Varduhi Petrosyan

Progress towards universal health coverage in BRICS: translating economic growth into better health

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--represent some of the worlds fastest growing large economies and nearly 40% of the worlds population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources.

Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition.

IntroductionSelf-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. This study identified the set of predictors of fair/poor self-rated health in adult female and male populations of Armenia during a period of long-lasting socio-economic transition to a market economy.MethodsDifferences in self-rated health were analyzed along three dimensions: socioeconomic, behavioral/attitudinal, and psychosocial. The study utilized data from a 2006 nationwide household health survey that used a multi-stage probability proportional to size cluster sampling with a combination of interviewer-administered and self-administered surveys. Both female and male representatives of a household aged 18 and over completed the self-administered survey. Multivariate odds ratios (OR) for fair/poor self-rated health were calculated for different sets of variables and logistic regression models fitted separately for women and men to identify the determinants of fair/poor self-rated health.ResultsOverall, 2310 women and 462 men participated in the survey. The rate of fair/poor self-rated health was 61.8% among women and 59.7% among men. For women, the set of independent predictors of fair/poor self-rated health included age, unemployment, poverty, low affordability of healthcare, depression, and weak social support. For men, the set included age, lower education, depression, weak social support, and drinking alcohol less than once a week. For both genders, depression and weak social support demonstrated the strongest independent association with fair/poor self-rated health.ConclusionsThe prevalence of fair/poor self-rated health was similar among men and women in this study, but the sets of independent predictors of perceived health differed somewhat, possibly, reflecting lifestyle differences between men and women in Armenia. Nevertheless, psychosocial variables were the strongest predictors of fair/poor self-rated health for both genders, indicating the importance of improving the country’s psychosocial environment through social reforms and poverty reduction.

Psychometric value of the Center for Epidemiologic Studies Depression (CES-D) scale for screening of depressive symptoms in Armenian population

BACKGROUND This study examined the psychometric value of the Center for Epidemiologic Studies Depression Scale (CES-D) translated for use with an Armenian population. METHODS Using data obtained from a country-wide health survey of 2310 households involving female and male respondents aged 18 and over, we investigated the response pattern to the CES-D items, the factor structure, internal consistency, inter-item correlations of the total scale and its negatively and positively formulated subscales. We used logistic regression analysis to relate the constructs measured by the CES-D and its subscales to known determinants of depression. RESULTS Armenian respondents of both genders significantly suppressed their positive emotions, thus over-endorsing positively formulated (reverse-coded) items, therefore producing artificially high depression scores. Factor analysis of the scale yielded a three-factor structure (combined Depressed/Somatic, Positive Affect, and Interpersonal). The Positive Affect factor correlated weakly with the other two factors, and its inclusion reduced the internal consistency of the whole scale. Unlike the 16-item subscale of negatively formulated items, Positive Affect was not related to several known determinants of depression and did not reflect known depression-specific differences between genders. The set of determinants of Positive Affect included mainly lifestyle and attitudinal variables. LIMITATIONS This study did not assess the concurrent and discriminate validity of the Armenian CES-D. CONCLUSIONS For Armenians, the construct measured by the four Positive Affect items of CES-D is not related to depressive symptoms as measured by the other items. It introduces ethnical/cultural response bias in CES-D score and reduces the cross-cultural comparability of the latter.

Reducing Children’s Exposure to Secondhand Smoke at Home: A Randomized Trial

OBJECTIVE: To develop and test an intervention to reduce children’s exposure to secondhand smoke (SHS) at homes in Yerevan, Armenia. METHODS: A single-blind, randomized trial in 250 households with 2- to 6-year-old children tested an intensive intervention (counseling sessions, distribution of tailored educational brochures, demonstration of home air pollution, and 2 follow-up counseling telephone calls) against minimal intervention (distribution of standard leaflets). At baseline and 4-month follow-up, researchers conducted biomonitoring (children’s hair) and surveys. The study used paired t tests, McNemar’s test, and linear and logistic regression analyses. RESULTS: After adjusting for baseline hair nicotine concentration, child’s age and gender, the follow-up geometric mean (GM) of hair nicotine concentration in the intervention group was 17% lower than in the control group (P = .239). The GM of hair nicotine in the intervention group significantly decreased from 0.30 ng/mg to 0.23 ng/mg (P = .024), unlike in the control group. The follow-up survey revealed an increased proportion of households with smoking restrictions and decreased exposure of children to SHS in both groups. The adjusted odds of children’s less-than-daily exposure to SHS at follow-up was 1.87 times higher in the intervention group than in the control group (P = .077). The GM of mothers’ knowledge scores at follow-up was 10% higher in the intervention group than in the control group (P = .006). CONCLUSIONS: Intensive intervention is effective in decreasing children’s exposure to SHS through educating mothers and promoting smoking restrictions at home. However, superiority over minimal intervention to decrease children’s exposure was not statistically significant.

Visual impairment and depression among socially vulnerable older adults in Armenia

Objectives: Visual impairment in older adults is a major public health problem. Untreated visual impairment might negatively impact physical and psychological health. This study assessed the association between visual impairment and depression among socially vulnerable older adults (those aged 50 and above) in Armenia.Method: The survey and eye screenings were carried out among 339 participants who were the residents of retirement homes and single older adults in the households. The study team used Golovin–Sivtsev chart and cycloplegic skiascopy to measure visual impairment and Center for Epidemiologic Studies Depression scale to measure depression.Results: The prevalence of visual impairment in the sample was 13.3%. Almost 24.0% of participants reported depression symptoms. Participants living in the retirement homes had substantially higher rates of visual impairment (21.5%) and depression (28.0%) than those living in households (9.3% and 15.0%, respectively). The odds of having depression were higher among those with visual impairment compared to those without after adjusting for confounders (OR = 2.75; 95% CI: 1.29–5.87). Having at least one non-communicable disease was associated with depression (OR = 2.47; 95% CI: 1.28–4.75). Living in the retirement home was marginally significantly associated with having depression. Other confounders included age, gender, education, physical activity, and smoking.Conclusion: Visual impairment was significantly associated with depression in socially vulnerable older adults in Armenia. Timely eye screenings in similar population groups could lead to early detection of visual impairment and prevention of visual loss and associated mental health problems.

Patient satisfaction with primary care in Armenia: good rating of bad services?

The study assessed the level of patient satisfaction at selected primary health-care facilities in Lori and Shirak provinces of Armenia. Self-administered questionnaires were distributed to 684 recent clients at primary health-care facilities. The majority of patients were satisfied with their provider (mean satisfaction score of 1.75 out of maximum 2). Most patients (89.0%) would visit the same provider again, and would recommend the provider to friends (85.6%). Satisfaction with other aspects of care, including waiting time, accessibility of services, confidentiality and cleanliness of the facility, was also high (mean score of 1.70 out of 2). Seventy-eight percent of respondents considered the care they received to be ‘excellent’ or ‘good’. The less educated and those in rural areas were more likely to be satisfied with the providers quality. Despite the fundamental problems now challenging the Armenian primary health-care sector, patient satisfaction remains high. Given the high level of reported satisfaction, more focused satisfaction research tools and alternative approaches to patient assessments of care are needed to inform quality improvement in the Armenian setting.

Estimated prevalence and predictors of undernutrition among children aged 5-17 months in Yerevan, Armenia.

OBJECTIVE Child undernutrition is a serious public health problem in many low- and middle-income countries. Data on child undernutrition prevalence and its risk factors in Armenia are limited. The present study aimed to estimate the prevalence and explore the predictors of undernutrition among children aged 5-17 months in Yerevan. DESIGN The study was cross-sectional and employed a review of the ambulatory charts of children selected through a multistage cluster sampling. This phase was followed by a case-control study. The cases were undernourished children identified during the record review and randomly matched with normally growing controls of the same age and gender from the same pool of records. Mothers of cases and controls participated in a telephone interview. The study used conditional logistic regression analysis. SETTING Yerevan, Armenia. SUBJECTS Children aged 5-17 months residing in Yerevan, Armenia. RESULTS Review of 570 ambulatory charts suggested the prevalence of stunting, underweight and wasting among 5-17-month-old children in Yerevan to be 17·9 %, 7·3 % and 3·1 %, respectively. The case-control study of eighty-nine matched pairs identified four significant predictors of child undernutrition: familys socio-economic status score (P = 0·030), childs length at birth (P = 0·027), duration of predominant breast-feeding (P = 0·046) and food diversity score (P = 0·039). CONCLUSIONS The factors determining growth patterns of children in Yerevan are mostly behavioral and environmental, hence modifiable. Reducing poverty and inequalities in food availability, promoting breast-feeding and adequate complementary feeding, and ensuring optimal care before, during and after pregnancy are likely to help reduce child undernutrition in Yerevan, Armenia and societies with similar public health concerns.

Short and long term determinants of incident multimorbidity in a cohort of 1988 earthquake survivors in Armenia

BackgroundMultimorbidity, presence of two or more health conditions, is a widespread phenomenon affecting populations’ health all over the world. It becomes a serious public health concern due to its negative consequences on quality of life, mortality, and cost of healthcare services utilization. Studies exploring determinants of multimorbidity are limited, particularly those looking at vulnerable populations prospectively over time. This study aimed at identifying short and long term socioeconomic, psychosocial, and health behavioral determinants of incident multimorbidity among a cohort of the 1988 Armenian earthquake survivors.MethodsThe study included a representative subsample of 725 from a larger initial cohort of the earthquake survivors. Data on this subsample were collected via four phases of this cohort study during the period 1990–2012. The final logistic regression analysis eliminated all those cases with baseline multimorbidity to investigate short and long term determinants of incident multimorbidity; this subsample included 600 participants.ResultsMore than 75% of the studied sample had multimorbidity. Perceived low affordability of healthcare services, poor living standards during the post-earthquake decade, and lower education were independent predictors of incident multimorbidity developed during the period 1990–2012. Stressful life events and poor social support were among psychosocial determinants of incident multimorbidity. Participants’ baseline BMI reported in 1990 was independently associated with incident multimorbidity.ConclusionsMost of the identified determinants of incident multimorbidity in our study population were markers of social inequities, indicating that inequities pose a serious threat to both individual and public health-related outcomes. Strategies targeting to decrease such inequities along with promotion of healthy lifestyle and strengthening of social networks may considerably reduce multimorbidity among population groups with similar socioeconomic and cultural profiles.

The prevalence of and major risk factors associated with diabetic retinopathy in Gegharkunik province of Armenia: cross-sectional study

BackgroundDiabetic retinopathy (DR) is one of the leading causes of blindness in adults in industrialized countries and the emerging cause of blindness in developing countries. The objective of this study was to describe the prevalence of DR and risk factors associated with it among diabetic patients.MethodsThe analytical cross-sectional survey and eye screenings were carried out among 625 diabetic patients from urban and rural areas of Gegharkunik region. DR was assessed by dilated ophthalmoscopy and defined based on the WHO International Classification of Diseases. The survey instrument, included questions about demographics, disease history, health status, medication use and healthy lifestyle. Descriptive statistics and logistic regression were used to analyze the data.ResultsThe prevalence of DR in the sample was 36.2%. A total of 90.2% of patients with DR had non-proliferative, while 9.8% had proliferative DR. In bivariate analysis, age, diabetes duration, being under insulin treatment, blood glucose level, having non-communicable diseases were significantly associated with DR. In the adjusted analysis being under insulin treatment (OR = 3.24; 95% CI: 1.56–6.75), diabetes duration (OR = 1.23; 95% CI: 1.16–1.31) and age (OR = 1.05; 95% CI: 1.02–1.08) were independently associated with DR.ConclusionEarlier diagnosis of diabetes and DR can help to control some of these factors and prevent further complications and vision loss. Population-based educational programs on diabetes and diabetic retinopathy and continuous medical education on diabetes management can improve diabetes care and self-management and prevent eye complications.

In search of patient-centred care in middle income countries: The experience of diabetes care in the former Soviet Union

In this study we apply the principles of patient-centred care to assess how health systems in middle income countries shape the experiences of patients with a common chronic disease and their care providers. We conducted semi-structured interviews with patients with diabetes, health professionals and key informants. We selected interviewees by purposive and snowball sampling. In total 340 respondents were interviewed in five countries: Armenia, Belarus, Moldova, Russia and Ukraine. Data were analysed according to a coding framework that was developed by three researchers, who then uncovered salient themes, similarities and differences between the five countries. Access to and consistent use of services was hampered by the lack of coordination and the financial weaknesses in the health systems. In many cases, lack of external support for individual patients left friends and family as the main providers of support. Patients were not expected to have a say or challenge the decisions concerning their treatment. Our study suggests the need for a radically different way of delivering care for people with diabetes and, by extension, other chronic diseases. Reforms should focus on improving self-management, the coordination of care, involving patients in decisions about their care, and providing emotional and practical support for patients.