Regional Disparities in Adult Chronic and Acute Regional Disparities in Adult Chronic and Acute Health in Albania: A Multilevel Analysis of the Health in Albania: A Multilevel Analysis of the

Albanian Living Standards Measurement Survey Albanian Living Standards Measurement Survey 20022002

Katie Bates (LSE), Dr Arjan Gjonça (LSE)

Source:Human Development Report (1993) – UNDP Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport

IntroductionIntroduction

• North-south gradient in mortality

• ‘Good health at low cost’ population

• Albania e15 1989 - 57.8

• U.K. e15 1992 – 58.7

Romania Albania

Bulgaria

Poland

Lithuania

Czechoslovakia

Hungary

Ukraina

EstoniaLatvia

Russia

2000

3000

4000

5000

6000

7000

8000

9000

69 69.5 70 70.5 71 71.5 72 72.5 73

Life expectancy at birth (in years)

GD

P pe

r cap

ita

in U

S $

• North-South Gradient in Mortality• Socioeconomic

– Communist policies population-wide• Behavioural

– Low smoking prevalence– Physical activity uniformly high

• Difference in Age Structure– Unlikely systematic difference– Internal migration restricted

• Diet Hypothesis– North-east – high in animal fats– South-west – ‘Mediterranean diet’ - Olive oil, fresh fruit and vegetables – CVDs

Gjonca, A., Bobak, M., - 1997 – ‘Albanian paradox, another example of the protective effect of Mediterranean lifestyle? ’ Lancet Vol. 350: 1815–17 Gjonca, A., Wilson, C., Falkingham, J. – 1999 – ‘Can Diet and Life Style Explain Regional Differences in Adult Mortality in the Balkans? ’ MPIDR WORKING PAPER WP 1999-003 Gjonça, A – 2001 - Communism, health and lifestyle: the paradox of mortality transition in Albania, 1950-1990. Greenwood Press, Westport

Diet HypothesisDiet Hypothesis Figure 2. Geographical distribution of olive production in Albania, 1985

Rationale for StudyRationale for Study

• North-South gradient in mortality prevailed 1950-1989

• Social and economic changes during post-communist transition

• Albania Living Standards and Measurement Survey 2002 provides opportunity to assess the relationship between region and health outcomes in Albania, post-1989, by drawing on correlation between ill-health and mortality

• Hypothesis: Regional disparities in health remain despite changing socioeconomic conditions

• Research Questions: Is region related to adult health outcomes in Albania?a) Is region related to chronic illness?b) Is region related to acute illness?

Research QuestionsResearch Questions

• Albania Living Standards Measurement Survey 2002

• Dichotomous Dependent Variables: Self-report chronic; Self-report acute

• Multistage Sample design, violation of independence

Table 1. Log Likelihood Ratio Test: Between-Cluster Variance

• Logistic Variance Components Models

INSTAT – 2003 – Albania Living Standard Measurement Survey 2002 Basic Information Document The World Bank, Albania Institute of Statistics (INSTAT)

Data and MethodsData and Methods

Model Dependent Variable Chi-Square Test Statistic P-Value

Chronic Illness

Suffers from chronic illness ‘Yes/No’

97.37*** <0.00001

Acute Illness Has had sudden illness or injury in last 4 weeks ‘Yes/No’

591.69*** <0.00001

*p<0.05, ** p<0.01, *** p<0.001

Data and MethodsData and Methods

•Explanatory Variables (individual and household level)

•Age•Marital Status•Education (years)•Income (percentiles)•Water source (inside/outside HH)•Toilet (inside/outside HH)•Distance to doctor

•Region as fixed effect

•Step-wise Model Selection

Fig. 3: Regions of Albania

Results: Chronic IllnessResults: Chronic Illness

Odds Ratio and 95% Confidence Intervals: Dependent Variable: Suffers from Chronic Illness (Yes/No)

0

5

10

15

20

25

30

age 40 to 59(ref 15-39)

age 60+ (ref: 15-39)

edu 4 years(ref: 0 years)

edu 8 years(ref: 0 years)

edu 10/12 yrs(ref: 0 years)

edu 16+years (ref: 0

years)

married (ref: single)

divorced (ref: single)

w idow ed (ref: single)

sex (ref: female)

central (ref: coastal)

northeast (ref: coastal)

tirana (ref: coastal)

ipc bottom20% (ref:

other 60%)

ipc top 20% (ref: other

60%)

Independent Variables

Od

ds

Rat

io

Results: Acute IllnessResults: Acute Illness

Odds Ratios and 95% Confidence Intervals: Dependent Variable - Had Acute Illness or Injury in last 4 weeks (Yes/No)

0

1

2

3

4

5

6

7

8

age 40 to 59(ref 15-39)

age 60+ (ref: 15-39)

central (ref: coastal)

northeast (ref: coastal)

tirana (ref: coastal)

sex (ref: female)

toilet (ref: inside)

ipc bottom 20%(ref: other 60%)

ipc top 20% (ref: other 60%)

Independent Variable

Od

ds

Rat

io

Results and Regional DisparitiesResults and Regional Disparities

Fig. 6: Geographic Distribution of Odds of Reporting Chronic Illness

Coastal region highest odds of reporting chronic illness

Internal migration as key factor?

Northeast region highest odds of reporting acute illness

Fig. 7: Geographic Distribution of Odds of Reporting Acute Illness

Carletto. G., Davis. B., Stampini. M., Trento. S., Zezza. A, - 2004 - "Internal Mobility and International Migration in Albania," Working Papers 04-13, Agricultural and Development Economics Division of the Food and Agriculture Organization of the United Nations (FAO - ESA)

Discussion/ConclusionDiscussion/Conclusion

•Acute Illness: north-south gradient persists

•Chronic Illness: change in regional pattern

•Change in behavioural risk factors

•Internal migration - ‘the Coastal region is [an] important absorbing area. The Mountain and the Centre regions…, are strong expellers’ (Carletto et al. 2004: 7)

•Future Research: control for migration since 1990

QuestionsQuestions

Model Adequacy and Interpretation: ChronicModel Adequacy and Interpretation: Chronic

0.2

.4.6

.81

prop

_one

s

0 2 4 6 8 10categorical

Figure 21: Predicted Probabilities of Reporting Chronic Illness Figure 21: Predicted Probabilities of Reporting Chronic Illness

Against Observed Probabilities:Against Observed Probabilities:

Model Adequacy and Interpretation: AcuteModel Adequacy and Interpretation: Acute

0.2

.4.6

.81

pro

por

tion

0 2 4 6 8 10categorical

Figure 24: Predicted Probabilities of Reporting Chronic Figure 24: Predicted Probabilities of Reporting Chronic Illness Against Reported Acute Illness:Illness Against Reported Acute Illness:

Odds Ratios for Random Intercept Logistic Regression Models for Reporting Odds Ratios for Random Intercept Logistic Regression Models for Reporting Chronic/No Chronic illness in the last three years: 2002 Albania LSMS:Chronic/No Chronic illness in the last three years: 2002 Albania LSMS:

Variable I II III IV V VI VII

Fixed Effects

Age (ref: 15-39 years)40-59 years 8.088*** 5.503*** 5.325*** 5.609*** 5.662*** 5.833***

(0.7081284) (0.5245048) (0.513209) (0.5473874) (0.5547783) (0.5745211)

60+ years 31.322*** 18.857*** 14.711*** 16.844*** 17.568*** 18.718***(3.52957) (2.222072) (1.817597) (2.163985) (2.278217) (2.456626)

Marital Status (ref:single)Married or living together 2.499*** 2.726*** 2.619*** 2.559*** 2.499***

(0.3278909) (0.359899) (0.3468857) (0.338976) (0.3311848)

Divorced or separated 4.169*** 4.195*** 3.852*** 3.889*** 3.836***(1.641469) (1.661995) (1.532106) (1.548519) (1.527792

Widowed 6.153*** 5.813*** 4.850*** 4.907*** 4.807***(1.171367) (1.110198) (0.9423209) (0.9530763) (0.933189)

Education (ref: 0 years)4 years 0.621 0.623 0.657 0.652

(0.2012638) (0.2034888) (0.2148844) (0.2133105)

8 years 0.417** 0.427** 0.456* 0.459* (0.1350226) (0.1393042) (0.1491049) (0.1499369)

10/12 years 0.273*** 0.289*** 0.323*** 0.335***(0.0892581) (0.0952222) (0.1064694) (0.11014288)

16+ years 0.201*** 0.226*** 0.276*** 0.298***(0.069645) (0.0786464) (0.0968357) (0.1048617)

Sex (ref=female) 0.707*** 0.697*** 0.689***(0.047283) (0.0466998) (0.0462339)

Stratum (ref:Coastal)Central 0.689*** 0.682***

(0.0708276) (0.0699105)

North-east 0.778* 0.718** (0.0810289) (0.0764261)

Tirana 0.521*** 0.532***(0.0660363) (0.0673335)

Per Capita Income Percentilesper hh (ref: other 60%)Bottom 20% 1.357**

(0.1467335)

Top 20% 0.847(0.0838399)

(Constant) 0.190*** 0.036*** 0.020*** 0.053*** 0.059*** 0.073*** 0.072***

Random Effects

Household (L2) sd(Constant) 0.919 1.225*** 1.243*** 1.225*** 1.241*** 1.227*** 1.218** (0.0633001) (0.0743653) (0.0740249) (0.073889) (0.0743424) (0.0742564) (0.0741396)

Household (L2) var(Constant) 0.844561 1.500625 1.545049 1.500625 1.540081 1.505529 1.483524

ICC Intra-Class Correlation 0.20427512 0.31325063 0.31956 0.313251 0.318861 0.313953 0.31079Log-Likelihood -4915.419 -4054.901 -4004.624 -3960.256 -3946.605 -3931.608 -3925.079Degrees of Freedom 2 4 7 11 12 15 17Log-Likelihood Difference 860.518*** 50.277*** 44.368*** 13.651*** 14.997** 6.529*Degrees of Freedom Difference 2 3 4 1 3 2P-Values 1.38E-187 7.00E-11 5.38E-09 0.00022 0.001819 0.038216AIC 9834.837 8117.801 8023.248 7942.512 7917.21 7893.217 7884.159N 10222 10222 10222 10222 10222 10222 10222

Model

Odds Ratios for Random Intercept Logistic Regression Models for Reporting Odds Ratios for Random Intercept Logistic Regression Models for Reporting Acute/No Acute illness in the last four weeks: 2002 Albania LSMS:Acute/No Acute illness in the last four weeks: 2002 Albania LSMS:

Variable I II III IV V VI

Fixed Effects

Age (ref: 15-39 years)40-59 years 2.282*** 2.426*** 2.549*** 2.599*** 2.629***

(0.2199198) (0.2342236) (0.2500288) (0.2549652) (0 .2582449 )

60+ years 4.014*** 4.465*** 5.132*** 5.247*** 5.511***(0.5219988) (0.583059) (0.6921795) (0.7072082) (0 .7466479)

Stratum (ref:Coastal)Central 1.518** 1.539** 1.567** 1.542**

(0.2392453) (0.2472751) (0.2501611) (0 .2453959)

North-east 2.497*** 2.582*** 2.466*** 2.219***(0.3911967) (0.4127569) (0.3915) (0 .356908)

Tirana 0.197*** 0.188*** 0.238*** 0.240***(0.0459697) (0.0446893) (0.0567664) (0 .0572852)

Sex (ref=female) 0.543*** 0.541*** 0.539***(0.04432) (0.0441844) (0 .044063)

Toilet (ref:inside hh) 1.961*** 1.791***(0.2522042) (0.23375)

Per Capita Income Percentilesper hh (ref: other 60%)Bottom 20% 1.870***

(0.2956277)

Top 20% 1.032 (0 .1618756)

(Constant) 0.040*** 0.020*** 0.017*** 0.021*** 0.016*** 0.015***

Random Effects

Household (L2) sd(Constant) 2.065*** 2.256*** 2.140*** 2.195*** 2.168*** 2.151***(0.095336) (0.1026171) (0.1021867) (0.1043542) (0.1042058) (0.1038974)

Household (L2) var(Constant) 4.264225 5.089536 4.5796 4.818025 4.700224 4.626801

ICC Intra-Class Correlation 0.564492 0.607386 0.581945301 0.5942388 0.588256546 0.5844378Log-Likelihood -3397.417 -3319.51 -3241.985 -3212.915 -3199.063 -3191.077Degrees of Freedom 2 4 7 8 9 11Log-Likelihood Difference 77.911*** 77.521*** 29.07*** 13.852*** 7.986**Degrees of Freedom Difference 2 3 1 1 2P-Values 1.21E-17 1.04394E-16 6.98097E-08 0.000197786 0.018444298AIC 6798.834 6647.012 6497.971 6441.829 6416.126 6404.154N 10222 10222 10222 10222 10222 10222

Model

Life Expectancy at Birth and GDP per capita in 2001 for Selected CEE Countries

EstoniaLatvia

Lithuania

Russia

Ukraine

Poland

Romania

Hungary

Albania

Bulgaria

Czech Republic

66

67

68

69

70

71

72

73

74

75

76

0 2000 4000 6000 8000 10000 12000 14000 16000

GDP per capita (US$ PPP) 2001

Avera

ge L

ife E

xp

ecta

ncy a

t B

irth

(years

) 2001

CEE context 2001CEE context 2001

Caldwell, J., - 1986 - Routes to Low Mortality in Poor Countries - Population and Development Review Vol. 12, No. 2 (Jun., 1986), pp. 171-220 Published by: Population Council http://www.jstor.org/stable/1973108

Good Health at Low CostGood Health at Low Cost

•Caldwell ‘Routes to low mortality’ (1986)

•Political will, egalitarianism, radicalism

•Government commitment to education

•Government commitment to health care

•Health care free and accessible to all

•Maternal and child health care

•Universal vaccination

•Education (particularly female)

•Female autonomy