improving equity in health: quantitative analysis of the Māori and Pacific Admission Scheme (MAPAS) process, 2008–2012 
Introduction
Achieving health equity for indigenous and ethnic minority populations requires the development of an ethnically diverse health workforce. This study explores a tertiary admission programme targeting Māori and Pacific applicants to nursing, pharmacy and health sciences (a precursor to medicine) at the University of Auckland (UoA), Aotearoa New Zealand (NZ). Application of cognitive and non-cognitive selection tools, including a Multiple Mini Interview (MMI), are examined.
Methods
Indigenous Kaupapa Māori methodology guided analysis of the Māori and Pacific Admission Scheme (MAPAS) for the years 2008–2012. Multiple logistic regression models were used to identify the predicted effect of admission variables on the final MAPAS recommendation of best starting point for success in health professional study i.e. ‘CertHSc’ (Certificate in Health Sciences, bridging/foundation), ‘Bachelor’ (degree-level) or ‘Not FMHS’ (Faculty of Medical and Health Sciences). Regression analyses controlled for interview year, gender and ancestry.
Results
Of the 918 MAPAS interviewees: 35% (319) were Māori, 58% (530) Pacific, 7% (68) Māori/Pacific; 71% (653) school leavers; 72% (662) females. The average rank score was 167/320, 40–80 credits below guaranteed FMHS degree offers. Just under half of all interviewees were recommended ‘CertHSc’ 47% (428), 13% (117) ‘Bachelor’ and 38% (332) ‘Not FMHS’ as the best starting point. Strong associations were identified between Bachelor recommendation and exposure to Any 2 Sciences (OR:7.897, CI:3.855-16.175; p < 0.0001), higher rank score (OR:1.043, CI:1.034-1.052; p < 0.0001) and higher scores on MAPAS mathematics test (OR:1.043, CI:1.028-1.059; p < 0.0001). MMI stations had mixed associations, with academic preparation and career aspirations more consistently associated with recommendations.
Conclusions
Our findings raise concerns about the ability of the secondary education sector to prepare Māori and Pacific students adequately for health professional study. A comprehensive tertiary admissions process using multiple tools for selection (cognitive and non-cognitive) and the provision of alternative entry pathways are recommended for indigenous and ethnic minority health workforce development. The application of the MMI within an equity and indigenous cultural context can support a holistic assessment of an applicant’s potential to succeed within tertiary study. The new MAPAS admissions process may provide an exemplar for other tertiary institutions looking to widen participation via equity-targeted admission processes.
doi:10.1186/s12939-015-0133-7
PMCID: PMC4319228
Māori; Pacific; Indigenous; Ethnic minority; Health workforce development; Tertiary admission; Multiple mini interview; Widening participation; Secondary education
15.  Perceived barriers to healthcare for persons living in poverty in Quebec, Canada: the EQUIhealThY project 
Introduction
Ensuring access to timely and appropriate primary healthcare for deprived patients is an issue facing all countries, even those with universal healthcare systems. There is a paucity of information on how patients living in a context of material and social deprivation perceive barriers in the healthcare system. This study combines the perspectives of persons living in poverty and of healthcare providers to explore barriers to responsive care for underserved persons with a view to developing equity-focused primary care.
Methods
In this participatory action research we used photovoice, together with a method known as ‘merging of knowledge and practice’ developed by ATD Fourth World, an international community organization working to eradicate poverty. The study was conducted in two teaching primary care practices in the Canadian province of Quebec. Participants consisted of 15 health professionals and six members of ATD Fourth World; approximately 60 group meetings were held. Data were analyzed through thematic analysis, in part with the involvement of persons living in poverty.
Results
Three main barriers to responsive care in a context of poverty were highlighted by all participants: the difficult living conditions of people living in poverty, the poor quality of interactions between providers and underserved patients, and the complexity of healthcare system organization and functioning.
Conclusion
Our research revealed that unhealthy living conditions prevent persons living in poverty from accessing quality healthcare and maintaining good health. Also, the complexity of the healthcare system’s organization and functioning has a negative impact on the interactions with healthcare providers. Changes in policy and practice are needed to address those barriers and to achieve greater equity and provide more responsive care for persons living in poverty.
doi:10.1186/s12939-015-0135-5
PMCID: PMC4300157  PMID: 25596816
Primary healthcare; Equity; Poverty; Quality of care; Participatory research; Social assistance
16.  Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem? 
Background
Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.
Methods
The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.
Results
Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.
Conclusion
Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
doi:10.1186/s12939-014-0130-2
PMCID: PMC4300159  PMID: 25595036
Voluntary health insurance; Universal coverage; Enrolment; Premium; Affordability; Ghana
17.  Exploring the social, emotional and behavioural development of preschool children: is Glasgow different? 
Background
Glasgow City has poorer adolescent and adult health outcomes in comparison to demographically similar cities in England and the rest of Scotland. Until now, little exploration of differences in child development between Glasgow and other areas has been made. The authors hypothesized that the poorer health outcomes and lifestyle behaviours of adults, coupled with relative economic deprivation, may impact on child social, emotional and behavioural development, compared with children from other parts of Scotland.
Methods
Data from the Growing Up in Scotland national birth cohort study were used. Differences between Strengths and Difficulties Questionnaire (SDQ) scores and child and family characteristics of children living in the Greater Glasgow and Clyde (GGC) Health board vs. other health boards were examined. Logistic regression and linear regression models were fitted in order to explore independent associations between health board and SDQ raw and banded scores, respectively, whilst controlling for other contributing factors.
Results
Children in GGC were demographically different from those in other areas of Scotland, being significantly more likely to live in the most deprived areas, yet no difference was found in relation to the mental health of preschool-aged children in GGC. Children in GGC had slightly better SDQ Conduct Problems scores once demographic factors were controlled for.
Conclusions
At 46 months, there does not appear to be any difference in Glasgow with regards to social, emotional and behavioural development. Glaswegian children appear to have slightly fewer conduct problems at this age, once demographics are taken into account. A range of theories are put forward as to why no differences were found, including the inclusion of areas adjacent to Glasgow City in the analysis, sleeper effects, and rater bias.
doi:10.1186/s12939-014-0129-8
PMCID: PMC4301859  PMID: 25596752
Child development; Child; Preschool; Poverty
18.  Socio-economic factors related with the subjective well-being of the rural elderly people living independently in China 
Background
Many Chinese elderly increasingly face the serious problem of the “empty nest” phenomenon. The elderly living independently, also called empty-nest elderly, refers to elderly people living alone whose children left home. However few studies concerned about the subjective well-being (SWB) of the elderly living independently.
Methods
This study employs The Memorial University of Newfoundland Scale of Happiness (MUNSH) to explore the SWB of the elderly living independently in rural areas of Wenzhou, a relatively developed region in China. 536 sampled are randomly selected.
Results
The results indicate that participants obtained low scores in positive affect, positive experience, and the total SWB score, but high scores in negative affect and negative experience. Age, low education, poor health condition and little income were found to be negatively correlated with SWB. The SWB score of the elderly living with a spouse is higher than those who divorced or lost their spouse and the score of women is lower than that of men. In addition, the survey revealed that children’s support has a positive influence on the SWB of the rural elderly living independently.
Conclusions
The elderly living independently in rural Wenzhou, China have unfavorable SWB. Poor socio-economic statuses are negative impact factors. But the children’s support can help to improve. Special attention is needed to those with lower socio-economic status and less children’s support.
doi:10.1186/s12939-015-0136-4
PMCID: PMC4299131  PMID: 25595196
MUNSH; SWB; The elderly living independently; Wenzhou; China
19.  A cross sectional survey on social, cultural and economic determinants of obesity in a low middle income setting 
Introduction
Obesity is an increasing problem in South Asian countries and Sri Lanka is no exception. The socioeconomic determinants of obesity in Sri Lanka, and in neighbouring countries are inadequately described. Aim was to describe social, cultural and economic determinants of obesity in a representative sample from Kalutara District in Sri Lanka.
Methods
This was a cross sectional descriptive study conducted among adults aged 35–64 years. A representative sample was selected using stratified random cluster sampling method from urban, rural and plantation sectors of Kalutara District. Data were collected using a pre-tested questionnaire. A body mass index of 23.01 kg/m2-27.50 kg/m2 was considered as overweight and ≥27.51 kg/m2 as obese. Waist circumference (WC) of ≥ 90 cm and ≥80 cm was regarded as high for men and women respectively. Significance of prevalence of obesity categories across different socio-economic strata was determined by chi square test for trend.
Results
Of 1234 adults who were screened, age and sex adjusted prevalence of overweight, obesity and abdominal obesity (high WC) were 33.2% (male 27.3%/female 38.7%), 14.3% (male 9.2%/female 19.2%) and 33.6% (male 17.7%/female 49.0%) respectively. The Muslims had the highest prevalence of all three obesity categories. Sector, education, social status quintiles and area level deprivation categories show a non linear social gradient while income shows a linear social gradient in all obesity categories, mean BMI and mean WC. The differences observed for mean BMI and mean WC between the lowest and highest socioeconomic groups were statistically significant.
Conclusion
There is a social gradient in all three obesity categories with higher prevalence observed in the more educated, urban, high income and high social status segments of society. The higher socioeconomic groups are still at a higher risk of all types of obesity despite other public health indicators such as maternal and infant mortality displaying an established social gradient.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-015-0140-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-015-0140-8
PMCID: PMC4300585  PMID: 25595202
Prevalence of obesity; Socioeconomic and cultural determinants of obesity; Obesity in plantation sector; Obesity in Muslims
20.  How the government intervention affects the distribution of physicians in Turkey between 1965 and 2000 
Introduction
One of the main weaknesses of the health system in Turkey is the uneven distribution of physicians. The diversity among geographical districts was huge in the beginning of the 1960s. After the 1980s, the implementation of a two-year compulsory service for newly graduated physicians is an interesting and specific experience for all countries. The aim of this study is to analyse the distribution of physicians, GPs and specialists between the years 1965-2000 and the efficiency of the strict 15 year government intervention (1981-1995).
Methods
The data used in this study includes the published data by the Ministry of Health and The State Institute of Statistics between the years 1965–2000. Covering 35 years for total physicians, GPs and specialists, Gini coefficients are calculated so as to observe the change in the distribution. In order to measure the efficiency of government intervention, Gini index belonging to the previous 15 years (first period-1965 to 1980) and the last 15 years (second period) of 1981 when the compulsory service was enacted is also analysed including the statistical tests.
Results
In 1965, the Gini for total physician is quite high (0.47), and in 2000 it decreases considerably (0.20). In 1965, the Gini for GPs and the Gini for specialists is 0.44 and 0.52, respectively and in 2000 these values decrease to 0.13 and 0.28, respectively. It is observed that, with this government intervention, the level of diversity has decreased dramatically up to 2000. Regarding to regression, the rate of decrease in Gini index in the second period is higher for the GPs than that of the specialists.
Conclusion
The inequalities in the distribution between GPs and specialists are significantly different; inequality of specialist distribution is higher than the GP. The improvement of the inequality in the physician distribution produced by the market mechanism shows a long period when it is left to its own devices. It is seen that the compulsory service policy is efficient since the physician distribution has improved significantly. The government intervention provides a faster improvement in the GP distribution.
doi:10.1186/s12939-014-0131-1
PMCID: PMC4307150  PMID: 25566790
Distribution of physicians; Government intervention on health; Compulsory service for physicians
21.  Annotated bibliography on participatory consultations to help aid the inclusion of marginalized perspectives in setting policy agendas 
The purpose of this bibliography is to present studies from peer-reviewed and grey literature that used consultations and other participatory strategies to capture a community’s perspective of their health priorities, and of techniques used to elevate participation from the implementation phase to a more upstream phase of prioritization, policymaking and agenda setting. The focus here is of those studies that worked with marginalized populations or sub-populations. This bibliography contains four areas of research. It begins by first offering some philosophical and conceptual frameworks that link participatory interventions with inclusive policy making or agenda setting, and a rationale for prioritizing marginalized populations in such an undertaking. After situating ourselves in this manner, the second section looks at various participatory instruments for participatory consultations, for reaching out to marginalized populations, and for communicating the results to policymakers. Two sets of distinctions are made here: one between external (non-invitation) and internal (stifling of opinions) exclusion, and between mere participation and from active inclusion within consultations and within the policies. In the third section, examples of consultations that created or changed policy in various jurisdictions are shared, followed by a final section on a reflective and evaluative look at the recruitment, instruments and examples. An earlier iteration of this bibliography was created to assist a multi-country research project by the author to inform the UN Post-2015 development framework of the views of several diverse and highly marginalized populations around the world on their health-related priorities.
doi:10.1186/s12939-014-0124-0
PMCID: PMC4279799  PMID: 25532831
Participation; Consultations; Inclusion; Marginalization; Post-2015; MDGs; Priorities; Frameworks; Methods
22.  Indicators for Universal Health Coverage: can Kenya comply with the proposed post-2015 monitoring recommendations? 
Introduction
Universal Health Coverage (UHC), referring to access to healthcare without financial burden, has received renewed attention in global health spheres. UHC is a potential goal in the post-2015 development agenda. Monitoring of progress towards achieving UHC is thus critical at both country and global level, and a monitoring framework for UHC was proposed by a joint WHO/World Bank discussion paper in December 2013. The aim of this study was to determine the feasibility of the framework proposed by WHO/World Bank for global UHC monitoring framework in Kenya.
Methods
The study utilised three documents—the joint WHO/World Bank UHC monitoring framework and its update, and the Bellagio meeting report sponsored by WHO and the Rockefeller Foundation—to conduct the research. These documents informed the list of potential indicators that were used to determine the feasibility of the framework. A purposive literature search was undertaken to identify key government policy documents and relevant scholarly articles. A desk review of the literature was undertaken to answer the research objectives of this study.
Results
Kenya has yet to establish an official policy on UHC that provides a clear mandate on the goals, targets and monitoring and evaluation of performance. However, a significant majority of Kenyans continue to have limited access to health services as well as limited financial risk protection. The country has the capacity to reasonably report on five out of the seven proposed UHC indicators. However, there was very limited capacity to report on the two service coverage indicators for the chronic condition and injuries (CCIs) interventions. Out of the potential tracer indicators (n = 27) for aggregate CCI-related measures, four tracer indicators were available. Moreover the country experiences some wider challenges that may impact on the implementation and feasibility of the WHO/World Bank framework.
Conclusion
The proposed global framework for monitoring UHC will only be feasible in Kenya if systemic challenges are addressed. While the infrastructure for reporting the MDG related indicators is in place, Kenya will require continued international investment to extend its capacity to meet the data requirements of the proposed UHC monitoring framework, particularly for the CCI-related indicators.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-014-0123-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-014-0123-1
PMCID: PMC4296682  PMID: 25532714
Universal health coverage; WHO/World Bank framework; Monitoring; Indicators; MDGs; Chronic conditions and injuries; Kenya
23.  Duration of residence and psychotropic drug use in recently settled refugees in Sweden - a register-based study 
Introduction
Recently settled refugee populations have consistently been reported to have high rates of mental health problems, particularly Post-traumatic stress disorder, depression, and anxiety disorders. The aim of this study was to investigate psychotropic drug use among young adult refugees according to duration of residence during the first 10 years in Sweden.
Methods
Cross-sectional register study of a national cohort of 43 403 refugees and their families (23–35 years old) from Iraq, Iran, Eritrea, Ethiopia, Somalia and Afghanistan and a comparison population of 1.1 million Swedish-born residents. Logistic regression was used to assess the association between duration of residence in Sweden and the dispensing of at least one psychotropic medication during 2009 in four categories (any drug, neuroleptics, antidepressants and anxiolytics/hypnotics), adjusting for age, gender and domicile.
Results
Rates of dispensed psychotropic drugs among recently settled refugees were low, compared to the Swedish-born, with an increase with duration of residence. For refugee men and women from Iraq/Iran who had resided for 0–3 years the adjusted ORs compared to Swedish natives, were 0.83 (95% CI 0.77-0.90) and 0.48 (0.44-0.53) respectively; for men and women from the Horn of Africa the ORs were 0.50 (0.42-0.61) and 0.36 (0.30-0.41) respectively. After 7–10 years of residence, the ORs in these refugee groups approached the Swedish comparison population. Refugees from Afghanistan presented ORs similar to the Swedish-born, with no consistent trend by duration of residence. Women from the Horn of Africa and Iraq/Iran consumed less psychotropic drugs compared with men from these regions of origin, relative to the Swedish-born (p < 0.01). The ORs for dispensed neuroleptics were similar between the different refugee study groups, while the ORs for dispensed antidepressants differed fourfold between the group with the lowest (Horn of Africa) and the highest (Afghanistan).
Conclusion
The rates of dispensed psychotropic drugs in the newly settled refugee populations in this study were low, with an increase with longer duration of residence. This pattern suggests barriers to access mental health care. Interventions that can lower these barriers are needed to enable newly settled refugees to access mental health care on equal terms with the native population.
doi:10.1186/s12939-014-0122-2
PMCID: PMC4297375  PMID: 25526935
Refugee; Migration; Mental health; Psychotropic drugs; Acculturation; Access
24.  Differences in health care utilisation between elderly from ethnic minorities and ethnic Dutch elderly 
Introduction
In the Netherlands, as in other Western countries, ethnic minority elderly are more often in poorer health than the indigenous population. The expectation is that this health disadvantage results in more frequent use of health care services.
Methods
We studied registered data on the proportion of health care receivers, frequency of use, and health care costs collected by a major Dutch health insurance company in 2010. Data from 10,316 Turkish, 14,490 Moroccan, 8,619 Surinamese, and 1,064 Moluccan adults aged 55 years and older were compared with data from a sample of 33,725 ethnic Dutch older adults.
Results
Unadjusted and adjusted (for age and gender) analyses showed the following. Moluccans had lower usage levels for all types of health care services. Use of primary health care facilities was higher for Turks, Moroccans, and Surinamese compared with the ethnic Dutch, with the exception that physical therapy was less frequently used among the Turks and Moroccans. Use of hospital care was lower, except for the Surinamese, who had a similar level of usage to that of the ethnic Dutch.
Conclusions
The health disadvantage previously observed within most ethnic minority elderly populations does not result in an overall more frequent use of health care services. Further research is needed for the interpretation of the ethnic variations in health care use as potentially inequitable, by taking medical need, patient treatment preferences, and treatment adherence into account.
doi:10.1186/s12939-014-0125-z
PMCID: PMC4297420  PMID: 25527126
Health care usage; Ethnic minorities; Elderly
25.  Road to better health and integration: a Delphi study on health service models for Hong Kong migrants 
Introduction
In Hong Kong, migrants arriving from Mainland China often have multiple roles and responsibilities while adapting to new lives in their host destination. This paper explored the factors that contribute to the inequity in health services utilisation experienced by these migrants; and, identified the elements that could constitute an effective health delivery model to address the service gap.
Methods
Site visits and a focus group discussion (n = 13) were held with both public and private health providers before a number of innovative health delivery models were formulated. They were then circulated among the panel in two further rounds of Delphi survey (n = 11) from March-April 2012 to systematically collect opinions and select the most endorsed health service models to serve this target population.
Results
Focus group members perceived that most migrants were unaware of, or even ignored, their own physical and mental health needs, and had low utilisation of healthcare services, because of their pre-occupation with daily chores and hardship as well as differing health values, practices and expectations. They further identified that the structural issues such as the healthcare setting or the operation of current service provisions had failed to meet migrants’ health needs. Consequently, four new service models that incorporated professional advice and empowerment, which were identified as the two most important elements, were put forward. Thus, the model of having a nurse with social work training, supported by volunteer groups, was selected as the best option to familiarise and empower patients within the labyrinth of local healthcare services.
Conclusion
Implementation of a social empowerment model by way of targeted support and specific health information is recommended. Further evaluation of this model is needed to understand its effectiveness for improving health literacy and health status in this disadvantaged group in the long term.
doi:10.1186/s12939-014-0127-x
PMCID: PMC4279966  PMID: 25527222
Healthcare delivery; Access to Health Care; Health Policy; Migrants; Delphi technique

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