{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T05:47:47Z","timestamp":1767764867385,"version":"3.48.0"},"reference-count":37,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T00:00:00Z","timestamp":1767657600000},"content-version":"unspecified","delay-in-days":5,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001713","name":"European & Developing Countries Clinical Trials Partnership","doi-asserted-by":"crossref","award":["RIA2017MC-2029"],"award-info":[{"award-number":["RIA2017MC-2029"]}],"id":[{"id":"10.13039\/501100001713","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2025,12,3]]},"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Direct non-medical out-of-pocket costs, such as transport and subsistence, can delay access to child healthcare and worsen health outcomes. This study examined socioeconomic differences in reimbursable out-of-pocket expenditure (OOPE) within the BabyGel trial in eastern Uganda.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a prospective cohort study nested within the BabyGel trial (2022\u20132024) in Budaka and Mbale districts. Reimbursed transport and inpatient subsistence costs were recorded for 2675 mother\u2013baby pairs. Socioeconomic status (SES) was derived using multiple correspondence analysis and categorised into low, middle and high SES. Gamma and quantile regression models were used to examine differences in OOPE.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We included 2675\u2009women (mean age 25 years (SD 6)). Children from low SES households had an average of 3.0 hospital visits, while those from middle SES households had the longest average hospital stay of 6.0\u2009days. Low-SES households had 82% higher OOPE (exp(b)=0.82; 95%\u2009CI 0.73 to 0.93). Secondary education and shorter distances to water source were associated with 10% lower OOPE, while diarrhoea increased OOPE by US$1.49 at the 25th percentile.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Reimbursing transport and subsistence costs can reduce financial barriers to newborn care, particularly benefiting low-SES households. These findings highlight the potential of targeted financial support mechanisms to promote equitable access to child healthcare in low-resource settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-003323","type":"journal-article","created":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T05:15:20Z","timestamp":1767762920000},"page":"e003323","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Socioeconomic differences and determinants of reimbursable out-of-pocket expenditures: a prospective cohort study within the BabyGel trial"],"prefix":"10.1136","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2786-8091","authenticated-orcid":false,"given":"Francis","family":"Okello","sequence":"first","affiliation":[{"name":"Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway"},{"name":"Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5757-609X","authenticated-orcid":false,"given":"Peter","family":"Olupot-Olupot","sequence":"additional","affiliation":[{"name":"Clinical & Infectious Disease Epidemiology, Busitema University Faculty of Health Sciences, Mbale, Eastern Region, Uganda"},{"name":"Directorate of Research, Mbale Clinical Research Institute, Mbale, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thorkild","family":"Tyllesk\u00e4r","sequence":"additional","affiliation":[{"name":"University of Bergen, Bergen, Norway"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ingunn Marie Stadskleiv","family":"Engebretsen","sequence":"additional","affiliation":[{"name":"Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antonieta","family":"Medina-Lara","sequence":"additional","affiliation":[{"name":"Department of Public Health and Sport Sciences, University of Exeter, Exeter, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,1,6]]},"reference":[{"key":"2026010621151055000_4.1.e003323.1","doi-asserted-by":"crossref","DOI":"10.7189\/jogh.06.010408","article-title":"Cost of management of severe pneumonia in young children: systematic analysis","volume":"6","author":"Zhang","year":"2016","journal-title":"J Glob Health"},{"key":"2026010621151055000_4.1.e003323.2","doi-asserted-by":"crossref","DOI":"10.1186\/s12939-019-1001-7","article-title":"Out-of-pocket expenditure and distress financing on institutional delivery in India","volume":"18","author":"Mishra","year":"2019","journal-title":"Int J Equity Health"},{"key":"2026010621151055000_4.1.e003323.3","doi-asserted-by":"crossref","DOI":"10.1186\/s41182-021-00385-1","article-title":"Health care seeking behaviour for children with acute childhood illnesses and its relating factors in sub-Saharan Africa: evidence from 24 countries","volume":"49","author":"Yaya","year":"2021","journal-title":"Trop Med Health"},{"key":"2026010621151055000_4.1.e003323.4","unstructured":"World Health Organization . Newborn mortality, key facts. 2024. 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World Health Organization (WHO) and the United Nations Children\u2019s Fund (UNICEF); 2021.:Geneva."},{"key":"2026010621151055000_4.1.e003323.19","doi-asserted-by":"crossref","DOI":"10.1186\/1742-7622-5-3","article-title":"Issues in the construction of wealth indices for the measurement of socio-economic position in low-income countries","volume":"5","author":"Howe","year":"2008","journal-title":"Emerg Themes Epidemiol"},{"key":"2026010621151055000_4.1.e003323.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.worlddev.2007.10.008"},{"key":"2026010621151055000_4.1.e003323.21","doi-asserted-by":"crossref","unstructured":"F\u00e1vero LP , Belfiore P , de Freitas Souza R . Chapter 13 - simple and multiple correspondence analysis. In: F\u00e1vero LP , Belfiore P , de Freitas Souza R , eds. Data science, analytics and machine learning with R. Academic Press, 2023: 215\u201334.","DOI":"10.1016\/B978-0-12-824271-1.00013-5"},{"key":"2026010621151055000_4.1.e003323.22","unstructured":"BOU . 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Tackling wasteful spending on health. Paris OECD; 2017."},{"key":"2026010621151055000_4.1.e003323.36","unstructured":"United Nations Children\u2019s Fund and World Health Organization . State of the world\u2019s hand hygiene: a global call to action to make hand hygiene a priority in policy and practice. 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