Ethnic inequalities in patient satisfaction with primary health care in England: Evidence from recent General Practitioner Patient Surveys (GPPS).

AIMS AND OBJECTIVES: This paper aims to improve understanding of factors that contribute to persistent ethnic disparities in patient satisfaction in England. The specific objectives are to (i) examine ethnic differences in patient satisfaction with their primary care in England; and (ii) establish factors that contribute to ethnic differences in patient satisfaction. DATA AND METHODS: The study is based on secondary analysis of recent General Practitioner Patient Survey (GPPS) datasets of 2019, 2020 and 2021. Descriptive bivariate analysis was used to examine ethnic differences in patient satisfaction across the three years. This was followed with multilevel linear regression, with General Practice (GP) at level-1 and Clinical Commissioning Group (CCG) at level-2 to identify factors contributing to ethnic differences in patient satisfaction. RESULTS: The findings show consistent negative correlations between the proportion of patients reporting good (very or fairly good) overall experience and each of the ethnic minority groups. Further examination of the distribution of patient satisfaction by ethnicity, based on combined ethnic minority groups, depicted a clear negative association between ethnic minority group and patient satisfaction at both GP and CCG levels. Multilevel regression analysis identified several service-related factors (especially ease of using GP website and being treated with care and concern) that largely explained the ethnic differences in patient satisfaction. Of all factors relating to patient characteristics considered in the analysis, none was significant after controlling for GP service-related factors. CONCLUSIONS: Ethnic minority patients in England continue to consistently report lower satisfaction with their primary health care in recent years. This is largely attributable to supply (service related) rather than demand (patient characteristics) factors. These findings have important implications for health care system policy and practice at both GP and CCG levels in England.

INDIVIDUAL- AND COMMUNITY-LEVEL DETERMINANTS OF ANTENATAL HIV TESTING IN ZIMBABWE.

This study contributes to the dialogue on the prevention of mother-to-child HIV transmission (PMTCT) through the use of HIV and antenatal care (ANC) integrated services. The determinants of antenatal HIV testing in Zimbabwe were explored. Multilevel logistic regression models were applied to data for 8471 women from 406 clusters who gave birth in the 5 years preceding Zimbabwe Demographic and Health Surveys conducted in 2005/6 and 2010/11. The uptake of antenatal HIV testing was found to be determined by a wide range of individual-level factors relating to women's economic and demographic status, as well as HIV-related factors, including HIV awareness and stigma within the community. Important individual-level enabling and perceived need factors included high socioeconomic status, not having observed HIV-related stigma and knowledge of HIV status (based on a previous HIV test), such that these groups of individuals had a significantly higher likelihood of being tested for HIV during pregnancy than their counterparts of lower socioeconomic status, and who had observed HIV-related stigma or did not know their HIV status. The results further revealed that community HIV awareness is important for improving antenatal HIV testing, while stigma is associated with reduced testing uptake. Most contextual community-level factors were not found to have much effect on the uptake of antenatal HIV testing. Therefore, policies should focus on individual-level predisposing and enabling factors to improve the uptake of antenatal HIV testing in Zimbabwe.

Understanding the gender disparity in HIV infection across countries in sub-Saharan Africa: evidence from the Demographic and Health Surveys.

Women in sub-Saharan Africa bear a disproportionate burden of human immunodeficiency virus (HIV) infections, which is exacerbated by their role in society and biological vulnerability. The specific objectives of this article are to (i) determine the extent of gender disparity in HIV infection; (ii) examine the role of HIV/acquired immune deficiency syndrome (AIDS) awareness and sexual behaviour factors on the gender disparity and (iii) establish how the gender disparity varies between individuals of different characteristics and across countries. The analysis involves multilevel logistic regression analysis applied to pooled Demographic and Health Surveys data from 20 countries in sub-Saharan Africa conducted during 2003-2008. The findings suggest that women in sub-Saharan Africa have on average a 60% higher risk of HIV infection than their male counterparts. The risk for women is 70% higher than their male counterparts of similar sexual behaviour, suggesting that the observed gender disparity cannot be attributed to sexual behaviour. The results suggest that the risk of HIV infection among women (compared to men) across countries in sub-Saharan Africa is further aggravated among those who are younger, in female-headed households, not in stable unions or marital partnerships or had an earlier sexual debut.

Investigating the association between HIV/AIDS and recent fertility patterns in Kenya.

Findings from previous studies linking the HIV/AIDS epidemic and fertility of populations have remained inconclusive. In sub-Saharan Africa, demographic patterns point to the epidemic resulting in fertility reduction. However, evidence from the 2003 Kenya Demographic and Health Survey (KDHS) has revealed interesting patterns, with regions most adversely affected with HIV/AIDS showing the clearest reversal trend in fertility decline. While there is suggestive evidence that fertility behaviour in some parts of sub-Saharan Africa has changed in relation to the HIV/AIDS epidemic, more rigorous empirical analysis is necessary to better understand this relationship. In this paper, we examine individual and contextual community HIV/AIDS factors associated with fertility patterns in Kenya, paying particular attention to possible mechanisms of the association. Multilevel models are applied to the 2003 KDHS, introducing various proximate fertility determinants in successive stages, to explore possible mechanisms through which HIV/AIDS may be associated with fertility. The results corroborate findings from earlier studies of the fertility inhibiting effect of HIV among infected women. HIV-infected women have 40 percent lower odds of having had a recent birth than their uninfected counterparts of similar background characteristics. Further analysis suggests an association between HIV/AIDS and fertility that exists through proximate fertility determinants relating to sexual exposure, breastfeeding duration, and foetal loss. While HIV/AIDS may have contributed to reduced fertility, mainly through reduced sexual exposure, there is evidence that it has contributed to increased fertility, through reduced breastfeeding and increased desire for more children resulting from increased infant/child mortality (i.e. a replacement phenomenon). In communities at advanced stages of the HIV/AIDS epidemic, it is possible that infant/child mortality has reached appreciably high levels where the impact of replacement and reduced breastfeeding duration is substantial enough to result in a reversal of fertility decline. This provides a plausible explanation for the patterns observed in regions with particularly high HIV prevalence in Kenya.

A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS).

This paper uses Demographic and Health Surveys data from 21 countries in sub-Saharan Africa to examine the use of maternal health services by teenagers. A comparison of maternal health care between teenagers and older women, based on bivariate analysis shows little variation in maternal health care by age. However, after controlling for the effect of background factors such as parity, premarital births, educational attainment and urban/rural residence in a multivariate analysis, there is evidence that teenagers have poorer maternal health care than older women with similar background characteristics. The results from multilevel logistic models applied to pooled data across countries show that teenagers are generally more likely to receive inadequate antenatal care and have non-professional deliveries. An examination of country-level variations shows significant differences in the levels of maternal health care across countries. However, there is no evidence of significant variations across countries in the observed patterns of maternal health care by maternal age. This suggests that the observed patterns by maternal age are generalizable across the sub-Saharan Africa region.

An investigation of district spatial variations of childhood diarrhoea and fever morbidity in Malawi.

Although diarrhoea and malaria are among the leading causes of child mortality and morbidity in Sub-Saharan Africa, few detailed studies have examined the patterns and determinants of these ailments in the most affected communities. In this paper, we investigate the spatial distribution of observed diarrhoea and fever prevalence in Malawi using individual data for 10,185 children from the 2000 Malawi Demographic and Health survey. We highlight inequalities in child health by mapping the residual district spatial effects using a geo-additive probit model that simultaneously controls for spatial dependence in the data and potential nonlinear effects of covariates. The residual spatial effects were modelled via a Bayesian approach. For both ailments, we were able to identify a distinct district pattern of childhood morbidity. In particular, the results suggest that children living in the capital city are less affected by fever, although this is not true for diarrhoea, where some urban agglomerations are associated with a higher childhood morbidity risk. The spatial patterns emphasize the role of remoteness as well as climatic, environmental, and geographic factors on morbidity. The fixed effects show that for diarrhoea, the risk of child morbidity appears to be lower among infants who are exclusively breastfed than among those who are mixed-fed. However, exclusive breastfeeding was not found to have a protective effect on fever. An important socio-economic factor for both diarrhoea and fever morbidity was parental education, especially maternal educational attainment. Diarrhoea and fever were both observed to show an interesting association with child's age. We were able to discern the continuous worsening of the child morbidity up to 8-12 months of age. This deterioration set in right after birth and continues, more or less linearly until 8-12 months, before beginning to decline thereafter. Independent of other factors, a separate spatial process produces district inequalities in child's health.

The inequality of maternal health care in urban sub-Saharan Africa in the 1990s.

Numerous studies document the disadvantage in child health of the urban poor in African cities. This study uses Demographic and Health Survey data from 23 countries in sub-Saharan Africa to examine whether the urban poor experience comparable disadvantages in maternal health care. The results show that, although on average the urban poor receive better antenatal and delivery care than rural residents, the care of the urban poor is worse than that of the urban non-poor. This suggests that the urban bias in the allocation of health services in Africa does not benefit the urban poor as much as the non-poor. Multilevel analyses reveal significant variations in maternal health in urban areas across countries of sub-Saharan Africa. The dis-advantage of the urban poor is more pronounced in countries where maternal health care is relatively good. In these countries the urban poor tend to be even worse off than rural residents, suggesting that the urban poor have benefited least from improvements in maternal health care.

Unplanned childbearing in Kenya: the socio-demographic correlates and the extent of repeatability among women.

Unplanned pregnancies account for a substantial proportion of births in Kenya and can have a variety of negative consequences on individual women, their families, and the society as a whole. This paper examines the correlates of mistimed and unwanted childbearing in Kenya, with special focus on the extent of repetitiveness of these events among women. A multilevel multinomial model is applied to the 1993 Kenya Demographic and Health Survey data. The results show that unplanned childbearing in Kenya is associated with a number of factors, including urban/rural residence, region, ethnicity, maternal education, maternal age, marital status, birth order, length of preceding birth interval, family planning practise, fertility preference and unmet need for family planning. In addition to these factors, women who have experienced an unplanned birth are highly likely to have a repeat occurrence.