Forgone healthcare and financial burden due to out-of-pocket payments in Bangladesh: a multilevel analysis

Background Ensuring access to health services for all is the main goal of universal health coverage (UHC) plan. Out-of-pocket (OOP) payment still remains the main source of funding for healthcare in Bangladesh. The association between barriers to accessing healthcare and over-reliance on OOP payments has not been explored in Bangladesh using nationally representative household survey data. This study is a novel attempt to examine the burden of OOP payment and forgone healthcare in Bangladesh, and further explores the inequalities in catastrophic health expenditures (CHE) and forgone healthcare at the national and sub-national levels. Methods This study used data from the most recent nationally representative cross-sectional survey, Bangladesh Household Income and Expenditure Survey, conducted in 2016–17 (N = 39,124). In order to identify potential determinants of CHE and forgone healthcare, multilevel Poisson regression was used. Inequalities in CHE and forgone healthcare were measured using the slope index of inequality. Results Around 25% of individuals incurred CHE and 14% of the population had forgone healthcare for any reasons. The most common reasons for forgone healthcare were treatment cost (17%), followed by none to accompany or need for permission (5%), and distance to health facility (3%). Multilevel analysis indicated that financial burden and forgone care was higher among households with older populations or chronic illness, and those who utilize either public or private health facilities. Household consumption quintile had a linear negative association with forgone care and positive association with CHE. Conclusion This study calls for incorporation of social safety net in health financing system, increase health facility, and gives priority to the disadvantaged population to ensure access to health services for all.

Structural Racism as an Environmental Justice Issue: A Multilevel Analysis of the State Racism Index and Environmental Health Risk from Air Toxics

Communities of color and poor neighborhoods are disproportionately exposed to more air pollution—a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black–white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.

Ethnicity and governing party support in Africa: A longitudinal multilevel analysis

Historically, ethnicity has been considered to play a fundamental role in voting behaviour in Africa. However, researchers on the issue have found contradictory conclusions. The most recent research concludes that the African voter is more rational than expected. Overall ethnicity seems to be less influential than theory used to suggest. Against this background, this paper analyses vote for governing party in Africa and presents evidence that the method and data set used will have an important influence upon the final result. The research takes form of a quantitative analysis making extensive use of survey data from 2005 to 2019. Results indicate that ethnicity, although not exclusively, is still an explanatory factor. At a glance, African vote is rationally ethnic.

Documenting design research by structured multilevel analysis: supporting the diversity of the design research community of practice

The diversity of design research studies and their associated methods and reporting style make it difficult for the design research community of practice to leverage its work into further advancing the field. We illustrate how a structured multilevel analysis of diverse studies creates a canonical model that allows for the transfer of insight between studies, enhances their comprehension, and supports improved study designs. The benefits of such an approach will increase if different stakeholders adopt such structured approaches to enrich the design research community of practice.