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The Korean government sought to include dental implant services for the elderly in the benefits package of the national health insurance. In 2014, the Citizens’ Jury was held to discuss the topic, during which thirty jurors, randomly selected from the 2665 applicants, participated in a day-long deliberation process after having an information session on the topic by a team of experts. There was a substantial shift in opinion during the deliberation session toward a more cost-conscious view. Most jurors supported limiting the coverage of dental implant to only one tooth per individual given the extent of the financial burden that will be imposed on the population. They opposed covering implant services for the front teeth, given that the implant of front teeth generally serves aesthetic purposes rather than restoring mastication function. The government’s final decision in 2014 was to offer coverage up to two teeth, regardless of tooth location. This scheme based on the jury’s recommendations in 2014 has been implemented without policy failure to date, which shows that the lay public can meaningfully contribute to a decision-making process regarding controversial agendas such as benefits packages for expensive health services.

Background Overcrowding of high-level health facilities is a major concern in a Vietnamese health system. This may increase an economic burden to the households since health insurance is still insufficient in providing financial risk protection. This paper sought to examine the association between the use of high-level health facilities and household-level expenditure status such as out-of-pocket (OOP), and catastrophic expenditure on health, as well as a moderating effect of health insurances in rural and urban districts of Vietnam. Methods Data utilized a health system community survey collected between 2015 and 2017 in two districts of Vietnam (one from rural area in northern part, and the other one from urban area in sourthern part). The world Health Organization’s definition of catastrophic expenditure was used. Multivariate tobit and logistic regression were employed for catastrophic expenditure and OOP respectively. Interaction term between health insurance status and visit frequency in high-level facilities was included to investigate the moderating effect of health insurance. Results Health insurance status was associated with neither OOP health expenditure nor catastrophic expenditure occurrence, whereas visit frequency of high-level health facilities was strongly associated with both outcomes in both districts(e.g., for catastrophic expenditure, ORs are 1.77 and 1.30 in northern and southern district respecitvely. P values are

Background: We aimed to report the prevalence and correlates of high-risk alcohol consumption and types of alcoholic beverages. Methods: The baseline data of the Health Examinees-Gem (HEXA-G) study participants, including 43,927 men and 85,897 women enrolled from 2005 through 2013, were used for analysis. Joinpoint regression was performed to estimate trends in the age-standardized prevalence of alcohol consumption. Associations of demographic and behavioral factors, perceived health-related effects, social relationships, and the diagnostic history of diseases with alcohol consumption were assessed using multinomial logistic regression. Results: The prevalence of alcohol consumption remained higher in men during the study period and increased in women. The amount of alcohol consumed has increased in women, especially that from beer and makgeolli, a traditional Korean fermented rice wine. Older participants were less likely to be high-risk drinkers (men and women who drink more than 40 or 20 g/day of alcohol, respectively) and drink Soju, a distilled liquor, and beer, and more likely to drink makgeolli. Educational level was negatively associated with high-risk drinking. However, it was positively associated with the consumption of strong spirits and wine. Smoking was associated with high-risk drinking and the consumption of soju and strong spirits. Engaging in regular exercise and having stress were associated with drinking all types of beverages except for soju. Conclusions: Sex-specific trends in alcohol consumption were influenced by demographic, behavioral, and perceived health-related factors. The findings will help improve the understanding of alcohol-related problems and provide evidence for establishing country-specific policies and campaigns in Korea.

The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and contextualisation, and behavioural science evidence and theory on public health interventions from a range of sources, we outline evidence for a range of institutional measures and behaviour-change measures. We cite examples of measures adopted by a range of countries, but especially jurisdictions that have, thus far, achieved low numbers of COVID-19 deaths and limited community transmission of severe acute respiratory syndrome coronavirus 2. Finally, we highlight gaps in knowledge where research should be undertaken. As countries consider long-term measures, there is an opportunity to learn, improve the response and prepare for future pandemics.

Most countries have implemented restrictions on mobility to prevent the spread of Coronavirus disease-19 (COVID-19), entailing considerable societal costs but, at least initially, based on limited evidence of effectiveness. We asked whether mobility restrictions were associated with changes in the occurrence of COVID-19 in 34 OECD countries plus Singapore and Taiwan. Our data sources were the Google Global Mobility Data Source, which reports different types of mobility, and COVID-19 cases retrieved from the dataset curated by Our World in Data. Beginning at each country’s 100th case, and incorporating a 14-day lag to account for the delay between exposure and illness, we examined the association between changes in mobility (with January 3 to February 6, 2020 as baseline) and the ratio of the number of newly confirmed cases on a given day to the total number of cases over the past 14 days from the index day (the potentially infective ‘pool’ in that population), per million population, using LOESS regression and logit regression. In two-thirds of examined countries, reductions of up to 40% in commuting mobility (to workplaces, transit stations, retailers, and recreation) were associated with decreased cases, especially early in the pandemic. Once both mobility and incidence had been brought down, further restrictions provided little additional benefit. These findings point to the importance of acting early and decisively in a pandemic.

Background Although social capital has been shown to be one of the important social determinants of health, the association between social trust and the risk of cardiovascular disease (CVD) is not clear yet. We aimed to investigate the association of social trust with CVD risk using a large Korean population based data. Methods The data of this study was derived from the Korean National Health Insurance Service database. Community-level social trust was determined from the Korean Community Health Survey. The study population consisted of 2,156,829 participants. According to social trust index measured in the area of residence during 2011, participants were followed-up from 1 January 2012 to 31 December 2016. Multivariate Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD risk according to quintiles of social trust. Results Compared to participants with the lowest quintile of social trust, those within the highest quintile had lower risk for CVD (aHR 0.91, 95% CI = 0.89 to 0.93), CHD (aHR 0.92, 95% CI = 0.89 to 0.95), and stroke (aHR 0.90, 95% CI = 0.87 to 0.93). The risk-reducing association of high social trust on CVD risk was preserved after additional adjustments for lifestyle behaviors including smoking, alcohol consumption, and physical activity. Conclusion Higher social trust was associated with reduced risk of CVD even after considering lifestyle behaviors. Social trust in a community level is an important determinant of CVD and enhancing social trust may lead to reduced risk of CVD.

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

Background Whether community level social capital is associated with mortality within an Asian population is yet unclear. Methods The study population was derived from the Korean National Health Insurance Service-National Sample Cohort. A total of 636,055 participants were followed-up during 2012–2013 for deaths from all causes, cardiovascular disease (CVD), cancer, and other causes. Community level social trust and reciprocity at the administrative district level were derived from the Korean Community Health Survey. Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for mortality according to levels of community level social trust and reciprocity. Results Compared to participants who reside in areas within the lower half of community level social trust, those who reside in areas within the upper half had lower risk of death from all causes (aHR 0.84, 95% CI 0.78–0.89), CVD (aHR 0.82, 95% CI 0.67–0.99), and cancer (aHR 0.85, 95% CI 0.73–0.98). Similarly, residing in areas in the upper half of community level social reciprocity was associated with reduced risk for all-cause mortality (aHR 0.80, 95% CI 0.75–0.86). The protective association of high community level social trust and reciprocity on mortality remained after additional adjustments for smoking, alcohol intake, and physical activity. Conclusions Residing in areas with high community level social trust and reciprocity may be associated with better population health status.

Background In South Korea, the number of coronavirus disease (COVID-19) cases has declined rapidly and much sooner than in other countries. South Korea is one of the most digitalized countries in the world, and YouTube may have served as a rapid delivery mechanism for increasing public awareness of COVID-19. Thus, the platform may have helped the South Korean public fight the spread of the disease. Objective The aim of this study is to compare the reliability, overall quality, title–content consistency, and content coverage of Korean-language YouTube videos on COVID-19, which have been uploaded by different sources. Methods A total of 200 of the most viewed YouTube videos from January 1, 2020, to April 30, 2020, were screened, searching in Korean for the terms “Coronavirus,” “COVID,” “Corona,” “Wuhan virus,” and “Wuhan pneumonia.” Non-Korean videos and videos that were duplicated, irrelevant, or livestreamed were excluded. Source and video metrics were collected. The videos were scored based on the following criteria: modified DISCERN index, Journal of the American Medical Association Score (JAMAS) benchmark criteria, global quality score (GQS), title–content consistency index (TCCI), and medical information and content index (MICI). Results Of the 105 total videos, 37.14% (39/105) contained misleading information; independent user–generated videos showed the highest proportion of misleading information at 68.09% (32/47), while all of the government-generated videos were useful. Government agency–generated videos achieved the highest median score of DISCERN (5.0, IQR 5.0-5.0), JAMAS (4.0, IQR 4.0-4.0), GQS (4.0, IQR 3.0-4.5), and TCCI (5.0, IQR 5.0-5.0), while independent user–generated videos achieved the lowest median score of DISCERN (2.0, IQR 1.0-3.0), JAMAS (2.0, IQR 1.5-2.0), GQS (2.0, IQR 1.5-2.0), and TCCI (3.0, IQR 3.0-4.0). However, the total MICI was not significantly different among sources. “Transmission and precautionary measures” were the most commonly covered content by government agencies, news agencies, and independent users. In contrast, the most mentioned content by news agencies was “prevalence,” followed by “transmission and precautionary measures.” Conclusions Misleading videos had more likes, fewer comments, and longer running times than useful videos. Korean-language YouTube videos on COVID-19 uploaded by different sources varied significantly in terms of reliability, overall quality, and title–content consistency, but the content coverage was not significantly different. Government-generated videos had higher reliability, overall quality, and title–content consistency than independent user–generated videos.

OBJECTIVE: To investigate the temporal trend of socioeconomic and rural‐urban disparities and geographical variation in the utilization of antenatal care (ANC) services in India before and throughout the Millennium Development Goals era. DATA SOURCES/STUDY SETTING: For this temporal analysis, secondary data from the Indian National Family Health Surveys between 1998 and 2015 (Waves 2, 3, and 4) were used. STUDY DESIGN: We analyzed the trend in inequality for at least one and four ANC visits to a health care professional (ANC1+ and ANC4+, respectively) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the temporal trend and the relative contribution of communities and states to the overall variation in ANC1+ and ANC4+. DATA COLLECTION/EXTRACTION METHODS: Data on utilization of ANC services for the last birth of women aged 15‐49 years during the three or five years preceding the survey (depending on the survey year) were used. PRINCIPAL FINDINGS: Educational and wealth inequality in ANC1+ and ANC4+ worsened between 1998 and 2005 and improved between 2005 and 2015 (for ANC4+, OR [95% CI] = 0.22 [0.19‐0.25] in Wave 2; OR [95% CI] = 0.19 [0.17‐0.22] in Wave 3; and OR [95% CI] = 0.38 [0.36‐0.40] in Wave 4 for the poorest). Rural‐urban inequality showed a consistent decline (for ANC4+, OR [95% CI] = 0.59 [0.54‐0.64] in Wave 2; OR [95% CI] = 0.63 [0.59‐0.68] in Wave 3; and OR [95% CI] = 0.82 [0.79‐0.85] in Wave 4 for rural area). The relative contribution of the community to the total geographic variation in the utilization of ANC services increased more than four times during the study period. CONCLUSIONS: The use of ANC services remains disproportionately lower among women with low socioeconomic status. Efforts to directly target these women are necessary to tackle inequality in ANC utilization in India.

Background: Forty years after Alma Ata, there is renewed commitment to strengthen primary health care as a foundation for achieving universal health coverage, but there is limited consensus on how to build strong primary health care systems to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create an enabling ecosystem for disruptive primary care innovation. We focused our discussion on four themes: workforce innovation and strengthening; impactful use of data and technology; private sector engagement; and innovative financing mechanisms. Findings: Here, we present a summary of our convening’s proceedings, with specific recommendations for strengthening primary health care systems within each of these four domains. Conclusions: In the wake of the Astana Declaration, there is global consensus that high-quality primary health care must be the foundation for universal health coverage. Significant disruptive innovation will be required to realize this goal. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Health for All by 2030.

Objectives The Korean government has been providing financial support to open and operate the maternal hospital in Obstetrically Underserved Areas (OUAs) since 2011. Our study aims to assess the effectiveness of the government-support program for OUAs and to suggest future directions for it. Methods We performed sequential-mixed method approach. Descriptive analyses and multi-level logistic regression were performed based on the 2015 Korean National Health Insurance claim data. Data for the qualitative analysis were obtained from in-depth interviews with health providers and mothers in OUAs. Results Descriptive analyses indicated that the share of babies born in the hospitals located in the area among total babies ever born from mothers residing in the area (Delivery concentration Index: DCI) was lower in government-supported OUAs than other areas. Qualitative analyses revealed that physical distance is no longer a barrier in current OUAs. Mothers travel to neighboring big cities to seek elective preferences only available at specialized maternal hospitals rather than true medical need. Increasing one-child families changed the mother’s perception of pregnancy and childbirth, making them willing to pay for more expensive services. Concern about an emergency for mothers or infants, especially of high-risk mothers was also an important factor to make mothers avoid local government-supported hospitals. Adjusted multi-level logistic regression indicated that DCIs of government-supported OUAs were higher than the ones of their counterpart areas. Conclusion Our results suggest that current OUAs do not reflect reality. Identification of true OUAs where physical distance is a real barrier to the use of obstetric service and focused investment on them is necessary. In addition, more sophisticated performance indicator other than DCI needs to be developed.

Background Although leprosy is portrayed as a disappearing disease, leprosy affected persons in India are still suffering massively. Even further, nearly 60% of the world’s newly detected cases are appearing from India alone. The problem has exacerbated due to the drastic decrease of global funding after India’s official declaration of ‘elimination’, which did not foster the actual pain of patients beyond prevalence. Leprosy patients have hardships in their lives due to disabilities, stigma and poverty; thus, they require sustained, continuous care even after release from treatment. Yet, current interventions mostly have a vertical, short-term approach, not showing much progress in lightening the burden of leprosy. In contrast, Little Flower Hospital Community (LFHC) in India has been remarkably providing holistic care for thousands of leprosy patients for 35 years. However, there has not been any research conducted to uncover the underlying factors of this longstanding leprosy control model. Therefore, this research explores the in-depth contextual attributes of this hospital community that has been able to successfully provide sustainable care for a long time even without excessive external funds. Methods and findings This qualitative research used a grounded theory approach, involving 28 in-depth interviews of 11 patients, 13 workers, and 4 board members from the hospital. The interview data were inductively analyzed to examine the contextual factors of the hospital’s sustainability. Open coding, axial coding and selective coding were conducted, and Glaser’s Six C’s model was used to create a theoretical model of the sustainability of LFHC. The fundamental cause of the sustainability was the leprosy patients’ strong craving for life with dignity, despite the isolation from the society. The desire resulted in a bottom-up formation of a ‘consumer-provider cooperative’, where patients mutually support each other with basic treatment learned from experience. The profits earned from the patients’ occupational efforts such as dairy farming, cover the costs needed to manage the hospital community, which contributes to economical sustainability. Social sustainability was established through the holistic care including psychosocial, educational, medical, and residential support. The wholesome care socially rehabilitated the patients to be included in the society with satisfaction, social justice and social cohesion. The main limitation of this study is that this study cannot be generalized due to the nature of Grounded Theory based study. Conclusions This study investigated the determinants that made LFHC sustainable, and the findings suggested the importance of forming a cooperative community and implementing social rehabilitation for sustainable leprosy control. More exploration on transferring this model to other leprosy colonies will have great impact in maintaining sustainable care for leprosy patients. Furthermore, this research may highlight the importance of sustainable development in policies targeting neglected tropical diseases beyond leprosy as well., Author summary A typical day for a leprosy patient starts like this. One wakes up and discovers that the ulcer on his left foot has worsened over a few days. Strong odor coming from the wound is disturbing and skin continues to deteriorate but he can’t visit the clinic because it is too far from home and also because he does not have enough money. He leaves the house to beg for money on the streets. As usual, people try to avoid being close to him and stares at him with fear. A typical day for a leprosy patient from Little Flower Hospital Community (LFHC) goes like this. One wakes up from the housing provided by LFHC and discovers that the ulcer on her left foot has worsened over a few days. She visits the hospital nearby and gets her wound checked up by the nurse. She leaves the hospital to work at the dairy farm, which is a job provided by the LFHC. The money that she earns is used to support her and the hospital both. As usual, people in the community greet her with a smile. LFHC created a vast difference in the life of the patient, meeting one’s holistic needs. This research explores how LFHC was able to provide appropriate care for leprosy patients and sustain itself for 35 years. The possibilities of implementing the sustainable model of LFHC to marginalized people in the rest of the world are noteworthy.

Objective Dietary diversity (DD) measures dietary variation in children. Factors at the child, community, and state levels may be associated with poor child nutritional outcomes. However, few studies have examined the role of macro-level factors on child DD. This study seeks to 1) describe the distribution of child DD in India, 2) examine the variation in DD attributable to the child, community and state levels, and 3) explore the relationship between community socioeconomic context and child DD. Research Methods and Procedures Using nationally representative data from children aged 6–23 months in India, multilevel models were used to determine the associations between child DD and individual- and community-level factors. Results There was substantial variation in child DD score across demographic and socioeconomic characteristics. In an age and sex-only adjusted regression model, the largest portion of variation in child DD was attributable to the child level (75%) while the portions of variance attributable to the community-level and state level were similar to each other (15% and 11%). Including individual-level socioeconomic factors explained 35.6 percent of the total variation attributed to child DD at the community level and 24.8 percent of the total variation attributed to child DD at the state level. Finally, measures of community disadvantage were associated with child DD in when added to the fully adjusted model. Conclusions This study suggests that both individual and contextual factors are associated with child DD. These results suggest that a population-based approach combined with a targeted intervention for at-risk children may be needed to improve child DD in India.

Inadequate child physical growth and cognitive development share common individual-level risk factors. Less understood is how outcomes co-cluster at the community level and to what extent certain community-level characteristics influence the clustering. This study aims to quantify the extent to which child growth and development co-occur across communities, and to identify community-level characteristics associated with the clustering of the two development dimensions. We used longitudinal data from 1824 children (aged 5 years) across 98 communities in Andhra Pradesh, India in round 2 (2006) of the Young Lives study, who were followed up 3 years later in round 3 (2009). A multivariate, multilevel statistical model was estimated wherein the responses were nested within individuals, and communities. We used z-scores of height-for-age, weight-for-age, Peabody Picture Vocabulary Test, and a mathematics test in 2009 as outcome variables. At the community level, we included compositional variables representing community characteristics while controlling for child socio-demographic characteristics at the individual level. At the community level, children&rsquo, s physical growth and cognitive development were strongly correlated (coefficient: 0.55&ndash, 0.76) and, even after controlling for individual-level covariables, a more pronounced correlation was shown at the community level than individual level correlation. Greater local healthcare resources were associated with better physical growth. More local programs run by government and NGOs/charities were associated with higher child language skills. Local social problems were inversely associated with math scores. Our study showed that physical growth and cognitive development tended to be clustered and co-occurred within communities as well as individual children.

Background Socioeconomic inequalities in access to maternal health care have received more attention as it challenges the sustainability of the ongoing achievement in reducing maternal mortality. By promoting access to maternal health care as one of the core targets of the Health Sector Reform, Lao People’s Democratic Republic has reduced maternal mortality dramatically over the last decade. In spite of this improvement, little has been known about the secular trends in disparities of service utilization across different socioeconomic subgroups. Methods Two waves of the Multiple Indicator Cluster Survey in the years 2000 and 2012 were pooled for the analysis. We used logistic regression to estimate the likelihood of using antenatal care (ANC) and delivery services with skilled birth attendants (SBA) across different socioeconomic subgroups. Difference-in-difference method was applied to examine the inequality trends across the years by analyzing the interaction terms of the survey years and socioeconomic factors (education, wealth, ethnicity, and residential areas). Results Urban-rural disparity was improved over time while there were no educational disparity changes. Rural residential areas showed significant changes than urban areas over time [OR = 2.40; 95% CI: 1.52–3.77 for ANC and OR = 2.16; 95% CI: 1.36–3.42 for SBA]. However, there were aggravations in the disparities between major and minor ethnic group as well as worsening disparities between the rich and poor: i.e. Ethnic minority showed significant aggravation over time [OR = 0.62; 95% CI: 0.44–0.89 for ANC and OR = 0.65; 95% CI: 0.44–0.97 for SBA]. Conclusions Efforts to increase maternal health service utilization in poor and minority ethnic groups should be emphasized to reduce social inequalities, thus encompassing multiple-sector interventions rather than focusing only on health sector related interventions. Electronic supplementary material The online version of this article (10.1186/s12889-018-5811-0) contains supplementary material, which is available to authorized users.

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.

Context Chronic noncommunicable diseases (NCDs) have been shown to be major causes of morbidity and mortality in hospitals for the whole country. Objective This study aims to describe the situation of health service utilization among people with NCDs in a rural area and identify association between the situation of health service utilization among people with chronic diseases and their socioeconomic status. Design This was a cross-sectional study. Setting A rural district located in the North of Vietnam. Participants People 15 years of age and older. Health service utilization was analyzed only among people who reported having NCD. Main outcome measures Data were collected through a personal household interview conducted by 12 trained field workers. The dependent variable is health care service utilization among people with chronic NCDs. The explanatory variables include both household attributes such as household economic conditions, and so forth, and individual characteristics. Results Eighteen percent of the adults and 51% of the elderly respondents reported having at least 1 of the NCDs. The proportions of people with NCDs who used at least 1 outpatient service and used at least 1 inpatient health service during the last 12 months were 68.1% and 10.7%, respectively (the nonutilization rates of 31.9% and 89.3%, respectively). The statistically significant correlates of health care service utilization among people with NCDs were ethnicity (ethnic minority was significantly associated with a lower odds of health care service utilization) and health insurance (no health insurance was significantly associated with lower odds of health care service utilization). Conclusion Given the evidence from this study, actions to improve access to health care services among people with NCDs are clearly needed. The capacity of primary health care system for the prevention and control of NCDs should be ranked a top priority.

ObjectivesThis study evaluated whether individuals with affected family member adhered to healthy behaviours.Design and settingThis was a cross-sectional study of participants selected from health examinees who underwent the national health check-up programme of Korea in 39 centres between 2004 and 2013.ParticipantsThe baseline data of 128 520 participants enrolled in the Health Examinees-Gem study were used for analysis.Main outcomes and measuresAssociations of family history of diabetes with adherence to regular exercise, healthy diet and body composition, and clusters of healthy behaviours were evaluated while adjusting for potential confounders selected by a directed acyclic graph.ResultsParticipants with a family history of diabetes were more likely to adhere to a regular exercise regimen (OR=1.12, 95% CI 1.06 to 1.18 for men and OR=1.10, 95% CI 1.07 to 1.14 for women) and healthy diet (OR=1.06, 95% CI 1.01 to 1.12 for men and OR=1.06, 95% CI 1.01 to 1.12 for women) but were less likely to have a normal body composition (OR=0.83, 95% CI 0.78 to 0.87 for men and OR=0.83, 95% CI 0.80 to 0.86 for women). These associations were strengthened when the affected family members were siblings, the number of affected members was increased or the age at diagnosis of the affected member was younger than 50 years. In men and women, having a normal body composition is important in determining the cluster of behaviours, and those with a family history of diabetes were less likely to adhere to the normal body composition cluster.ConclusionsThe group with high risk of diabetes showed healthy behaviors, but they did not have a normal body composition. Policies and campaigns targeting integrated health behaviors will be needed to reduce the burden of diseases and improve public health.

Aims Little is known about the association of changes in moderate to vigorous physical activity (MVPA) level with cardiovascular disease (CVD), especially in older adults whose ability to engage in frequent MVPA naturally wanes as they age. We aimed to examine the association of changes in MVPA and CVD in older adults. Methods and results In a nationwide cohort study of older adults aged 60 years or older, we identified more than 1.1 million subjects without previous history of CVD at baseline who underwent two consecutive national health screening from 2009 to 2012. We prospectively assessed the risk of CVD occurred between 2013 and 2016 according to changes in frequency of MVPA by initial MVPA status. Compared to those who were continuously physically inactive, those who increased their frequency of MVPA from physically inactive to 1–2 times per week [0.7/1000 person-years (PY) decrease in incidence rate (IR); adjusted hazard ratio (aHR) 0.95; 95% confidence interval (CI) 0.92–0.99], 3–4 times per week (1.5/1000 PY decrease in IR; aHR 0.89; 95% CI 0.84–0.94), ≥5 times per week (0.4/1000 PY decrease in IR; aHR 0.91; 95% CI 0.85–0.97) had a significantly reduced risk for total CVD (P for trend Conclusion Among older adults, engaging in higher frequency of MVPA or maintaining MVPA level was associated with reduced risk of CVD.

Abstract Background Vietnam has been successful in increasing access to maternal, neonatal, and child health (MNCH) services during last decades; however, little is known about whether the primary MNCH service utilization has been properly utilized under the recent rapid urbanization. We aimed to examine current MNCH service utilization patterns at a district level. Methods The study was conducted qualitatively in a rural district named Quốc Oai. Women who gave a birth within a year and medical staff at various levels participated through 43 individual in-depth interviews and 3 focus group interviews. Results Primary MNCH services were underutilized due to a failure to meet increased quality needs. Most of the mothers preferred private clinics for antenatal care and the district hospital for delivery due to the better service quality of these facilities compared to that of the commune health stations (CHSs). Mothers had few sociocultural barriers to acquiring service information or utilizing services based on their improved standard of living. A financial burden for some services, including caesarian section, still existed for uninsured mothers, while their insured counterparts had relatively few difficulties. Conclusions For the improved macro-efficiency of MNCH systems, the government needs to rearrange human resources and/or merge some CHSs to achieve economies of scale and align with service volume distribution across the different levels.

Background: Child vaccination coverage in low- and middle-income countries is still far from complete, mainly among marginalized people such as children with illiterate mothers. Objective: This study aims to examine the association between maternal literacy and immunization status of children in Ethiopia and southeastern India (Andhra Pradesh and Telangana) and test whether state-run health centers and community health workers moderate that association. Methods: This study is based on cross-sectional data from samples of children in Ethiopia and India, collected as part of round 2 within the Young Lives study (2006). Multilevel logistic regression was conducted to estimate the association between maternal literacy and the completion of four kinds of child vaccinations. We further tested for cross-level interactions between state-run health centers or community health workers and maternal literacy. Estimates were adjusted for several individual- and household-level demographic and socioeconomic factors. Results: Literate mothers were more likely to complete all four kinds of vaccinations for their children compared to illiterate mothers in Ethiopia (Odds Ratio (OR)=4.84, Confidence Interval (CI)=1.75-13.36). Presence of a health center was positively associated with completed vaccinations in India only (OR = 6.60, CI = 1.57–27.70). A cross-level interaction between community health workers and maternal literacy on the vaccination completion status of children was significant in Ethiopia only (OR = 0.29, CI = 0.09–0.96). Conclusions: Our findings suggest that increased availability of community health workers may reduce the child vaccination gap for illiterate mothers, depending on the country context.

ObjectivesThe interaction between positive and negative social support as well as each domain of social support and income on depressive symptom has not been much explored. We aimed to examine the associations of positive and negative social support with the risk of depressive symptoms among urban-dwelling adults in Korea, focusing on those interaction effects.DesignWe used the first wave of a large-scale cohort study called The Health Examinees-Gem Study. Positive and negative support scores ranged between 0 and 6; the variables were then categorised into low, medium, and high groups. A two-level random intercept linear regression model was used, where the first level is individual and the second is the community. We further tested for interactions between each domain of social supports and household income.SettingA survey conducted at 38 health examination centres and training hospitals in major Korean cities and metropolitan areas during 2009–2010.Participants21 208 adult men and women aged between 40 and 69 in Korea (mean age: 52.6, SD: 8.0).Outcome measuresDepressive symptoms score measured by Epidemiologic Studies-Depression Scale, with scores ranging from 0 to 60.ResultsLevel of positive and negative social support showed a negative and positive association with depressive symptom score with statistical significance at pConclusionsOur findings suggest that strategies for encouraging positive social support and discouraging negative social support for disadvantaged individuals might be effective in reducing depression in Korea.

ObjectiveSeveral studies identified neighbourhood context as a predictor of prognosis in ischaemic heart disease (IHD). The present study investigates the relationships of neighborhood-level and individual-level socioeconomic status with the odds of ongoing management of IHD, using baseline survey data from the Korea Health Examinees-Gem study.DesignIn this cross-sectional study, we estimated the association of the odds of self-reported ongoing management with the neighborhood-level income status and percentage of college graduates after controlling for individual-level covariates using two-level multilevel logistic regression models based on the Markov Chain Monte Carlo function.SettingA survey conducted at 17 large general hospitals in major Korean cities and metropolitan areas during 2005–2013.Participants2932 adult men and women.Outcome measureThe self-reported status of management after incident angina or myocardial infarction.ResultsAt the neighbourhood level, residence in a higher-income neighbourhood was associated with the self-reported ongoing management of IHD, after controlling for individual-level covariates [OR: 1.22, 95% credible interval (CI): 1.01 to 1.61). At the individual level, higher education was associated with the ongoing IHD management (high school graduation, OR: 1.33, 95% CI: 1.08 to 1.65); college or higher, OR: 1.63, 95% CI: 1.22 to 2.12; reference, middle school graduation or below).ConclusionsOur study suggests that policies or interventions aimed at improving the quality and availability of medical resources in low-income areas may associate with ongoing IHD management. Moreover, patient-centred education is essential for ongoing IHD management, especially when targeted to patients with IHD with a low education level.

Road traffic deaths (RTDs) remain the 9th most common cause of mortality in South Korea despite their decreasing trends in high-income countries. In 2010 and 2011, the Korean government deregulated the process for obtaining a driving licence, and there has been significant concern that such deregulation of the driving licence policy could reduce road safety. This study aimed to explore the effects of the deregulation of driving licence policy on road safety by examining the incidence of road traffic collisions (RTCs), road traffic injuries (RTIs) and RTDs.The monthly incidence of RTCs, RTIs and RTDs was generated by using numbers of RTCs, RTIs and RTDs as numerators and numbers of registered vehicles as denominators. Changes in incidence since the deregulation implementation in February 2010 (phase I) and June 2011 (phase II) were evaluated via interrupted time-series analysis.The second deregulation phase demonstrated significant changes in numbers of RTCs and RTIs: numbers of RTCs and RTIs decreased until they began to increase in November 2011. Since then, the monthly incidence of RTCs and RTIs have increased by 133.5 and 123.8 per 100 000 vehicles per month, respectively (p0.05). RTD secular trends began to increase consecutively at rates of 0.024 (June 2010), 0.018 (between July 2010 and June 2011) and 0.273 (July 2011 onward) per 100 000 vehicles per month. Over the entire study period, the RTD incidence rate increased by 0.018 deaths per month on average subsequent to the first deregulation phase (p0.05).The deregulation policies that simplified the driving licence process were associated with increased incidence of RTCs, RTIs and RTDs in Korea.

Introduction : Early birth registration, childhood care, and education are essential rights for children and are important for their development and education. This study investigates changes and socioeconomic inequalities in early birth registration and indicators of care and education in children aged under 5 years in Vietnam. Design : The analyses reported here used data from the Vietnam Multiple Indicator Cluster Surveys (MICS) in 2006 and 2011. The sample sizes in 2006 and 2011 were 2,680 and 3,678 for children under 5 years of age. Four indicators of childcare and preschool education were measured: birth registration, possession of books, preschool education attendance, and parental support for early childhood education. The concentration index (CI) was used to measure inequalities in gender, maternal education, geographical area, place of residence, ethnicity, and household wealth. Results : There were some improvements in birth registration (86.4% in 2006; 93.8% in 2011), preschool education attendance (57.1% in 2006; 71.9% in 2011), and parental support for early childhood education (68.9 and 76.8%, respectively). However, the possession of books was lower (24.7% in 2006; 19.6% in 2011) and became more unequal over time (i.e. CI=0.370 in 2006; CI=0.443 in 2011 in wealth inequality). Inequalities in the care and education of children were still persistent. The largest inequalities were for household wealth and rural versus urban areas. Conclusion : Although there have been some improvements in this area, inequalities still exist. Policy efforts in Vietnam should be directed towards closing the gap between different socioeconomic groups for the care and education of children under 5 years old. Keywords: inequality; birth record; school admission; childhood care; childhood education (Published: 29 February 2016) Citation: Glob Health Action 2016, 9 : 29470 - http://dx.doi.org/10.3402/gha.v9.29470 This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants . More papers from this issue can be found at www.globalhealthaction.net

ObjectiveTo explore how three indicators of social capital (ie, group membership, social support and cognitive social capital and specific types within each type) are associated with infant birth weight.Study design and settingsCross-sectional analyses of the first wave of Young Lives Survey data collected in 2002 from India (Andhra Pradesh state), Peru and Vietnam.Participants807 mothers in India, 1528 mothers in Peru and 1706 mothers in Vietnam.Outcomes measureInfant birth weight was measured in grams. Participation in specific groups, receipt of social support from specific groups or individuals and perceptions of their community were measured for social capital indicators. Two-level random intercept linear regression models were fit separately by country (first level: individual and second level: community).ResultsMaternal group membership displayed a consistent positive association with infant birth weight across the three countries. There was no relationship with maternal cognitive social capital. Membership in a women’s group was associated with infant birth weight consistently in all three countries (b=119.6, 95% CI 21.7 to 217.4 in India, b=133.4, 95% CI 40.9 to 225.9 in Peru, b=60.6, 95% CI 0.5 to 120.6 in Vietnam). However, membership in a political group in Peru was inversely associated with infant birth weight (b=−276.1, 95% CI −465.7 to −86.5).ConclusionAlthough a higher level of social capital is associated with higher infant birth weight, specific types of social capital may have different associations with infant birth weight depending on the social, political or cultural specificity of the country. These results pave the way for additional research on the mechanisms through which social capital influences birth weight outcomes in each country.

Background In order to provide essential scientific evidence on the population's health status and social health determinants as well as the current capacity of the health care system in Vietnam to health policy makers and managers, Vietnam Ministry of Health, Hanoi University of Public Health, Hanoi Medical University, and Ho Chi Minh University of Medicine and Pharmacy collaborated with Seoul National University (Korea) and conducted a health system survey in the Quoc Oai district (of Hanoi capital) that represented northern rural Vietnam. Methods The study design was a cross-sectional study. The survey covered different topics (more than 200 questions) and was administered in three separate questionnaires: 1) Basic information of all household members; 2) Household characteristics; and 3) Individual characteristics. Socio-demographic characteristics among the households and individuals were collected from 2,400 households sampled by multi-stage cluster sampling method: more than 200 questions. Results The household size of Quoc Oai was larger than the national average and there was no significant difference in gender composition. In addition, the proportions of pre-elderly, age 55–64, and elderly group (65 years old and over) were higher than the national population statistics. In this context, demographic transition has begun in Quoc Oai. Conclusion This study design description provides the basic information about a baseline survey of a future prospective cohort (as a part of a collaborative project on strengthening the health system in Vietnam) to the prospective data user of this survey., Graphical Abstract

Physical child punishment is a critical public health problem that exhibits negative and long-lasting mental and physical health consequences. Yet, the predictors of physical punishment are understudied in developing countries, and disparities that exist between levels of economic status are not known well. The socioeconomic predictors of physical child punishment were investigated using three rounds of the Multiple Indicator Cluster Survey (MICS) results in a lower middle-income country, Viet Nam from 2006 to 2014. A total of 16,784 households that have answered the child punishment questionnaire from MICS data from 2006 to 2014 were included in the analysis. Descriptive statistics, univariate, and multivariate logistic regression analyses were conducted. A secular trend of disparity was investigated with and without the parents' normative values on physical punishment. Children in Viet Nam have been subject to some form of violent physical punishment by their parents or caregivers. About half of the children in the poorest households (44.7%) experienced physical child punishment while lesser percentage of children in the richer households experienced physical child punishment. Disparities existed across different wealth groups as the prevalence of physical child punishment decreased: the gap between the poorest and the richest group widened. Compared to the richest households, the poorest households were more likely to experience physical child punishment AOR 1.58 (95% CI 1.39-1.79). There is a decrease in the prevalence of physical punishment over the recent years in Viet Nam, socioeconomic disparities, in contrast, have increased, and the poorest children have a higher risk of experiencing physical child punishment. Such disparities should be considered in future research and intervention development.

Background/Objectives This study aimed to examine socioeconomic inequalities in the prevalence of biomarkers of cardiovascular disease and diabetes in the newly developed large-scale genomic cohort study of Korean adults, the Health Examinees-Gem (HEXA-G), with a comparison of the nationally representative cross-sectional study, the Korea National Health and Nutrition Examination Survey (K-NHANES). Subjects/Methods Using the HEXA-G and the K-NHANES from 2007–2012, we analyzed the age-adjusted relative risk (RR) and prevalence of enlarged waist circumference (EWC), elevated triglycerides (ET), low HDL cholesterol (LHC), elevated blood pressure (EBP) and elevated blood glucose (EBG) by income and educational groups for adults at age 40–69. Results For men, the prevalence of risk factors was similar across different income and educational groups (p>0.1), and between the K-NHANES and the HEXA-G. Among five risk factors, EBG showed the greatest discrepancy by 7 to 11 percentage points (i.e., the prevalence of 0.43 and 0.36 for college graduates, respectively, in K-NHANES and HEXA-G). For women, socioeconomic inequalities appeared for the five risk factors. Prevalence of risk factors was mostly lower in the HEXA-G than the K-NHANES, by approximately 11.0 percentage points. Especially, the discrepancy between K-NHANES and HEXA-G was largest in EBG (i.e., the prevalence of 0.31 and 0.20 for the lowest income groups, respectively). Conclusion The HEXA-G shows broadly similar socioeconomic inequality in prevalence of cardio-metabolic risk factors to the nationally representative sample with more modest socioeconomic inequality among women in the HEXA-G than the K-NHANES.

Background: The prevalence of underweight is high among women in Asian countries, despite nutritional changes in the region. Previous studies have demonstrated independent associations between female body weight, marital status and economic status. However, few studies have investigated possible interaction between marital and economic status in relation to Asian women’s body weight. Objective: This study aimed to test associations between household wealth, marital status and underweight among women living in the Quoc Oai district of Vietnam and to identify wealth–marital status interaction in relation to body weight in these women. Methods: Data from 1087 women aged 19–60 years were collected via a baseline community survey conducted in the Quoc Oai district of Hanoi, Vietnam, in 2016. Underweight was defined using an Asian-specific body mass index cut-off (

OBJECTIVE The aim of this study was to investigate whether gender-based disparities in health and well-being extend to a female disadvantage in height in infancy, childhood, and adolescence in Andhra Pradesh and Telangana. METHODS Using longitudinal data from the Young Lives study in Andhra Pradesh and Telangana, India, linear mixed effects and linear regression models examined associations between gender and height and the modifying influences of birth order and older siblings' gender composition. RESULTS In the younger cohort, at 6-18 months, girls were 0.17-SDs of height for age z-scores (HAZ) taller than boys (P = .01). In the same cohort, the girls' advantage in HAZ was attenuated to 0.02 (P = .58) by 11-12 years. In the older cohort, the difference in HAZ between girls and boys was 0.04 (P = .61) at the beginning of the study when they were 7-8 years old; by 18-19 years of age, the difference had switched, with boys being 0.22-SD (P = .05) taller. There was no difference by birth order except in the younger cohort in which children with 2 or more siblings experienced height deficits compared with only children at 7-8 and 11-12 years. There was no differential effect of gender by birth order nor by the gender composition of siblings. CONCLUSION A female disadvantage in undernutrition, as manifest in differences between girls and boys in HAZ, did not appear until later ages. Identifying how and why gendered disparities in standardized height emerge in late adolescence will help target more resources to improve conditions for girls and women in south India.

Increase in the elderly population and early retirement imposes immense economic burden on societies. Previous studies on the association between medical expenditure and working status in the elderly population have not adequately addressed reverse causality problem. In addition, the pre-elderly group has hardly been discussed in this regard. This study assessed possible causal association between employment status and medical expenditure as well as employment status and medical unmet needs in a representative sample of the Korean elderly (aged≧65) and the pre-elderly (aged ≧50 and < 65) adults from the Korea Health Panel Data (KHP). Dynamic panel Generalized Method of Moments (GMM) estimation was employed for the analysis of medical expenditure to address reverse causality, and fixed effect panel logistic regression was used for the analysis of unmet need. The results showed no significant association between job status and medical expenditure in the elderly, but a negative and significant influence on the level of medical expenditure in the pre-elderly. Unemployment was a significant determinant of lowering unmet need from lack of time while it was not associated with unmet need from financial burden in the fixed-effect panel model for both the elderly and pre-elderly groups. The pre-elderly adults were more likely to reduce necessary health service utilization due to unemployment compared to the elderly group because there is no proper financial safety net for the pre-elderly, which may cause non-adherence to treatment and therefore lead to negative health effects. The policy dialogue on safety net currently centers only on the elderly, but should be extended to the pre-elderly population.

This study aims to provide a systematical introduction of age-period-cohort (APC) analysis to South Korean readers who are unfamiliar with this method (we provide an extended version of this study in Korean). As health data in South Korea has substantially accumulated, population-level studies that explore long-term trends of health status and health inequalities and identify macrosocial determinants of the trends are needed. Analyzing long-term trends requires to discern independent effects of age, period, and cohort using APC analysis. Most existing health and aging literature have used cross-sectional or short-term available panel data to identify age or period effects ignoring cohort effects. This under-use of APC analysis may be attributed to the identification (ID) problem caused by the perfect linear dependency across age, period, and cohort. This study explores recently developed three APC models to address the ID problem and adequately estimate the effects of A-P-C: intrinsic estimator-APC models for tabular age by period data; hierarchical cross-classified random effects models for repeated cross-sectional data; and hierarchical APC-growth curve models for accelerated longitudinal panel data. An analytic exemplar for each model was provided. APC analysis may contribute to identifying biological, historical, and socioeconomic determinants in long-term trends of health status and health inequalities as well as examining Korean's aging trajectories and temporal trends of period and cohort effects. For designing effective health policies that improve Korean population's health and reduce health inequalities, it is essential to understand independent effects of the three temporal factors by using the innovative APC models.

An increase in mean body mass index (BMI) or prevalence of obesity may be accompanied by changes in the population BMI distribution. This study aimed to examine how the distributions of BMI and waist circumference (WC) have changed in South Korea over a 16-year interval (1998–2014). Using the Korea National Health and Nutrition Examination Survey, we analyzed changes in mean, standard deviation (SD), 5th, and 95th percentile values of BMI and WC distributions for 46,343 (BMI) and 46,327 (WC) adults aged 25–64 years. For men, mean BMI increased at an annual rate of 0.060 units (95% CI: 0.047–0.073) with annual increases of 0.029 units in SD (95% CI: 0.019–0.039), 0.121 units in the 95th percentile (95% CI: 0.097–0.145) and 0.042 units in the 5th percentile (95% CI: 0.021–0.062). The 95th percentile and SD of the WC distribution increased, but not mean WC and the 5th percentile. For women, mean BMI decreased at an annual rate of 0.030 units (95% CI: 0.010–0.049) with a 0.030-unit increase in SD (95% CI: 0.012–0.048) and a 0.049-unit decrease in the 5th percentile (95% CI: 0.029–0.070). Mean WC also decreased with an increase in SD and a decrease in the 5th percentile. These findings suggest increasing dispersion in the distribution of BMI and WC derived from significant shifts in the upper tails for Korean men, but not women. Future research needs to identify the factors that underlie the increasing dispersion of obesity measures.

Background. Vietnam is experiencing an unprecedented demographic transition. Its proportion of elderly people is growing rapidly. Objective. This study explored the health status and health-related quality of life (HRQoL) of rural elderly Vietnamese and assessed their needs for healthcare services. Design. This study used a survey with stratified proportion sampling and quota assignment. In 2016, data was collected from 713 people in the rural Quoc-Oai district of Hanoi aged 60 or older. Results. The mean age of the respondents was 70.9. Both self-rated health status and functional status decreased with age. Women reported more functional limitations than men. Musculoskeletal disorders were the most frequently reported chronic diseases, followed by hypertension, gastrointestinal diseases, and cardiovascular diseases. Age, self-rated health status, BMIs, and the number of noncommunicable diseases (NCDs) were found to be significant determinants of HRQoL, after controlling for socioeconomic effects. More than half the respondents requested more healthcare information, particularly on disease management. Conclusions. Vietnam’s healthcare system is being challenged to make health services easily accessible and meet the growing needs for chronic illness management, risk reduction, promoting healthy lifestyles, and improving the aging population’s quality of life.

Background Previous research has demonstrated health benefits of marriage and the potential for worse outcomes during widowhood in some populations. However, few studies have assessed the relevance of widowhood and widowhood duration to a variety of health-related outcomes and chronic diseases among older adults in India, and even fewer have examined these relationships stratified by gender. Methods Using a cross-sectional representative sample of 9,615 adults aged 60 years or older from 7 states in diverse regions of India, we examine the relationship between widowhood and self-rated health, psychological distress, cognitive ability, and four chronic diseases before and after adjusting for demographic characteristics, socioeconomic status, living with children, and rural–urban location for men and women, separately. We then assess these associations when widowhood accounts for duration. Results Being widowed as opposed to married was associated with worse health outcomes for women after adjusting for other explanatory factors. Widowhood in general was not associated with any outcomes for men except for cognitive ability, though men who were widowed within 0–4 years were at greater risk for diabetes compared to married men. Moreover, recently widowed women and women who were widowed long-term were more likely to experience psychological distress, worse self-rated health, and hypertension, even after adjusting for other explanatory variables, whereas women widowed 5–9 years were not, compared to married women. Conclusions Gender, the duration of widowhood, and type of outcome are each relevant pieces of information when assessing the potential for widowhood to negatively impact health. Future research should explore how the mechanisms linking widowhood to health vary over the course of widowhood. Incorporating information about marital relationships into the design of intervention programs may help better target potential beneficiaries among older adults in India. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3682-9) contains supplementary material, which is available to authorized users.

Background : Child malnutrition is not only a major contributor to child mortality and morbidity, but it can also determine socioeconomic status in adult life. The rate of under-five child malnutrition in Vietnam has significantly decreased, but associated inequality issues still need attention. Objective : This study aims to explore trends, contributing factors, and changes in inequalities for under-five child malnutrition in Vietnam between 2000 and 2011. Design : Data were drawn from the Viet Nam Multiple Indicator Cluster Survey for the years 2000 and 2011. The dependent variables used for the study were stunting, underweight, and wasting of under-five children. The concentration index was calculated to see the magnitude of child malnutrition, and the inequality was decomposed to understand the contributions of determinants to child malnutrition. The total differential decomposition was used to identify and explore factors contributing to changes in child malnutrition inequalities. Results : Inequality in child malnutrition increased between 2000 and 2011, even though the overall rate declined. Most of the inequality in malnutrition was due to ethnicity and socioeconomic status. The total differential decomposition showed that the biggest and second biggest contributors to the changes in underweight inequalities were age and socioeconomic status, respectively. Socioeconomic status was the largest contributor to inequalities in stunting. Conclusions : Although the overall level of child malnutrition was improved in Vietnam, there were significant differences in under-five child malnutrition that favored those who were more advantaged in socioeconomic terms. The impact of socioeconomic inequalities in child malnutrition has increased over time. Multifaceted approaches, connecting several relevant ministries and sectors, may be necessary to reduce inequalities in childhood malnutrition. Keywords: trend; malnutrition; inequality; decomposition; Vietnam (Published: 29 February 2016) Citation: Glob Health Action 2016, 9 : 29263 - http://dx.doi.org/10.3402/gha.v9.29263 This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants . More papers from this issue can be found at www.globalhealthaction.net

Background : The prevalence of modern contraceptive use is an important indicator that reflects accessibility to reproductive health services. Satisfying unmet needs for family planning alone could reduce the number of maternal deaths by almost a third. This study uses multiple data sources to examine multilevel factors associated with the use of modern contraceptives among married women in Vietnam aged 15–49 years. Design : Data from different national surveys (Vietnam Population and Housing Census, Vietnam Living Standard Survey, and Multiple Indicator Cluster Survey) were linked to create a dataset including individual and contextual (provincial) variables ( N= 8,341). Multilevel modeling was undertaken to examine the impact of both individual and provincial characteristics on modern contraceptive use. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Results : Individual factors significantly associated with the use of modern contraceptives were age 30–34 years (reference 15–19 years) (OR=1.63); high socioeconomic status (SES) (OR=0.8); having two living children (OR=2.4); and having a son (OR=1.4). The provincial poverty rate mediated the association between the individual’s SES and the likelihood of using modern contraceptives. Conclusions : The proportion of women in Vietnam using modern contraceptive methods has remained relatively high in recent years with significant variation across Vietnam’s 63 provinces. Women of lower SES are more likely to use modern contraceptive methods, especially in the poorer provinces. Achieving access to universal reproductive health is one of the Millennium Development Goals. Vietnam must continue to make progress in this area. Keywords: contraception; family planning; reproductive health; maternal health; differentials; multilevel modeling; MDG (Published: 29 February 2016) Citation: Glob Health Action 2016, 9 : 29574 - http://dx.doi.org/10.3402/gha.v9.29574 This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants . More papers from this issue can be found at www.globalhealthaction.net

No abstract.(Published: 29 February 2016)Citation: Glob Health Action 2016, 9: 31271 - http://dx.doi.org/10.3402/gha.v9.31271This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants. More papers from this issue can be found at www.globalhealthaction.net

BACKGROUND:While controversies on limitation of coverage by the national health insurance and relatively high direct or "out-of-pocket" household payments by the national health insurance in South Korea still remain, potential unfavorable influence of the insufficiency of the universal health coverage on depression has not yet been evaluated. METHODS AND FINDINGS:Baseline information were obtained from a community cohort (The Korean Genome and Epidemiology Study) of middle-aged subjects without depression at enrollment period (2001-2002). Subjects were followed-up biennially, and new onset depression was assessed using Becks Depression Inventory at 2nd round follow-up (2005-2006). Influence of direct medical expenditure on depression onset was investigated in all subjects and in stratified groups of different income level. Increasing risk of depression onset was observed for increased medical expenditure (OR [95% CI];1.44 [0.97-2.13], 1.90 [1.19-3.05], 1.71 [1.01-2.91] for spending

Purpose: The purpose of this study was to derive contextual indicators of medical provider quality and assess their relative importance along with the individual utilization of antenatal care (ANC) and institutional births with a skilled birth attendant (SBA) in India using a multilevel framework. Methods: The 2015~2016 Demographic and Health Survey (DHS) from India was used to assess the outcomes of neonatal, infant, and under-five child mortality. The final analytic sample included 182,980 children across 28,283 communities, 640 districts, and 36 states and union territories. The contextual indicators of medical provider quality for districts and states were derived from the individual-level number of ANC visits (

Background : Despite progress made by the Millennium Development Goal (MDG) number 7.C, Vietnam still faces challenges with regard to the provision of access to safe drinking water and basic sanitation. Objective : This paper describes household trends in access to improved water sources and sanitation facilities separately, and analyses factors associated with access to improved water sources and sanitation facilities in combination. Design : Secondary data from the Vietnam Multiple Indicator Cluster Survey in 2000, 2006, and 2011 were analyzed. Descriptive statistics and tests of significance describe trends over time in access to water and sanitation by location, demographic and socio-economic factors. Binary logistic regressions (2000, 2006, and 2011) describe associations between access to water and sanitation, and geographic, demographic, and socio-economic factors. Results : There have been some outstanding developments in access to improved water sources and sanitation facilities from 2000 to 2011. In 2011, the proportion of households with access to improved water sources and sanitation facilities reached 90% and 77%, respectively, meeting the 2015 MDG targets for safe drinking water and basic sanitation set at 88% and 75%, respectively. However, despite these achievements, in 2011, only 74% of households overall had access to combined improved drinking water and sanitation facilities. There were also stark differences between regions. In 2011, only 47% of households had access to both improved water and sanitation facilities in the Mekong River Delta compared with 94% in the Red River Delta. In 2011, households in urban compared to rural areas were more than twice as likely (odds ratio [OR]: 2.2; 95% confidence interval [CI]: 1.9–2.5) to have access to improved water and sanitation facilities in combination, and households in the highest compared with the lowest wealth quintile were over 40 times more likely (OR: 42.3; 95% CI: 29.8–60.0). Conclusions : More efforts are required to increase household access to both improved water and sanitation facilities in the Mekong River Delta, South East and Central Highlands regions of Vietnam. There is also a need to address socio-economic factors associated with inadequate access to improved sanitation facilities. Keywords: MICS; Vietnam; improved water sources; sanitation facilities (Published: 29 February 2016) Citation: Glob Health Action 2016, 9 : 29434 - http://dx.doi.org/10.3402/gha.v9.29434 This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants . More papers from this issue can be found at www.globalhealthaction.net

Objective We sought to assess how widowhood among older adults in India was associated with alcohol consumption, smoking, and use of chewing tobacco or other drugs. Method Data were collected in 2011 from 9,852 adults aged 60 and older from seven regionally diverse states in India. Regression analyses provided estimates of the relationship between widowhood and having smoked cigarettes, consumed alcohol, or used chewed tobacco or other drugs in the past month among men, adjusting for demographic and socioeconomic factors. We also estimated the relationship between widowhood and past-month substance use among women. Results Recently widowed men (within 0-4 years) were 1.76 times (95% confidence interval [CI] 1.01-3.09, p < .05) more likely to have consumed alcohol and 1.62 times (95% CI 1.01-2.59, p < .05) more likely to have used chewing tobacco or other drugs as compared with married men. Women widowed for any length of time were 1.37 times (95% CI 1.11-1.69, p < .01) more likely to have used chewing tobacco or other drugs. Discussion Interventions aimed at reducing use of chewing tobacco or other drugs among older adults in India should consider focusing on recently widowed men and women widowed for any amount of time.

Introduction : Under current HIV transmission mechanisms operating in Vietnam, women are seen as victims of their male partners. Having multiple sexual partners is one of the well-known risk factors for HIV infection. However, little is known about women’s risky sexual behaviour and their vulnerability to HIV in Vietnam. This study aims to explore association between early sexual initiation and the number of lifetime sexual partners in Vietnamese women. Although the Vietnamese culture is socially conservative in this area, identifying women’s risky sexual behaviour is important for the protection of women at risk of HIV and other sexually transmitted diseases. Design : A total of 8,791 women, who reported having had sexual intercourse, were included in this analysis of data from the 2011 Multiple Indicator Cluster Survey in Vietnam. Data were collected using two-stage strata sampling, first at the national level and second across six geographical regions ( n =8,791). Multivariable logistic regressions describe association between early initiation of a sexual activity and lifetime multiple sexual partners. Results : Early sexual intercourse was significantly associated with having lifetime multiple sexual partners. Women who were aged 19 or younger at first sexual intercourse were over five times more likely to have multiple sexual partners, compared with women whose first sexual intercourse was after marriage; aged 10–14 years (OR=5.9; 95% CI=1.9–18.8) at first intercourse; and aged 15–19 years (OR=5.4; 95% CI=4.0–7.2) at first intercourse. There was significant association with having multiple sexual partners for women of lower household wealth and urban residence, but the association with educational attainment was not strong. Conclusions : The study results call for health and education policies to encourage the postponement of early sexual activity in young Vietnamese women as protection against risky sexual behaviour later in life. Keywords: early sexual initiation; multiple sexual partners; first intercourse; risky sexual behaviours; adolescent sexual behaviour (Published: 29 February 2016) Citation: Glob Health Action 2016, 9 : 29575 - http://dx.doi.org/10.3402/gha.v9.29575 This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants. More papers from this issue can be found at www.globalhealthaction.net

Background: Knowledge of the aggregate effects of multiple socioeconomic vulnerabilities is important for shedding light on the determinants of growing health inequalities and inequities in maternal healthcare.Objective: This paper describes patterns of inequity in maternal healthcare utilization and analyzes associations between inequity and multiple socioeconomic vulnerabilities among women in Vietnam.Design: This is a repeated cross-sectional study using data from the Vietnam Multiple Indicator Cluster Surveys 2000, 2006, and 2011. Two maternal healthcare indicators were selected: (1) skilled antenatal care and (2) skilled delivery care. Four types of socioeconomic vulnerabilities – low education, ethnic minority, poverty, and rural location – were assessed both as separate explanatory variables and as composite indicators (combinations of three and four vulnerabilities). Pairwise comparisons and adjusted odds ratios were used to assess socioeconomic inequities in maternal healthcare.Results: In all three surveys, there were increases across the survey years in both the proportions of women who received antenatal care by skilled staff (68.6% in 2000, 90.8% in 2006, and 93.7% in 2011) and the proportions of women who gave birth with assistance from skilled staff (69.9% in 2000, 87.7% in 2006, and 92.9% in 2011). The receipt of antenatal care by skilled staff and birth assistance from skilled health personnel were less common among vulnerable women, especially those with multiple vulnerabilities.Conclusions: Even though Vietnam has improved its coverage of maternal healthcare on average, policies should target maternal healthcare utilization among women with multiple socioeconomic vulnerabilities. Both multisectoral social policies and health policies are needed to tackle multiple vulnerabilities more effectively by identifying those who are poor, less educated, live in rural areas, and belong to ethnic minority groups.Keywords: healthcare; skilled antenatal care; skilled delivery; multiple socioeconomic vulnerabilities; inequity; inequality(Published: 29 February 2016)Citation: Glob Health Action 2016, 9: 29386 - http://dx.doi.org/10.3402/gha.v9.29386This paper is part of the Special Issue: Millennium Development Goals in Vietnam: the Progress and Social Determinants. More papers from this issue can be found at www.globalhealthaction.net