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Ethics of care and selective organisational caregiving by private employers for employees with chronic illness in a middle-income country

Vijayasingham L, Jogulu U, Allotey P

Soc Sci Med, 2021 01;269:113608.
PMID: 33360218 DOI: 10.1016/j.socscimed.2020.113608

For people with chronic illnesses in low-and-middle-income countries, access to enabling resources that contribute to health, economic and social resilience such as continued employment, often fall outside the health sector's remit or delivery of national structural protection. In the absence of sufficient laws and policies that mitigate discrimination and enhance reasonable work modifications, private employers have a high degree of agency and discretion in how they hire, manage, or terminate employees with chronic illnesses (ECI). There is a scarcity of research on how employers make decisions under these conditions. Using a constructivist grounded theory approach, we interviewed and analysed data from 30 human resource (HR) professionals and decision-makers within private organisations in Klang Valley, Malaysia (June 2015-September 2016). In this paper, we use 'ethics of care' as an analytic, and moral lens to present HR's decision-making rationales in caring for and managing ECI. Respondents described the positive influence of international practices, including through parent company policies, as a reference for best practice. While overt bias and discriminatory perceptions were predictably described, participants also discussed care as relational organisational culture, and strategy, albeit selectively. Apart from illness factors such as duration and severity, descriptions of 'selective caregiving' included considerations of an employee's duration in organisations, the perceived value of the employee to employers, organisation size, ethos, resources and capabilities, and how organisations managed the uncertainty of illness futures as a potential risk to organisation outcomes. Selective caregiving can contribute to social, economic and health inequalities in populations with chronic illness. Nevertheless, global health actors can use the problems identified by participants, as entry points to engage more closely with employers and the broader private and commercial sectors in LMICs, to facilitate more inclusive care, and care-based intersectoral work to address the social and economic determinants of health.
An ecological study of the relationship between urban built environment and cardiovascular hospital admissions (2004-2016) in an Asian developing country

Kwan SC, Ismail R, Ismail NH, Mohamed N

Soc Sci Med, 2021 05;276:113868.
PMID: 33799201 DOI: 10.1016/j.socscimed.2021.113868

This study aims to evaluate the relationship between urban built environment and hospital admissions from cardiovascular diseases in Kuala Lumpur, Malaysia. Hospital admission data from 2004 to 2016 for cardiovascular diseases were used with patient residential postcodes as the unit of analysis. Data was split into 2004-2009 (12,551 cases) and 2010-2016 (17,154 cases) periods corresponding to land use data. We used generalized linear mixed model to analyse population density, property value, entropy index, and the kernel density (800 m) of specific land use, bus and rail stations, and road junctions, with time period and postcodes as the random effects to generate incidence rate ratios (IRRs). Results indicated that entropy index and recreational area density were associated with fewer hypertensive disease and ischemic heart disease hospital admissions (IRR range: 0.49-0.68, 95%CI: 0.27, 0.97). Population density and property value were associated with fewer cerebrovascular disease hospital admissions (IRR range: 0.29-0.34, 95%CI: 0.11, 0.75). Contrarily, density of road junctions was associated with 2.5-6.3 times more hospital admissions for cardiovascular disease hospital admissions (IRR range: 2.53-6.34, 95%CI: 1.07,17.91). There were no significant association between hospital admission and density of residential area, undeveloped land, rail and bus stations. The shapes of relationships for all attributes were non-linear, and changed markedly at the third quartile except for recreational area density. The findings suggest that land use attributes have some protective effects on the cardiovascular disease admission cases as compared to the transport attributes. These findings have important merits for integrating health into urban planning.
Offspring's labor migration and its implications for elderly parents' emotional wellbeing in Indonesia

Kumar S

Soc Sci Med, 2021 05;276:113832.
PMID: 33784552 DOI: 10.1016/j.socscimed.2021.113832

Population ageing and labor out-migration are increasingly challenging normative intergenerational support systems and familial welfare in parts of Asia. Extant studies look at how migration affects the material wellbeing of sending-households, but less is known about how migration shapes the emotional health of non-migrants as origin and destination conditions evolve. This study examines how labor migration among adult children shape the emotional health of elderly parents in Indonesia, and how observed implications are modified by alternative care arrangements and different migrant destinations. Using panel data from 2101 respondents age 50+ in the 2007 and 2014 Indonesia Family Life Survey, and individual-level fixed effects regressions, this study finds that offspring's migration is associated with increased parental depression, net of covariates. Depressive outcomes are abated if resulting care deficits are offset by co-residence or daily interactions with adult children, or if children move to economically lucrative international destinations; however, having a child in Malaysia - a destination characterized by high informal labor employment - increased parental depression. These findings draw attention to the non-economic implications of migration and the distress experienced specifically by parents who lack intergenerational support and who have concerns about child's wellbeing at destination.
Barriers and facilitators to health screening in men: A systematic review

Teo CH, Ng CJ, Booth A, White A

Soc Sci Med, 2016 09;165:168-176.
PMID: 27511617 DOI: 10.1016/j.socscimed.2016.07.023

RATIONALE: Men have poorer health status and are less likely to attend health screening compared to women.
OBJECTIVE: This systematic review presents current evidence on the barriers and facilitators to engaging men in health screening.
METHODS: We included qualitative, quantitative and mixed-method studies identified through five electronic databases, contact with experts and reference mining. Two researchers selected and appraised the studies independently. Data extraction and synthesis were conducted using the 'best fit' framework synthesis method.
RESULTS: 53 qualitative, 44 quantitative and 6 mixed-method studies were included. Factors influencing health screening uptake in men can be categorized into five domains: individual, social, health system, healthcare professional and screening procedure. The most commonly reported barriers are fear of getting the disease and low risk perception; for facilitators, they are perceived risk and benefits of screening. Male-dominant barriers include heterosexual -self-presentation, avoidance of femininity and lack of time. The partner's role is the most common male-dominant facilitator to screening.
CONCLUSIONS: This systematic review provides a comprehensive overview of barriers and facilitators to health screening in men including the male-dominant factors. The findings are particularly useful for clinicians, researchers and policy makers who are developing interventions and policies to increase screening uptake in men.
Chronic illness and sustainable careers: How individuals with multiple sclerosis negotiate work transitions in a middle-income country

Vijayasingham L, Jogulu U, Allotey P

Soc Sci Med, 2020 01;245:112699.
PMID: 31785425 DOI: 10.1016/j.socscimed.2019.112699

Reports of work change and transitions are common amongst individuals with chronic illnesses such as multiple sclerosis (MS). However, there is little research on the lived experience of these work transitions. The scarcity of this research is particularly evident within low-and-middle-income countries, where protection laws and resources such as anti-discrimination laws and reasonable work modifications may not exist or be well enforced. In this paper, we explore how and why individuals with MS seek and achieve work transitions in the structural context of Malaysia. We interviewed ten working individuals with MS (July-december 2015) using a joint hermeneutic phenomenology and constructivist grounded theory approach. Using a broad conceptual lens of 'sustainable careers', we examine their careers as a series of experiences, decisions, and events, paying attention to the influences of context, time, their personal levels of agency and sense of meaning. Participants described work transitions as early as within the first year of diagnosis, that were prompted by voluntary, involuntary and semi-voluntary reasons. Key aspects of the process of seeking new roles included an exploration of alternative roles and paths, and then acquiring, trialing/adapting and remaining engaged in their new roles. Participants identified the perception and experience of 'being unemployable', based on how their diagnosis and short-term symptoms were responded to by employers. Nevertheless, participants used various strategies and career resources to obtain and maintain meaningful work roles. However, success in obtaining or maintaining new roles were not equally achieved. This research draws attention to the cumulative economic disadvantage of a chronic illness diagnosis, even at milder and episodic stages. Furthermore, it reiterates the need for cohesive structural protection in low-and-middle-income countries to facilitate a more equal ability to remain economically resilient and capable of engaging in meaningful long-term careers when living with a chronic illness.
Predicting intention to participate in self-management behaviors in patients with Familial Hypercholesterolemia: A cross-national study

Hagger MS, Hamilton K, Hardcastle SJ, Hu M, Kwok S, Lin J, et al.

Soc Sci Med, 2019 12;242:112591.
PMID: 31630009 DOI: 10.1016/j.socscimed.2019.112591

RATIONALE: Familial Hypercholesterolemia (FH) is a genetic condition that predisposes patients to substantially increased risk of early-onset atherosclerotic cardiovascular disease. FH risks can be minimized through regular participation in three self-management. BEHAVIORS: physical activity, healthy eating, and taking cholesterol lowering medication.
OBJECTIVE: The present study tested the effectiveness of an integrated social cognition model in predicting intention to participate in the self-management behaviors in FH patients from seven countries.
METHOD: Consecutive patients in FH clinics from Australia, Hong Kong, Brazil, Malaysia, Taiwan, China, and UK (total N = 726) completed measures of social cognitive beliefs about illness from the common sense model of self-regulation, beliefs about behaviors from the theory of planned behavior, and past behavior for the three self-management behaviors.
RESULTS: Structural equation models indicated that beliefs about behaviors from the theory of planned behavior, namely, attitudes, subjective norms, and perceived behavioral control, were consistent predictors of intention across samples and behaviors. By comparison, effects of beliefs about illness from the common sense model were smaller and trivial in size. Beliefs partially mediated past behavior effects on intention, although indirect effects of past behavior on intention were larger for physical activity relative to taking medication and healthy eating. Model constructs did not fully account for past behavior effects on intentions. Variability in the strength of the beliefs about behaviors was observed across samples and behaviors.
CONCLUSION: Current findings outline the importance of beliefs about behaviors as predictors of FH self-management behaviors. Variability in the relative contribution of the beliefs across samples and behaviors highlights the imperative of identifying sample- and behavior-specific correlates of FH self-management behaviors.
Fulltext The gender responsiveness of social entrepreneurship in health - A review of initiatives by Ashoka fellows

Khalid S, Dixon S, Vijayasingham L

Soc Sci Med, 2022 Jan;293:114665.
PMID: 34954676 DOI: 10.1016/j.socscimed.2021.114665

There are vocal calls to act on the gender-related barriers and inequities in global health. Still, there are gaps in implementing programmes that address and counter the relevant dynamics. As an approach that focuses on social problems and public service delivery gaps, social entrepreneurship has the potential to be a closer health sector partner to tackle and transform the influence of gender in health to achieve health systems goals better. Nevertheless, social entrepreneurs' engagement and impact on gender and health remain understudied. Using the Ashoka Fellows database as a sampling frame in November 2020 (n = 3352, health n = 129), we identified and reviewed the work of 21 organizations that implemented gender-responsive health-related programmes between 2000 and 2020. We applied the UNU-IIGH 6-I Analytic Framework to review the gender issues, interventions, included populations, investments, implementation, and impact in each organization. We found that a low proportion of fellows engage in gender-responsive health programming (<1%). Many organizations operate in low-and middle-income countries (16/21). The gender-responsive programmes include established health sector practices, to address gendered-cultural dynamics and deliver people-centred resources and services. Interestingly, most organizations self-identify as NGOs and rely on traditional grant funding. Fewer organizations (6/21) adopt market-based and income-generating solutions - a missed opportunity to actualise the potential of social entrepreneurship as an innovative health financing approach. There were few publicly available impact evaluations-a gap in practice established in social entrepreneurship. All organizations implemented programmes at community levels, with some cross-sectoral, structural, and policy-level initiatives. Most focused on sexual and reproductive health and gender-based violence for predominantly populations of women and girls. Closer partnerships between social entrepreneurs and gender experts in the health sector can provide reciprocally beneficial solutions for cross-sectorally and community designed innovations, health financing, evidence generation and impact tracking that improve the gender-responsiveness of health programmes, policies, and systems.
The impact of lifestyle guidance intervention on health outcomes among Japanese middle-aged population with metabolic syndrome: A regression discontinuity study

Li Y, Babazono A, Jamal A, Liu N, Fujita T, Zhao R, et al.

Soc Sci Med, 2022 Dec;314:115468.
PMID: 36327638 DOI: 10.1016/j.socscimed.2022.115468

Metabolic syndrome (MetS) prevalence has increased globally with considerable morbidity and economic burden at both individual and national levels. Japan is the first and only country that has introduced a nationwide lifestyle guidance intervention program to manage and control MetS. We conducted a quasi-experiment approach-regression discontinuity design-to evaluate the impact of this intervention on health outcomes at the population level. We retrospectively collected data of adults aged ≥35 years who participated in health checkups in 2015. Age in 2015 was used as the assignment variable, and an age of 40 years old was the threshold because those with MetS aged ≥40 were required to receive lifestyle guidance intervention. Among 26,772 MetS adults, those who received the intervention had significant reductions in obesity measurements (bodyweight, waist circumference, and body mass index [BMI]) after 1 year of this intervention. Blood pressure was also significantly reduced in men after 1 year of undertaking the intervention. The results were similar when including demographic, socioeconomic, and behavioral covariates and using alternative functional forms to estimate the impact, or when bandwidths around intervention thresholds were changed. Our results showed that lifestyle guidance intervention for MetS has an important impact on weight loss and blood pressure reduction at the population level. This intervention could address the high burden of obesity and cardiovascular diseases in Japan and other countries with an unmet need for MetS prevention and management.
Fulltext Handwashing adherence during the COVID-19 pandemic: A longitudinal study based on protection motivation theory

Szczuka Z, Siwa M, Abraham C, Baban A, Brooks S, Cipolletta S, et al.

Soc Sci Med, 2023 Jan;317:115569.
PMID: 36436259 DOI: 10.1016/j.socscimed.2022.115569

RATIONALE: The associations between the number of COVID-19 cases/deaths and subsequent uptake of protective behaviors may reflect cognitive and behavioral responses to threat-relevant information.
OBJECTIVE: Applying protection motivation theory (PMT), this study explored whether the number of total COVID-19 cases/deaths and general anxiety were associated with cross-situational handwashing adherence and whether these associations were mediated by PMT-specific self-regulatory cognitions (threat appraisal: perceived vulnerability, perceived illness severity; coping appraisal: self-efficacy, response efficacy, response costs).
METHOD: The study (#NCT04367337) was conducted in March-September 2020 among 1256 adults residing in 14 countries. Self-reports on baseline general anxiety levels, handwashing adherence across 12 situations, and PMT-related constructs were collected using an online survey at two points in time, four weeks apart. Values of COVID-19 cases and deaths were retrieved twice for each country (one week prior to the individual data collection).
RESULTS: Across countries and time, levels of adherence to handwashing guidelines were high. Path analysis indicated that smaller numbers of COVID-19 cases/deaths (Time 0; T0) were related to stronger self-efficacy (T1), which in turn was associated with higher handwashing adherence (T3). Lower general anxiety (T1) was related to better adherence (T3), with this effect mediated by higher response efficacy (T1, T3) and lower response cost (T3). However, higher general anxiety (T1) was related to better adherence via higher illness severity (T1, T3). General anxiety was unrelated to COVID-19 indicators.
CONCLUSIONS: We found a complex pattern of associations between the numbers of COVID-19 cases/deaths, general anxiety, PMT variables, and handwashing adherence at the early stages of the pandemic. Higher general anxiety may enable threat appraisal (perceived illness severity), but it may hinder coping appraisal (response efficacy and response costs). The indicators of the trajectory of the pandemic (i.e., the smaller number of COVID-19 cases) may be indirectly associated with higher handwashing adherence via stronger self-efficacy.
Fulltext Clinician resistance to broaching the topic of weight in primary care: Digging deeper into weight management using strong structuration theory

Hajizadeh A, Heath L, Ahmad A, Kebbe M, Jebb SA, Aveyard P, et al.

Soc Sci Med, 2023 Jul;329:115997.
PMID: 37327596 DOI: 10.1016/j.socscimed.2023.115997

Clinical trials have shown that providing advice and support for people with excess weight can lead to meaningful weight loss. Despite this evidence and guidelines endorsing this approach, provision in real-world clinical settings remains low. We used Strong Structuration Theory (SST) to understand why people are often not offered weight management advice in primary care in England. Data from policy, clinical practice and focus groups were analysed using SST to consider how the interplay between weight stigma and structures of professional responsibilities influenced clinicians to raise (or not) the issue of excess weight with patients. We found that general practitioners (GPs) often accounted for their actions by referring to obesity as a health problem, consistent with policy documents and clinical guidelines. However, they were also aware of weight stigma as a social process that can be internalised by their patients. GPs identified addressing obesity as a priority in their work, but described wanting to care for their patients by avoiding unnecessary suffering, which they were concerned could be caused by talking about weight. We observed tensions between knowledge of clinical guidelines and understanding of the lived experience of their patients. We interpreted that the practice of 'caring by not offering care' produced the outcome of an absence of weight management advice in consultations. There is a risk that this outcome reinforces the external structure of weight stigma as a delicate topic to be avoided, while at the same time denying patients the offer of support to manage their weight.
Cultural tightness-looseness and normative social influence in eight Asian countries: Associations of individual and collective norms with vaccination intentions

Shi J, Kim HK, Salmon CT, Tandoc EC, Goh ZH

Soc Sci Med, 2024 Jan;340:116431.
PMID: 38000175 DOI: 10.1016/j.socscimed.2023.116431

RATIONALE: Countries worldwide faced the same public health crisis that required promoting the same health behavior-vaccinations-during the COVID-19 pandemic. Thus, scholars have a unique opportunity to test behavioral change theories across countries with different cultural backgrounds.
OBJECTIVE: Employing the extended theory of social normative behavior, this study examines the influence of individual and collective norms on COVID-19 vaccination intention across eight Asian countries. We examine how cultural tightness-looseness, defined as the degree of a culture's emphasis on norms and tolerance of deviant behavior, shapes normative social influence on COVID-19 vaccination intention.
METHODS: We conducted a multicountry online survey (N = 2676) of unvaccinated individuals in China, Indonesia, Japan, Malaysia, Singapore, South Korea, Thailand, and Vietnam in May and June 2021, when COVID-19 vaccination mandates had not yet been implemented in those countries. We conducted hierarchical regression analyses with interaction terms for the total sample and then re-categorizied the eight countries as either "tight" (n = 1102) or "loose" (n = 1574) to examine three-way interactions between individual norms, collective norms, and cultural tightness-looseness.
RESULTS: Perceived injunctive norms exerted the strongest impact of all normative factors on vaccination intention. Collective injunctive norms' influence depended on both perceived injunctive and descriptive norms, which was larger when norms were lower (vs. higher). The interactive pattern between perceived and collective norms was more pronounced in countries with greater cultural tightness.
CONCLUSION: Our findings reveal nuanced patterns of how individual and collective social norms influence health behavioral decisions, depending on the degree of cultural tightness-looseness.
Fulltext Health poverty among people with type 2 diabetes mellitus (T2DM) in Malaysia

Parra-Mujica F, Roope LS, Abdul-Aziz A, Mustapha F, Ng CW, Rampal S, et al.

Soc Sci Med, 2024 Jan;340:116426.
PMID: 38016309 DOI: 10.1016/j.socscimed.2023.116426

In the context of the escalating burden of diabetes in low and middle-income countries (LMICs), there is a pressing concern about the widening disparities in care and outcomes across socioeconomic groups. This paper estimates health poverty measures among individuals with type 2 diabetes mellitus (T2DM) in Malaysia. Using data from the National Diabetes Registry between 2009 and 2018, the study linked 932,855 people with T2DM aged 40-75 to death records. Cox proportional hazards models were used to estimate the 5-year survival probabilities for each patient, stratified by age and sex, while controlling for comorbidities and area-based indicators of socio-economic status (SES), such as district-level asset-based indices and night-time luminosity. Measures of health poverty, based on the Foster-Greer-Thorbecke (FGT) measures, were employed to capture excessive risk of premature mortality. Two poverty line thresholds were used, namely a 5% and 10% reduction in survival probability compared to age and sex-adjusted survival probability of the general population. Counterfactual simulations estimated the extent to which comorbidities contribute to health poverty. 43.5% of the sample experienced health poverty using the 5% threshold, and 8.9% were health poor using the 10% threshold. Comorbidities contribute 2.9% for males and 5.4% for females, at the 5% threshold. At the 10% threshold, they contribute 7.4% for males and 3.4% for females. If all patients lived in areas of highest night-light intensity, poverty would fall by 5.8% for males and 4.6% for females at the 5% threshold, and 4.1% for males and 0.8% for females at the 10% threshold. In Malaysia, there is a high incidence of health poverty among people with diabetes, and it is strongly associated with comorbidities and area-based measures of SES. Expanding the application of health poverty measurement, through a combination of clinical registries and open spatial data, can facilitate simulations for health poverty alleviation.

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