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Background This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. Methods A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus–post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. Results After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). Conclusions A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

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.

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 study data 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 intake, 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.

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 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. Methods The study data was derived from the Korean National Health Insurance Service database. Community-level social trust was determined from the Koran Community Health Survey. The study population consisted of 2,156,829 participations. 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 intake, 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.

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.

Introduction: 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 stroke and cardiovascular disease (CVD) is not clear yet. We aimed to investigate the association of social trust with stroke and CVD risk using a large Asian population. Methods: The study data was derived from the Korean National Health Insurance Service database. Community-level social trust was determined from the Koran Community Health Survey. The study population consisted of 2,156,829 participations. 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 stroke and CVD risk according to quintiles of social trust. Results: Compared to those with the lowest quintile of social trust, participants within the highest quintile had lower risk for stroke (aHR 0.90, 95% CI 0.87-0.93) and CVD (aHR 0.91, 95% CI 0.89-0.93), and the risk-reducing association of high social trust on CVD risk was preserved after additional adjustments for lifestyle behaviors including smoking, alcohol intake, and physical activity. Conclusion: Higher social trust was associated with reduced risk of stroke and CVD even after considering lifestyle behaviors. Social trust in a community level is an important determinant of stroke risk and enhancing social trust may lead to reduced risk of stroke and CVD.

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.

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.

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.

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.

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.

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: India has been making long-term efforts toward increasing antenatal care (ANC) to reduce maternal and neonatal mortality and morbidity. We aimed to investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in utilization of ANC services before and throughout the MDG era. Methods: Using a series of National Family Health Survey between 1998 and 2015 (Wave II, III, and IV), we analyzed the trend in inequality for at least one and four ANC visits to health care professional for ANC (ANCS1, ANCS4) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the trend in relative contribution of various geographical levels (states and communities). Age at pregnancy, history of terminated pregnancy, marital status, religions, birth order, caste were adjusted for. Findings: Educational and economic inequality in ANCS1 and ANC4 worsened in between 1998 and 2005. However, there was a huge decrease in inequality between 2005 and 2015 that compensated for increase in inequality during preceding half period. Educational inequality narrowed down more than wealth inequality(e.g., ORs of the poorest and the least educated for ANC4 are 0.23, 0.20, and 0.38 and 0.26, 0.28 and 0.58 in wave II, III, and IV. P values for all are

Background: Rabies remains as one of the neglected zoonotic diseases. Although its incidence shows seasonal pattern, how the climate conditions affect mortality of rabies is rarely known. Methods: An ecological study was conducted in two provinces of seven ecological regions in Vietnam, using Human Rabies Surveillance Data of Vietnam between 1997 and 2015. Monthly rabies post-exposure prophylaxis (PEP) cases, monthly human death cases from rabies, and climate characteristics were collected. Using Poisson regression, we estimated the association between monthly human rabies death cases and air temperature, humidity, precipitation, and sunshine duration in both PEP-used and PEP-not-used group. Findings: 2390 place (province)-time (specific year-month) ecological measurements with 920 510 PEP cases were included in this study. Twenty-two death cases were recorded in PEP-used group, while 344 patients without PEP were died from rabies. There was significant positive association between absolute humidity and death cases in PEP-used group (coefficient 0·3367 [95% CI: 0·0618 to 0·6115]). Human rabies deaths in PEP-not-used group are increased by higher absolute humidity, and lower monthly average air temperature, monthly total precipitation and sunshine duration. Interpretation: Lowering absolute humidity might be helpful for the suspicious rabid animal bite victim to prevent rabies death. Inverse relationship between average temperature and human rabies death in PEP-not-used group suggests ambient temperature modulation of the Milwaukee Protocol should be reassessed. Our findings can be applied to patients who are exposed to rabid animals along with further experimental researches for better treatment. Funding Statement: Seoul National University College of Medicine; Ministry of Health, Vietnam. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: For the data collection, the certificate of approval from the institutional review board at NIHE was obtained (IRB-VN01057-07/2017). Since this study protocol did not use the information of individual patients directly, no additional ethical approval was required.

Background Prevalence of Cesarean section (C-section) is unequally distributed. Since both extremely low and high levels of C-section can not only cause adverse birth outcomes but also impose a double burden of inefficiency within maternal health care, it is important to monitor the dynamics of key factors associated with the use of C-section. Objectives To examine the association between type of provider and C-section in India in three-time points: 1999, 2006, and 2016, and also to assess whether this association differed across maternal education and wealth level. Methods Data were from three waves of cross-sectional and nationally representative Indian National Health Family Survey: Wave II (1999), III (2006), and IV (2016). Target population is women aged 15 and 49 who had an institutional delivery for the most recent live birth during the three or five years preceding the survey (depending on the survey round). Multivariate logistic regression models adjusting for state cluster effect were performed to determine the association between the type of providers and C-section. Differential association between the type of providers and C-section by maternal education and wealth level was examined by stratified analyses. Results The prevalence of C-section among institutional delivery increased from 20.5% in 1999 to 24.8% in 2006 while it declined to 19.4% in 2016. The positive association between private providers and C-section became stronger over the study period (Odds Ratio (OR) = 1.39, 95% Confidence Interval (CI) 1.18–1.64 in 1999, OR = 3.71 95% CI 2.93–4.70 in 2016). The association was consistently significant across all states in 2016. The gap in C-section between public and private providers was greater among less-educated and poorer women. The ORs gradually increased from the poorest to the richest quintiles, and also from the least educated group (no formal education) to the most educated group (college graduate or above) Conclusions Our results suggest that disparity in C-section between private and public providers has increased over the last 15 years and was higher in lower SES women. The behavior of providers needs to be closely monitored to ensure that C-section is performed only when medically justified.

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

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.

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.

Background: To investigate whether preeclampsia is independently associated with risk of future metabolic syndrome and whether any such primary associations are modified by different ages at first pregnancy. Methods: Based on the Health Examinees Study, a cross-sectional analysis was conducted. Data of women (n = 49780) who had experienced at least 1 pregnancy during their lifetime and had never been diagnosed with any metabolic disorder before their pregnancy were analyzed using multiple logistic regression models. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated after adjusting for age, lifestyle characteristics, and reproductive factors. A stratified analysis was also conducted to estimate the extent of the primary association between preeclampsia and future metabolic syndrome by age at first pregnancy. Results: Women with a history of preeclampsia had significantly increased odds of developing metabolic syndrome (adjusted OR 1.23; 95% CI, 1.12–1.35), central obesity (adjusted OR 1.36; 95% CI, 1.25–1.47), elevated blood pressure (adjusted OR 1.53; 95% CI, 1.41–1.67), or elevated fasting glucose (adjusted OR 1.13; 95% CI, 1.03–1.25) in later life. In the stratified analysis, women who first became pregnant at ages >35 years and had preeclampsia were found to be at significantly increased likelihood of metabolic syndrome later in life (adjusted OR 4.38; 95% CI, 1.62–11.9). Conclusions: Our findings suggest that preeclampsia increases the risk of metabolic syndrome in later life, and late age at first pregnancy can further exacerbate this risk.

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.

Vietnam has pursued universal health insurance coverage for two decades but has yet to fully achieve this goal. This paper investigates the barriers to achieve universal coverage and examines the validity of facilitating factors to shorten the transitional period in Vietnam. A comparative study of facilitating factors toward universal coverage of Vietnam and Korea reveals significant internal forces for Vietnam to further develop the National Health Insurance Program. Korea in 1977 and Vietnam in 2009 have common characteristics to be favorable of achieving universal coverage with similarities of level of income, highly qualified administrative ability, tradition of solidarity, and strong political leadership although there are differences in distribution of population and structure of the economy. From a comparative perspective, Vietnam can consider the experience of Korea in implementing the mandatory enrollment approach, household unit of eligibility, design of contribution and benefit scheme, and resource allocation to health insurance for sustainable government subsidy to achieve and sustain the universal coverage of health insurance. Graphical Abstract

Objective: We assessed health-related quality of life in cancer survivors treated in designated cancer centers when compared with the general population in Korea. Methods: A multicenter survey was conducted from July through August 2008 using the quotasampling approach. A general population sample was drawn from the Fourth Korean National Health and Nutrition Examination Survey, second year. We compared the multivariate-adjusted least square means of cancer patients with those of the general population to examine relationships between EuroQol five-dimensional questionnaire components and cancer sites, cancer stage and time since diagnosis. The independent variables of responses to the EuroQol five-dimensional questionnaire were evaluated using logistic regression analysis. Results: Cancer patients scored significantly poorer on measures of self-care (means: stomach 1.25; lung 1.40; liver 1.27; colon 1.26; breast 1.27; cervical 1.29 vs. general 1.18), engagement in usual activities (means: stomach 1.47; lung 1.63; liver 1.45; colon 1.44; breast 1.46; cervical 1.47 vs. general 1.33) and anxiety/depression (means: stomach 1.41; lung 1.50; liver 1.41; colon 1.42; breast 1.50; cervical 1.47 vs. general 1.28). Those in the local stage scored significantly better on mobility (mean ¼ 1.35) than the general population (mean ¼ 1.40). Cancer patients, especially those with lung cancer, in the advanced stage and more than 5 years since diagnosis had poorer health-related quality of life than the general population. Some factors such as medical insurance and healthcare services were related to health-related quality of life among cancer patients. Conclusions: Health-related quality of life of cancer survivors with lung cancer at advanced stages, ,1 year earlier and more than 5 years since diagnosis was poorer than that for the noncancer control group, and these differences were statistically significant. Cancer survivors should be continuously observed and offered support.

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 : 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

We sought to examine the association between area deprivation and outcomes of out-of-hospital cardiac arrest in Korea.Data were obtained from the emergency medical service (EMS) system. A nationwide OHCA cohort database from January 2006 to December 2007 was constructed via hospital chart review and ambulance run sheet data. We enrolled all EMS-assessed OHCA victims and excluded cases without available hospital outcome data or residential address. The Carstairs index was used to categorize districts according to level of deprivation into five quintiles, from (Q1, the least deprived) to (Q5, the most deprived). Main outcomes were survival to hospital discharge, survival to admission, and return of spontaneous circulation (ROSC).34,227 patients were included. Initial rhythm, witnessed status, attempted bystander cardiopulmonary resuscitation (CPR), CPR by EMS, CPR in the emergency department (ED), and elapsed time interval significantly varied according to area deprivation level (p0.001). OHCA outcomes were consistently worse in the most deprived areas. The adjusted OR (95% CI) for survival to hospital discharge was 0.58 (0.45-0.77) in the most deprived areas compared to the least deprived areas.Community deprivation was strongly associated with survival among out-of-hospital cardiac arrest patients in Korea.

We sought to explore a possible association between higher parental socioeconomic position and lower child cancer mortality. We examined total cancer mortality as well as site-specific cancer mortality. We constructed a retrospective birth cohort by linking South Korean birth records to death records from 1995 to 2004. Parental socioeconomic position and birth characteristics were identified from the birth records. Parental education and occupation were examined as socioeconomic variables while sex, parental age, gestational age, birth weight, multiple birth, birth order, and the death of previous children were included as birth characteristics. Cancer deaths were identified from the death records. In total, 5711,337 births were analyzed, including 30,844,015 total person-years. The total number of deaths was 21,217, including 1102 children who died of cancer. Hazard ratios of cancer mortality according to parental socioeconomic position were calculated using a Cox proportional hazard analysis with adjustment for the birth characteristics. All socioeconomic measures except maternal occupation showed a significant inverse association with cancer mortality after adjusting for the birth characteristics. For paternal education, high school and middle school graduation or lower was associated with an increased hazard ratio of cancer mortality compared to university education or higher: 1.14 (1.00-1.29) and 1.29 (1.02-1.62), respectively. For maternal education, middle school graduation or lower was associated with a hazard ratio of 1.54 (1.21-1.95). For paternal occupation, manual work and economic inactivity were associated with increased hazard ratios as compared to non-manual work: 1.17 (1.02-1.34) and 1.34 (1.04-1.73), respectively. Inequalities were also found for leukemia and central nervous system tumors. The extent of the inequalities decreased after age 5, and only the 1-4-year-old group showed significant associations with parental socioeconomic position. We conclude that there is an inverse relationship between childhood cancer mortality and parental socioeconomic position in Korea.

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 (

It has been shown that childhood mortality is affected by parental socioeconomic positions; in this article, we investigate the extent and distribution of inequalities across major causes of childhood death. We built a retrospective birth cohort using individually linked national birth and death records in South Korea. 1,329,540 children were followed up to exact age eight from 1995 to 1996 and total observed person-years were 10,594,168.18. Causes of death were identified from death records while parental education, occupation and birth characteristics were identified from birth records. Survival analysis was performed according to parental socioeconomic positions. Cox proportional hazard analysis was done according to parental education and occupation with adjustment of birth characteristics such as sex, parental age, gestational age, birth weight, multiple birth, the number of total births, and previous death of children. Cumulative incidence of mortality by age was obtained through a competing-risk method in each cause according to maternal education. From these results, distribution of inequalities across major causes of death was calculated. In total, 7018 deaths occurred during the eight years and mortality rate was 66.24 per 100,000 person-years. External cause was the most common cause of death followed by congenital malformations, nervous system diseases, perinatal diseases, cancer, respiratory, cardiovascular, infectious and gastrointestinal diseases. For all-cause mortality, hazard ratios (HR) were 1.98 (95% CI: 1.83–2.13) for paternal education, 1.90 (1.75–2.07) for maternal education, 1.40 (1.33–1.47) for paternal occupation and 2.33(1.98–2.73) for maternal occupation (between middle school graduation or lower and university or more for education, between manual and non-manual for occupation). Mortality differentials were found in every cause of death. External cause, respiratory, cardiovascular and infectious diseases showed larger HR than all-cause mortality: 2.20 (1.90–2.56), 2.87 (2.02–4.08), 2.50 (1.67–3.75) and 2.12 (1.43–3.15) respectively according to maternal education. On the contrary, congenital malformations and cancer had smaller HR than all-cause mortality: 1.49 (1.22–1.82) and 1.43 (1.00–2.05) respectively according to maternal education. In all-cause mortality and most of the causes, cumulative incidence of mortality increased rapidly until one or two years after birth and then slowed down. But in external cause and cancer, cumulative incidence of mortality accumulated at a constant pace. Thus, inequalities in these causes of death consistently widened. External cause was the leading cause of overall inequalities and its proportion was 36–42% followed by congenital malformations, respiratory diseases etc. We conclude that there were inequalities of childhood mortality in every major cause of death. External cause was the leading cause of both all-cause mortality and overall inequalities. Public health interventions to reduce inequalities are necessary and external cause should be primarily considered.

Government has extended the benefit coverage and reduced out-of-pocket (OOP) payment for cancer patients in 2005. This paper intends to examine the impact of the above policy on the equity in health care utilization. This paper analyzed the national health insurance data and compared the health care utilization of cancer patients before and after the policy change for people with 10 different income levels. For the equity in health care utilization, we examined the change in concentration index (CI) for visit days, inpatient days, and health expenditure. In the case of outpatient care, CI of visit days and health expenditure were positive(favoring the rich) in both regional and employee health insurance members and both `before` and `after` the policy change. CI values rarely changed after the policy change, and the policy change seems to have little impact on the equity of outpatient care utilization except expenditure of regional subscriber. In the case of inpatient care, CI of inpatient days was negative and CI of health expenditure was positive in both regional and work subscriber and both `before` and `after` the policy change. After the policy change, CI of inpatient expenditure in both groups of members decreased. CI of inpatient days changed in the direction favoring the poor in regional insurance members, but it rarely changed in employee insurance members. These results suggest that the policy of reducing OOP payment has a positive impact and reduced the inequity particularly in the utilization of inpatient care of cancer patients.