Multivariate Relationships Between Health Outcomes and Health System Performance Indicators: An Integrated Factor Analysis With Canonical Correlations.

OBJECTIVES: This study aimed to investigate the relationships between sets of variables related to health system performance indicators and health outcomes. METHODS: The relationships between a set of health outcomes and a set of health system performance indicators of a developing country were examined using multivariate statistical analysis techniques. A combinative strategy of explanatory factor analysis and the canonical correlation coefficient was used to define linear structural relationships between study variables. Province-based data were gathered from2 official statistical records of the Turkish Statistical Institute for the year 2019. Life expectancy at birth, infant mortality rate, and crude death rate were accepted as health outcome indicators. RESULTS: The explanatory factor analysis indicated 2 independent variable groups, namely (1) health-related human resources and capacity and (2) health service utilization characteristics. The results of the canonical correlation analysis illustrated good performance to define sparse linear combinations of the 2 groups of variables. There existed strong positive correlations between health outcomes and health-related human resources and capacity indicators (rc = 0.83; P < .001) and health service utilization indicators (rc = 0.59; P < .001). CONCLUSIONS: The results of this study support the view that there is a linear and strong positive relationship between health outcomes and health-related human resources and capacity indicators. Further studies will combine big data analytics with multivariate statistical analysis techniques by studying large health system performance data sets.

Efficiency effects of public hospital closures in the context of public hospital reform: a multistep efficiency analysis.

In the wake of hospital reforms introduced in 2011 in Turkey, public hospitals were grouped into associations with joint management and some shared operational and administrative functions, similar in some ways to hospital trusts in the English National Health Service. Reorganization of public hospitals effect hospital and market area characteristics and existence of hospitals. The objective of this study is to examine the effect of closure on competitive hospital performances. Using administrative data from Turkish Public Hospital Statistical Yearbooks for the years 2005 to 2007 and 2014 to 2017, we conducted a three-step efficiency analysis by incorporating data envelopment analysis (DEA) and propensity score matching techniques, followed by a difference-in-differences (DiD) regression. First, we used bootstrapped DEA to calculate the efficiency scores of hospitals that were located near hospitals that had been closed. Second, we used nearest neighbour propensity score matching to form control groups and ensure that any differences between these and the intervention groups could be attributed to being near a hospital that had closed rather than differences in hospital and market area characteristics. Lastly, we employed DiD regression analysis to explore whether being near a closed hospital had an impact on the efficiency of the surviving hospitals while considering the effect of the 2011 hospital reform policies. To shed light on a potential time lag between hospital closure and changes in efficiency, we used various periods for comparison. Our results suggest that the efficiency of public hospitals in Turkey increased in hospitals that were located near hospitals that closed in Turkey from 2011. Hospital closure improves the efficiency of competitive hospitals under hospital market reforms. Future studies may wish to examine the efficiency effects of government and private sector collaboration on competition in the hospital market.

Exploring Predictors of Preterm Birth: A Comparative Study of Turkish and Syrian Refugee Women.

OBJECTIVE: This study is designed to explore associated sociodemographic, birth-related and household characteristics with preterm birth (< 37 weeks) among Turkish and Syrian refugee women. METHODS: The data utilized in this study were obtained from the Turkey Demographic and Health Survey (TDHS) conducted in 2018. Various statistical analyses, including descriptive statistics, independent sample t-tests, and Chi-square tests, were employed to examine the differences in study variables between Turkish and Syrian refugee women. Furthermore, logistic regression analysis was conducted to identify the associated factors with preterm birth among Turkish and Syrian refugee women, allowing for comparative analysis. RESULTS: The key findings of this study revealed significant differences in sociodemographic (p < 0.05), birth-related (p < 0.05), and household characteristics (p < 0.05) that are associated with preterm birth among Turkish and Syrian refugee women. Also, nationality (OR: 3.427; 95% CI 2.770-4.241), delivery by c-section (OR: 1.630; 95% CI 1.370-1.939), educational status (OR: 0.674; 95% CI 0.547-0.832), place of delivery (OR: 0.806; 95% CI 0.666-0.975), and number of household members (OR: 1.206; 95% CI 1.013-1.437) were found to be important factors associated with preterm birth risk. CONCLUSIONS: The key findings of this study contribute to the identification of women's factors in preterm birth. By understanding the factors that contribute to preterm birth among both Syrian refugee and Turkish women, appropriate interventions can be developed to improve maternal and child health outcomes.

Does increasing the number of beds or health workers contribute to the rational use of scarce public health resources?

Turkey makes substantial investments to increase the number of qualified beds in hospitals, the shortage in health professionals remains one of the main obstacles of the health system in the country. To address this research gap, the study aims to formulate a rational solution for the dilemma on whether to invest in beds or health professionals contribute to the rational use of scarce public health resources. Data for testing the model were derived from the Turkish Statistical Institute across 81 provinces in Turkey. The path analytic approach was used to determine the associations among hospital size, utilization/facility, health workforce, and indicators of health outcomes. The results point to a strong link between quantity of qualified beds, utilization of health services, and facility indicators, and health workforce. Rational use of scarce resources, optimal capacity planning, and increased quantity of health professionals will be beneficial for the sustainability of health care services.

The effect of increases in the Syrian refugee population in Turkey on public maternal and child health outcomes.

Our purpose in this study is to explore the effect that increases in the Syrian refugee population could have on public maternal and child health outcomes. Data collected from official records from 81 Turkish provinces in 2018, and then, subjected to mediating analysis using a path analytic approach to examine the interrelationships between the Syrian population, adolescent marriage, and economic integration factors on refugee maternal and child health outcomes. An increase in the Syrian population would lead to a rise in adolescent birth rates and under-5 mortality under the mediating effect of an increase in adolescent female marriage.

Distributive Pattern of Health Services Utilization Under Public Health Reform and Promotion in Turkey.

OBJECTIVES: Inclusive health policies and health promotion to ensure strong primary healthcare systems are main tenets of health reforms in developing countries, such as Turkey. Nevertheless, there has been a lack of interest regarding the assessment of equity in health services utilization under public health reform and promotion of primary care. This study aims to analyze equity by measuring deviations from proportionality in the relationship between the utilization of health services and income using indices and curve approaches. METHODS: A cross-sectional national Turkey Health Survey used the years 2008, 2010, 2012, and 2014. Gini and Kakwani indices and concentration curves were estimated, and the degree of regressivity was analyzed to understand the sources of equity in health services utilization. RESULTS: Health services utilization for inpatient and outpatient services and family medicine and general practitioner services were regressive between the years 2008 and 2014. The most regressive pattern was observed in the year 2014 regarding medicine usage (Kakwani index = -0.1808904). CONCLUSIONS: Differences in the utilization of health services have increased, hurting the poorest during the health reform in Turkey. Policies focused on health promotion to strengthen the primary health system and continuous monitoring of health services utilization by vulnerable groups are essential for ensuring a fairer health service usage in developing countries.

Associated patient demographic characteristics and disease-related self-care behaviors with diabetes: a mediation model.

OBJECTIVE: The burden of diabetes is increasing rapidly in Turkey; however, there is insufficient information regarding the interrelated factors of diabetes. This study aims to fill this gap by investigating associated characteristics and self-care behaviors of patients with diabetes. METHODS: Path analysis was used to test interrelated factors of diabetes. Data were obtained from a cross-sectional, population-based study (Turkey Health Survey) from 2014. The determined sample size was 9,740 households, and 26,075 individuals were interviewed. There were 19,129 persons who reported having diabetes. Age and gender characteristics and disease-related self-care behaviors of individuals were collected through a self-reported questionnaire. Goodness-of-fit indices were used to assess model fit. RESULTS: The results demonstrated that patient characteristics, self-care behaviors, and diabetes are causally interrelated (p < 0.0001). Blood glucose monitoring mediated the interrelationships between patient demographic characteristics and diabetes. The model fit indices indicated a good fit of the path model to the data (goodness-of-fit index = 0.96; comparative fit index = 0.89; incremental fit index = 0.89; normed fit index = 0.89). The fight against the increasing prevalence of diabetes mandates enhancing self-care behaviors of individuals with diabetes, including regular blood glucose monitoring and the inculcation of healthy dietary habits. CONCLUSIONS: The results can guide health policy makers to promote patient-centered management of diabetes in the age of the escalating burden of this disease.

Intensive Care Unit Services Preparedness for the Pandemic: An Efficiency Analysis.

Intensive care unit (ICU) services efficiency and the shortage of critical care professionals has been a challenge during pandemic. Thus, preparing ICUs is a prominent part of any pandemic response. The objective of this study is to examine the efficiencies of ICU services in Turkey right before the pandemic. Data were gathered from the Public Hospital Statistical Year Book for the year 2017. Analysis are presented at hospital level by comparing teaching and non-teaching hospitals. Bootstrapped data envelopment analysis procedure was used to gather more precise efficiency scores. Three analysis levels are incorporated into the study such as, all public hospitals (N = 100), teaching (N = 53), non-teaching hospitals (N = 47), and provinces that are providing high density of ICU services through the country (N = 54). Study results reveal that average efficiency scores of ICU services obtained from teaching hospitals (eff = 0.65) is higher than non-teaching (eff = 0.54) hospitals. After applying the bootstrapping techniques, efficiency scores are significantly improved and the difference between before and after bootstrapping results are statistically significant (P < .05). Province based analysis indicates that, ICU services efficiencies are high for provinces located in southeast part of the country and highly populated places, such as Istanbul. Evidence-based operational design that considers the spatial distribution of health resources and effective planning of critical care professionals are critical for efficient management of intensive care. Study results will be helpful for health policy makers to deeply understand dynamics of critical care.

Cluster analysis of health systems in Europe according to life expectancy at birth.

PURPOSE: The aim of this study was to group European countries according to life expectancy at birth and to determine the impact of economic growth and financial indicators on European country groups. METHOD: This study planned and conducted by using life expectancy at birth time series, economic growth and financial development indicators data for the period of 1980 to 2015. European countries are classified in terms of life expectancy (LE) at birth time series data from 1980 to 2015 by using hierarchical clustering analysis method. Random Forest and Classification and Regression Tree (CART) algorithm was used to examine predictors of European country groups in terms of long-term LE time series data by using economic growth and financial development indicators. RESULTS: The results of this study show that Eastern and Western countries are mostly in two different clusters in terms of long-term LE time series. This study sheds light on the difference between Eurosceptic countries and other European countries. This study revealed that inflation in consumer prices, which is an indicator of economic growth, outperforms financial development indicators to predict country groups in terms of long-term life expectancy at birth data. CONCLUSION: Countries in the same cluster may have similar problems and solutions in their health care systems. Priority should be given to health problems that adversely affect the life expectancy of the countries in the same cluster in order to raise the quality of life and extend life expectancy in the European continent.

Health behaviors and health services accessibility factors associated with diabetes: a propensity score matching analysis.

Background: Despite the increasing burden of diabetes in Turkey, there is a lack of information regarding behaviors and accessibility factors associated with diabetes. This study aims to explore diabetes prevalence and to identify the associated health behaviors and accessibility factors. Research design and methods: Data was gathered from TurkStat-Health Survey for the year 2014. 1996 individuals who had reported diabetes were matched to similar non-diabetes participants in terms of socio-demographic characteristics and comorbidities by using 1:1 nearest matching based on estimated propensity scores. Results: The weighted point prevalence of diabetes among adults was 8.98%. Compared with smokers, non-smokers were less likely to develop diabetes (OR:0.96; 95% CI:0.95-0.97). Individuals engaging in regular physical activity were less likely to have experienced diabetes than individuals not engaging in any physical activity (OR:0.51; 95% CI:0.41-0.52). Conclusions: Improving the health behaviors of individuals and promoting a culture of exercise, healthy food consumption and better planning of preventive services are necessary strategies to fight against diabetes in Turkey. Collaboration between health professionals will result in effective clinical decision making and the development of diabetes self-management programs.

Oncology services efficiency in the age of pandemic: A jackknife and bootstrap sensitivity analysis for robustness check of DEA scores.

BACKGROUND: Developing countries face great challenges in health care because of changing disease dynamics and the increasing burden of chronic diseases such as cancers. Thus, effective operational design of health services is critical to better manage scarce health care resources. This study aimed to examine the spatial distribution of the efficiency of Turkey's oncology services. METHODS: Data was collected from the 2017 Public Hospitals Statistical Yearbook, and a total of 55 provinces with advanced centers for cancer were analyzed. This study applied Charnes, Cooper, and Rhodes's input-oriented data envelopment analysis (DEA) and performed jackknifing for robustness check of DEA scores. RESULTS: The iteration procedure generated four models. The final model included 38 decision-making units (DMUs), and 50 % of provinces were found to have efficient oncology services. The final model's average conventional efficiency score was 0.79. Next, bootstrapped DEA procedure was incorporated into the final model to gather bias-corrected efficiency scores. After applying the bootstrapping approach, efficiency scores are significantly improved and the difference between conventional and bias-corrected efficiency scores are statistically significant (U = 475; p < 0.05). CONCLUSIONS: Geographic planning of cancer care services is a relevant principle in health operations design that requires specific health service configurations for preparedness of health crisis such as pandemic. The results highlighted that health policymakers must be aware of regional imbalances and eliminate them to provide advanced oncology care services for population groups in poor areas of the country. POLICY SUMMARY: Health policy makers should prioritize a balanced geographical distribution of professional oncology services to provide vulnerable groups better access to critical care.

Poverty effects of public health reforms in Turkey: A focus on out-of-pocket payments.

RATIONALE, AIMS, AND OBJECTIVES: Expanded financial coverage is critical to fight against poverty through public health reforms in developing countries. This study explores inequity in public health financing reforms in Turkey between 2003 and 2015. METHODS: This paper has two parts. The first part examines inequity in health care financing in Turkey between 2003 and 2015. Gini, entropy (Theil and mean logarithmic deviation), and Atkinson indexes were calculated. In the second part of the paper, we investigated the degree of progressivity by using Kakwani index and Lorenz and concentration curves. RESULTS: We found a decreasing trend in terms of inequity. After major public health reforms and unification of the health financing system, it is seen that the distribution of out-of-pocket expenditure on health stands on the shoulders of vulnerable groups. CONCLUSIONS: Study results provide a deep understanding of the effects of poverty on public health financing reforms on households in Turkey. To reduce out-of-pocket health spending inequities and to protect vulnerable groups from increasing the level of health expenditures, we suggest that the government enlarges health insurance coverage for the poor.

Integrated k-means clustering with data envelopment analysis of public hospital efficiency.

The goal of this study is to integrate k-means clustering with data envelopment analysis to examine technical efficiencies in public hospitals in Turkey. A two-step analysis procedure involving provinces and public hospitals is applied in this study. The first step examines similar provinces in terms of welfare state indicators by using k-means clustering and silhouette (Sil) cluster validity index measures. Then, the efficiencies of public hospitals in different groups of provinces are determined. The data are taken from the Turkish Statistical Institute and the 2017 Public Hospitals Statistical Year Book for eighty-one provinces and 688 public hospitals. Study results show that, relative to similarities of welfare state indicators, there are five province groups (Sil = .58). The number of technically inefficient public hospitals is greater than the number of technically efficient public hospitals in all groups. Study results emphasize that incorporated methodology of k-means clustering with data envelopment analysis is useful to identify efficiencies of public hospitals located in provinces that have similar welfare status.

Nonclinical predictors of caesarean section: a path analytic approach.

The objective of this study was to explore nonclinical predictors of cesarean sections (CS) and how they interact with each other, specifically in Turkey. Data was gathered from official statistical records for the year 2017 from the 81 different provinces throughout Turkey. A path analytic model was constructed to examine the interrelationships between socioeconomic factors, utilization of health services, patient satisfaction, and number of CS procedures. The overall performance of the final path model was quite good (GFI = 0.98, AGFI = 0.93, and CFI = 0.96). The study results emphasize the substantial impact of an increase in the number of hospital admissions on the increase in the rate of CS procedures (PC = 0.70). Additionally, the increase in the number of hospital admissions mediates the interrelationship between geographic region, high education, and CS. The findings demonstrate the significant interrelationships among the several major nonclinical predictors of CS in Turkey.Impact StatementWhat is already known on this subject? There has been a considerable increase in the rate of CS in Turkey and the current study examined the nonclinical predictors of CS, and how they interact with each other, specifically in Turkey. The insights developed by this study are due to its scope and topicality. Although of course clinical factors associated with CS are reflected in the literature, this study focused on nonclinical predictors of CS.What the results of this study add? This study empirically clarifies the causal interrelationships among nonclinical predictors of CS, using data from Turkey where CS rates are very high, causing great concern by health professionals and decision-makers. The results of this study provide a stronger understanding of how nonclinical factors relate to CS in Turkey. Significant factors include the connective role of geographic region, the increasingly high level of education being received by women, and the total number of hospital admissions.What the implications are of these findings for clinical practice and/or further research? Study results empirically prove interconnection among geographic region, education, health services utilisation and the number of CS. Health decision makers need to consider the important indirect effects of region, education and number of hospital admissions on the demand for CS procedures.

Prevalence of upper respiratory tract infections and associated factors among children in Turkey.

PURPOSE: Upper respiratory tract infections (URIs) are the most common diseases observed in children aged 0-6 years in Turkey. This study was conducted to investigate URIs in 0-6 year-old children in Turkey. DESIGN AND METHODS: Data of children aged 0-6 years who were included in the 2014 Turkey Health Survey conducted by the Turkish Statistical Institute were collected from their parents. RESULTS: In total, 1,293 and 1,732 children with and without URIs, respectively, were identified. The weighted point prevalence of URIs was 42.23%. Compared with the uninsured and female children belonging to high-income families, insured male children belonging to low-income families were more likely to develop URIs (p < .001). Moreover, comorbidities such as communicable diseases, anemia and diarrhea, and factors like health services utilization were associated with URIs. Analysis of health services utilization highlights that URIs were reported more among the children who had not visited a hospital than among those who had visited a hospital, with an odds ratio of 1.23. CONCLUSIONS: The results of this study provide a deeper understanding of sociodemographic, comorbid, and health services utilization factors associated with URIs. These results provide useful insights for pediatric nursing professionals to improve the quality and efficiency of pediatric respiratory nursing services. PRACTICE IMPLICATIONS: Collaborative networks with other health professionals, parents, and public health policy-makers are essential to decrease the prevalence of URIs in Turkey. These study results provide several insights for health professionals to improve pediatric action plans for ultimately improving child health status.

Politics and health outcomes: A path analytic approach.

Social and health policies and political participation are associated with each political tradition related to public health outcomes. However, there is a lack of evidence for the relationship between policy and outcomes. This study seeks to determine the relationship between politics, labour and welfare state indicators, economic inequality, and health outcome indicators. Data to test the model was obtained from the Turkish Statistical Institute (TurkStat) that belongs to the 81 provinces of Turkey. Path analysis was used to model the associations between policy, labour and welfare states, economic inequality, and health outcomes. To test the goodness of fit of the model, multiple criteria of model fit indices were utilised. The fit of the respecified path analytic model data is good (normed fit index [NFI] is 0.91, comparative fit index [CFI] is 0.92, goodness of fit index [GFI] is 0.91, and adjusted goodness of fit index [AGFI] is 0.93). Study results illustrate a strong relationship between voter partisanship, employment rate, satisfaction from both social security and health services, and life expectancy at birth and mortality. These results represent an important step towards understanding the elusive relationship between policy and health outcomes. Designing socially inclusive policies, considering labour market opportunities, and enhancing the population's well-being are advisable strategies for policymakers who wish to optimise public health outcomes.

Explanatory Factors of Quality of Care from Cataract Patients' Perspectives.

PURPOSE: The purpose of this study is to examine explanatory factors of perceived quality of care among cataract surgery patients. METHODS: This study was administered to 264 cataract patients within one eye hospital located in Ankara, Turkey. The study was designed to determine the latent structure of quality of care. In order to assess cataract surgery patients' views about quality of care, the QUOTE-Cataract survey was used. The questionnaire's internal consistency was assessed using Cronbach's Alpha (0.96) and appropriateness of the factor analytic model was assessed using KMO (0.50) and Bartlett's test ([Formula: see text]=2004.959, p<0.001). Explanatory factor analysis with Varimax rotation was performed in order to determine the underlying factors in the model. RESULTS: Four factors emerge from the explanatory factor analysis: relaying information about care process and behaviors; diagnosis and treatment process; accessibility/punctuality of physicians; and hospital facilities. The four factors explain 86% of total variance. CONCLUSION: The results of this study highlight the importance of sharing information with patients about treatment processes and accessibility/punctuality of physicians in the perception of quality of care among cataract surgery patients.