Association between forgone care and household income among the elderly in five Western European countries - analyses based on survey data from the SHARE-study

Exploring unmet healthcare needs and associated inequalities among middle-aged and older adults in Eastern China during the progression toward universal health coverage

BACKGROUND

Given the rapid population aging in China, achieving universal health coverage (UHC) presents a primary challenge in addressing unmet healthcare needs and associated inequalities among middle-aged and older adults. Several studies have focused on healthcare utilization and its inequalities, but little attention has been paid to the inequality in unmet healthcare needs. This study aimed to analyze the inequalities in unmet the healthcare needs of middle-aged and older adults in eastern China during the progression toward UHC.

METHODS

Data were obtained from the fourth, fifth, and sixth National Health Service Survey (NHSS) of Jiangsu Province, located in eastern China, during the years 2008, 2013, and 2018, respectively. Logistic regression models were used to assess the associated factors of unmet healthcare needs. The inequality was measured according to the concentration index (CI) and its decomposition.

RESULTS

In this study, we found that 12.86%, 2.22%, and 48.89% of middle-aged and older adults reported unmet needs for outpatient and inpatient services and physical examinations, respectively. The prevalence of unmet outpatient needs increased from 2008 to 2018, while the prevalence of unmet inpatient services was lower but maintained. The prevalence of unmet needs for physical examinations among middle-aged and older adults markedly decreased since 2008. Rural areas had a higher prevalence of unmet needs for inpatient services and physical examinations than urban areas. Unmet healthcare needs were more prevalent among the poor. The pro-poor inequalities of unmet healthcare needs have been mitigated during the progression toward UHC; however, they remain predominant among rural middle-aged and older adults for outpatient and inpatient services. Socioeconomic factors significantly influenced unmet healthcare needs and contributed to their inequalities.

CONCLUSIONS

The findings characterize the prevalence and inequality of unmet healthcare need among middle-aged and older adults in eastern China during the progression toward UHC. Policy interventions should be actively advocated to effectively mitigate the unmet healthcare needs and address the associated inequalities.

Inequalities in patients' experiences with cancer care: the role of economic and health literacy determinants

BACKGROUND

Patients with fewer socioeconomic and health literacy resources are disadvantaged in their access and use of healthcare, which may give rise to worse experiences with care and thus inequalities in patient experiences. However, only a limited number of studies have examined how socioeconomic and health literacy factors shape inequalities in patients' experiences with cancer care.

OBJECTIVE

To examine whether patients' experiences with cancer care differ according to their economic status and health literacy.

METHODS

Secondary analysis of data on 2789 adult patients diagnosed with cancer from the Swiss Cancer Patient Experiences-2 (SCAPE-2) study, a cross-sectional survey conducted in eight hospitals across Switzerland from September 2021 to February 2022. Regression analysis was applied to examine the independent effect of patients' economic status and health literacy on various outcomes of experiences with cancer care, covering eight different dimensions of patient-centred care, controlling for confounding factors.

RESULTS

Adjusted regression analysis showed that patients with lower economic status reported significantly worse experiences with cancer care in 12 out of 29 specific care experiences, especially in the dimensions of 'respect for patients' preferences' and 'physical comfort' where all items of experiences were associated with economic status. Additionally, lower health literacy was associated with worse patient experiences in 23 specific care experiences. All items in the dimensions of 'respect for patients' preferences', 'physical comfort' and 'emotional support' were associated with health literacy.

DISCUSSION

This study revealed significant inequalities in experiences with cancer care shaped by the economic status and health literacy of patients across different dimensions of patient-centred care. It is essential to address the needs of more disadvantaged patients who face obstacles in their access and use of the healthcare system, not only to mitigate inequalities in cancer care but also to avoid inequalities in health outcomes.

Unmet healthcare needs in Southeastern Europe: a systematic review

Objectives

This study sought to systematically review the existing literature on self-reported unmet healthcare needs in Southeastern Europe.

Methods

A systematic literature review of quantitative evidence in English and Bulgarian was performed in July 2023 using the following databases: Medline, Embase and EconLit. Publications were only included if they used self-reported unmet healthcare needs as an indicator of access to healthcare, concerned people living in Albania, Bosnia and Herzegovina, Bulgaria, Greece, Kosovo, Montenegro, Serbia, North Macedonia or Romania and if they were published after 2003. Quality assessment of the included publications was performed using the Appraisal tool for Cross-Sectional Studies (AXIS) tool.

Results

Twenty-three publications of varying quality were included in the review. Significantly more evidence was available for Greece, Bulgaria and Romania than for the rest of the region. Data collected through Pan-European surveys were commonly used, but almost half of the studies were only descriptive. Generally, the prevalence of unmet healthcare needs has decreased over the years. Unmet healthcare needs were higher among people of lower socioeconomic and educational status, ethnic minorities and migrants and high cost was consistently identified as the primary barrier to accessing healthcare.

Conclusion

Unmet healthcare needs are more prevalent among already disadvantaged societal groups. A trend of a declining prevalence of unmet needs has been observed, but it is more notable in the more socioeconomically developed countries. Improving financial protection should be a priority for the healthcare systems.

Predictors of Unmet Healthcare Needs during Economic and Health Crisis in Greece

(1) Background: The aim of this study was to identify predictors of the unmet healthcare needs during the financial and recent health crisis in Greece. (2) Methods: Time series analysis was performed for the years 2008 through 2022 using the Eurostat database. The dependent variable was the percentage of people who reported unmet need for medical care. Demographic, socioeconomic, and health data, as well as health expenditures, were used as independent variables. Correlation analysis and simple linear regression models were conducted to analyze the results. (3) Results: Unmet health needs in Greece increased from the start of the crisis until 2016, as a gradual de-escalation of the crisis was observed. However, in 2019 the country recorded the second highest level of unmet needs for medical care before the health crisis. Limitations in usual activities, reporting bad/very bad health status, being unemployed, and having low income increased the likelihood of unmet needs. Health expenditures (public or private) were also significant determinants of unmet healthcare needs. (4) Conclusions: The increased unmet health needs widen inequalities in health and healthcare access. Therefore, health policies should eliminate barriers which restrict the access to health and enhance healthcare services, developing conditions for citizens' well-being.

Unmet health care needs during the COVID-19 pandemic among adults: a prospective cohort study in the Canadian Longitudinal Study on Aging

BACKGROUND

The COVID-19 pandemic affected access to health care services in Canada; however, limited research examines the influence of the social determinants of health on unmet health care needs during the first year of the pandemic. The objectives of this study were to describe unmet health care needs during the first year of the pandemic and to investigate the association of unmet needs with the social determinants of health.

METHODS

We conducted a prospective cohort study of 23 972 adults participating in the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study (April-December 2020) to identify the social determinants of health associated with unmet health care needs during the pandemic. Using logistic regression, we assessed the association between several social determinants of health on the following 3 outcomes (separately): experiencing any challenges in accessing health care services, not going to a hospital or seeing a doctor when needed, and experiencing barriers to accessing testing for SARS-CoV-2 infection.

RESULTS

From September to December 2020, 25% of participants experienced challenges accessing health care services, 8% did not go to a hospital or see a doctor when needed and 4% faced barriers accessing testing for SARS-CoV-2 infection. The prevalence of all 3 unmet need outcomes was lower among older age groups. Differences were observed by sex, region, education, income and racial background. Immigrants (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.09-1.27) or people with chronic conditions (OR 1.35, 95% CI 1.27-1.43) had higher odds of experiencing challenges accessing health care services and had higher odds of not going to a hospital or seeing a doctor (immigrants OR 1.26, 95% CI 1.11-1.43; chronic conditions OR 1.45, 95% CI 1.31-1.61). Prepandemic unmet health care needs were strongly associated with all 3 outcomes.

INTERPRETATION

Substantial unmet health care needs were reported by Canadian adults during the first year of the pandemic. The results of this study have important implications for health equity.

Descriptive phenomenology study of the reasons for the low uptake of free health service package among type II diabetic patients

BACKGROUND

Although several diabetes management and control programs are introduced in Iran, rate of using such cares in patients with Type II Diabetic in Ahvaz is low and they show no tendency for receiving free diabetes service package. The aim of this study was to identify reasons behind low uptake of free health service package among T2DM patients in Ahvaz, Iran.

METHODS

This descriptive phenomenology study based on semi-structured guided interviews of patients with Type II Diabetic in Ahvaz, was carried out in the year 2021. Through purposeful sampling, 495 patients with diabetics who not received health services package more than 6 months were interviewed until the data saturation. The gathered data were analyzed through conventional content analysis.

RESULTS

Reasons were categorized into three themes which include 13 subthemes and 57 codes. Themes included individual, accessibility, and structural factors. Besides, subthemes were lack of awareness, poor health literacy, adverse patients experience, difficulties to use services, verbal miscommunication cultural barriers, low trust, geographic barriers, time barriers, financial difficulties, lack of human resources, poor service delivery, and organizational factors were as barriers to participation.

CONCLUSION

Regarding individual level, there is a need for further training of diabetic patients. Besides, for accessibility and structural factors Iranian healthcare system needs a comprehensive integrated care for the management of diabetes, this underlines the collaboration for improving patients' uptake of free health service package.

Access to healthcare for people aged 50+ in Europe during the COVID-19 outbreak

This paper combines SHARE Corona Survey and SHARE Wave 7 data for 25 European countries and Israel (N = 40,919) with institutional and epidemic-related country characteristics to investigate healthcare access for Europeans aged 50+ during the outbreak of COVID-19. We use a micro-macro approach to examine whether and to what extent barriers to accessing healthcare measured by reported unmet healthcare needs vary within and between countries. We consider various aspects of barriers and distinguish among: (1) respondents who forewent medical treatment because they were afraid of becoming infected with the Coronavirus; (2) respondents who had pre-scheduled medical appointments postponed by health providers due to the outbreak; and (3) respondents who tried to arrange a medical appointment but were denied one. Limited access to healthcare during the initial outbreak was more common for the occupationally active, women, the more educated and those living in urban areas. A bad economic situation, poor overall health and higher healthcare utilisation were robust predictors of unmet healthcare. People aged 50+ in countries of 'Old' Europe, countries with higher universal health coverage and stricter containment and closure policies were more likely to have medical services postponed. Policymakers should address the healthcare needs of older people with chronic health conditions and a poor socio-economic status who were made more vulnerable by this pandemic. In the aftermath of the health crisis, public health systems might experience a great revival in healthcare demand, a challenge that should be mitigated by careful planning and provision of healthcare services.

Income level and antibiotic misuse: a systematic review and dose-response meta-analysis

OBJECTIVES

To quantify the association between income and antibiotic misuse including unprescribed use, storage of antibiotics and non-adherence.

METHODS

We identified pertinent studies through database search, and manual examination of reference lists of selected articles and review reports. We performed a dose-response meta-analysis of income, both continuous and categorical, in relation to antibiotic misuse. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated under a random-effects random effects model.

RESULTS

Fifty-seven studies from 22 countries of different economic class were included. Overall, the data are in agreement with a flat linear association between income standardized to socio-economic indicators and antibiotic misuse (OR per 1 unit increment = 1.00, p-value = 0.954, p-value non-linearity = 0.429). Data were compatible with no association between medium and high income with general antibiotic misuse (OR 1.04; 95% CI 0.89, 1.20 and OR 1.03; 95% CI 0.82, 1.29). Medium income was associated with 19% higher odds of antibiotic storage (OR 1.19; 95% CI 1.07, 1.32) and 18% higher odds of any aspect of antibiotic misuse in African studies (OR 1.18; 95% CI 1.00, 1.39). High income was associated with 51% lower odds of non-adherence to antibiotic treatment (OR 0.49; 95% CI 0.34, 0.60). High income was also associated with 11% higher odds of any antibiotic misuse in upper-middle wealth countries (OR 1.11; 95% CI 1.00, 1.22).

CONCLUSIONS

The association between income and antibiotic misuse varies by type of misuse and country wellness. Understanding the socioeconomic properties of antibiotic misuse should prove useful in developing related intervention programs and health policies.

Predictors of Healthcare Utilization Among Older Adults with Moderate to Severe Cognitive Limitations in Ghana: A Cross-Sectional Analysis of the WHO Study on Global Ageing and Adult Health (SAGE) Wave 1

BACKGROUND

As the number of older adults in Ghana keeps increasing, so does the prevalence of aging-related diseases and conditions that tend to lead to cognitive decline. However, knowledge on the predicting factors of healthcare utilization among older adults with cognitive limitations is still scarce.

OBJECTIVE

This study examines the predictive factors of healthcare-seeking behavior among older adults with moderate-to-severe cognitive limitations in Ghana.

METHODS

Based on Andersen's behavioral model of health service utilization, the study analyzed data from 3106 older adults with moderate to severe cognitive limitations in Ghana aged 50+ using Bivariate Probit Regression and the Heckman Selection Model.

RESULTS

Results showed that individuals who were aged 75+, living in urban settlements, educated, higher income levels and parents who had some level of education, pension benefits, and both mandatory and voluntary health insurance were more likely to seek inpatient care. Enabling resources such as the national health insurance scheme and other types of medical insurance, household income, pension benefits, and predisposition factors like education influenced outpatient and inpatient healthcare consumption for older adults with moderate to severe cognitive limitations but had little influence on the choice of healthcare facility except for health insurance.

CONCLUSION

Since the healthcare-seeking behavior of older adults with moderate-to-severe cognitive limitations is driven by an amalgamation of several internal and external factors, there is a need for policy change to understand and cautiously incorporate these factors into the decision to improve equitable access to healthcare services for these individuals, as not all sizes fit all in providing quality care for them.

Older Europeans' experience of unmet health care during the COVID-19 pandemic (first wave)

BACKGROUND

During the COVID-19 pandemic the utilization of health services has changed. People were living in a very different social, economic and epidemiological context. Unmet health care is expected to happen. The purposes of this work are i) to compare the differences between unmet care across countries, ii) to find the main factors which are associated with unmet health care, which includes giving up and postponing medical care, as well as denial of medical care provision by the health services, and iii) to determine if health systems' characteristics and government decisions on lockdown were related to unmet care.

METHODS

We have used the most recent dataset collected by the SHARE-COVID Survey during the summer of 2020. These data cover all EU countries and are applied to people over 50. We have estimated a set of logistic regressions to explain unmet health care.

RESULTS

The results indicate that women, people who are slightly younger, with higher education and income, who find it hard to make ends meet each month, and people with poorer health were more likely to experience unmet health care. We also found that in health systems with high out-of-pocket payments people are more likely to give up health care while in countries with previous high levels of unmet health needs this likelihood was the opposite; people in countries with a high number of beds per capita and with a Beveridge-type health system were reporting less postponement of health care.

CONCLUSION

Some policy measures may be suggested such as social and economic measures to mitigate loss of income, expansion of the points and forms of access to health care to improve utilisation.

Education level and misuse of antibiotics in the general population: a systematic review and dose-response meta-analysis

BACKGROUND

Numerous studies evaluated the association of education level with misuse of antibiotics by the general population, yet divergent findings were reported. Therefore, a meta-analysis was conducted to summarize this association.

METHODS

A categorical and continuous dose-response meta-analysis of the association of education level with antibiotic misuse was undertaken. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated using random-effect model.

RESULTS

The meta-analysis included 85 studies from 42 countries of different socioeconomic status. Compared to low education (≤ 9 years), medium education (> 9-12 years) is associated with 20% lower odds of antibiotic misuse in high-income countries (OR = 0.80; 95% CI 0.66, 0.97), while high education (> 12 years) is associated with 14% lower odds of any aspect of antibiotic misuse (OR = 0.86; 95% CI 0.72, 1.03). The association is more pronounced in Middle East (OR = 0.64; 95% CI 0.42, 1.00) and countries of lower-middle economies (OR = 0.67, 95% CI 0.41, 1.11). Inversely, in Europe, high education is associated with 25% higher odds of antibiotic misuse (OR = 1.25, 95% CI 1.00, 1.58). Each additional year of education was associated with 4% lower odds of any aspect of antibiotic misuse in lower-middle economies (OR = 0.96; 95% CI 0.92, 1.00) and in Middle East (OR = 0.96; 95% CI 0.93, 1.00). Conversely, it was associated with 3% higher odds of antibiotic storage, a specific type of misuse (OR = 1.03, 95% CI 1.01, 1.06).

CONCLUSION

Individuals misuse antibiotics irrespective of their education level. Intervention programs to enhance the proper use of antibiotics should target all communities independent of their education level.

Health-related biological and non-biological consequences of forgoing healthcare for economic reasons

Forgoing healthcare for economic reasons has been previously associated with adverse health outcomes, including a higher risk of hospitalization, a lower quality of life, and worse self-reported health. However, the exact cause-to-effect relation between forgoing healthcare and health-related outcomes has been insufficiently described. Here, we investigate the prospective health consequences of forgoing healthcare for economic reasons using data from “ReBus” (N = 400), a prospective study examining the health consequences of forgoing healthcare (Baseline: 2008–2013, Follow-up: 2014–2016). Using regression models, we explored the baseline determinants of forgoing healthcare, including socioeconomic, demographic, and pre-existing health-risk factors, and examined the associations between forgoing healthcare at baseline and health deterioration at follow-up, using highly pertinent biomarkers (glucose, glycated hemoglobin, lipids, blood pressure) and SF-36 questionnaire data.

Low income, low occupation, low education, and smoking were associated with higher odds of forgoing healthcare at baseline. Forgoing healthcare for economic reasons at baseline was subsequently related to detrimental changes in glucose, high-density lipoprotein cholesterol (HDL), and blood pressure (BP) at follow-up, independently of baseline socioeconomic factors (Glucose-β = 0.19, 95%CI[0.03;0.34], HDL-β = -0.07, 95%CI[-0.14;0.01], BP-β = 3.30, 95%CI[-0.01;6.60]). Moreover, we found strong associations between forgoing healthcare and adverse SF-36 health scores at follow-up, with individuals forgoing healthcare systematically displaying worse health scores (6%–11% lower scores).

For the first time, we show that forgoing healthcare for economic reasons predicts adverse health-related consequences 2–8 years later. Our findings shall further encourage the implementation of public health measures aimed at identifying individuals who forgo healthcare and preventing the adverse health consequences of unmet medical needs.

The Unmet Medical Demand among China's Urban Residents

Our work aimed to build a reasonable proxy for unmet medical demands of China's urban residents. We combined health demand modeling and stochastic frontier analysis to produce a frontier medical demand function, which allowed us to disentangle unmet medical demands from the unobservable effects. We estimated unmet medical demands by using China's provincial dataset that covered 2005-2018. Our estimates showed that unmet medical demand at the national level was 12.6% in 2018, and regions with high medical prices confronted more unmet medical demands than regions with moderate or low medical prices during 2005-2018. Furthermore, medical prices and education were the main factors that affected unmet medical demand; therefore, policy making should pay more attention to reducing medical costs and promoting health education.

Forgone care in patients with type 2 diabetes: a cross-sectional study

BACKGROUND AND OBJECTIVE

Diabetes mellitus is a complex chronic disease requiring appropriate continuous medical care and delayed, or forgone care may exacerbate the severity of the disease. This study aimed to investigate the factors affecting forgone care in patients with type2 diabetes.

MATERIALS AND METHODS

This was a cross-sectional study involving 1139 patients with type 2 diabetes aged> 18 years in 2019 in Tabriz, Iran. The researcher-made questionnaire was used for data collection. Data were analyzed using IBM SPSS software version 22 and IBM AMOS 22. Exploratory Factor Analysis (EFA) was performed for dimension reduction of the questionnaire, and Confirmatory Factor Analysis (CFA) used to verify the result of EFA. We applied the binary logistic regression model to assess the factors affecting forgone care.

RESULTS

Of the 1139 patients, 510 patients (45%) reported forgone care during the last year. The percentage of forgoing care was higher in patients without supplementary insurance coverage (P = 0.01), those with complications (P = 0.01) and those with a history of hospitalization (P = 0.006). The majority of patients (41.5%) reported that the most important reason for forgoing care is financial barriers resulting from disease treatment costs. Of the main four factors affecting, quality of care had the highest impact on forgone care at 61.28 (of 100), followed by accessibility (37.01 of 100), awareness and attitude towards disease (18.52 of 100) and social support (17.22 of 100).

CONCLUSION

The results showed that, despite the implementation of the Islamic Republic of Iran on a fast-track to beating non-communicable diseases (IraPEN), a considerable number of patients with type2 diabetes had a history of forgoing care, and the most important reasons for forgoing care were related to the financial pressure and dissatisfaction with the quality of care. Therefore, not only more financial support programs should be carried out, but the quality of care should be improved.

Health Insurance Deductibles and Health Care-Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage

IMPORTANCE

Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined.

OBJECTIVE

To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire.

EXPOSURES

Insurance plan deductible level.

MAIN OUTCOMES AND MEASURES

The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII).

RESULTS

The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.

Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries

Background

Little attention has been devoted to the role of macro-level determinants in preventive health inequalities, particularly in cancer screening participation. Research has evidenced inequalities in cancer screening uptake yet has mainly focused on the screening programmes’ moderating role at the macro-level. To address this gap, this study examines how welfare provision and healthcare system features modify cancer screening uptake and inequalities across European countries.

Methods

Data from 99 715 (Pap smear) and 54 557 (mammography) women in 29 countries from the European Health Interview Survey (EHIS) 2014 wave and Swiss Health Interview Survey (SHIS) 2012 wave was analysed. We estimated multilevel logistic regression models, including cross-level interactions, to examine whether social protection expenditure in particular policy areas and healthcare system characteristics explained cross-country differences in Pap smear and mammography uptake and inequalities.

Results

Main findings revealed that GP gatekeeping systems were associated with reduced screening uptake likelihood in both Pap smear and mammography, and so were stronger primary care systems in Pap smear, while higher expenditures on old age and survivors were associated with increased mammography uptake. Cross-level interactions showed that in countries with higher expenditures on sickness/healthcare, disability, social exclusion and public health, and a higher number of GPs, educational inequalities in both Pap smear and mammography uptake were smaller, while higher out-of-pocket payments had the opposite effect of increasing inequalities.

Conclusions

Overall, our results show that social protection policies and healthcare system features affect cancer screening participation. We conclude that institutional and policy arrangements interact with individuals’ (educational) resources and, through the (re)distribution of valued goods and resources at the macro level, these arrangements may contribute to enhancing preventive healthcare use and mitigating screening uptake inequalities.

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Welfare provision and healthcare system features affect Pap smear and mammography uptake.

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Social spending and healthcare features moderate inequalities in cancer screening uptake.

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Policymakers should consider macro-level factors for cancer screening strategies and programmes.

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Policies and institutions shape social determinants of preventive healthcare use.

Healthcare-Seeking Behavior among Chinese Older Adults: Patterns and Predictive Factors

This study aimed to investigate the patterns and predictive factors of healthcare-seeking behavior among older Chinese adults. A sample of 10,914 participants aged ≥60 years from the 2011, 2013 and 2015 China Health and Retirement Longitudinal Study (CHARLS) was included. The bivariate analyses and Heckman selection model was used to identify predictors of healthcare-seeking behavior. Results shows that the utilization rate of outpatient services increased from 21.61% in 2011 to 32.41% in 2015, and that of inpatient services increased from 12.44% to 17.68%. In 2015, 71.93% and 92.18% chose public medical institutions for outpatient and inpatient services, 57.63% and 17.00% chose primary medical institutions. The individuals who were female, were younger, lived in urban, central or western regions, had medical insurance, had poor self-rated health and exhibited activity of daily living (ADL) impairment were more inclined to outpatient and inpatient services. Transportation, medical expenses, the out-of-pocket ratio and the urgency of the disease were associated with provider selection. The universal medical insurance schemes improved health service utilization for the elderly population but had little impact on the choice of medical institutions. The older adults preferred public institutions to private institutions, preferred primary institutions for outpatient care, and higher-level hospitals for hospitalization.

Who Benefits from the Fixed Copayment of Medical and Pharmaceutical Expenditure among the Korean Elderly?

The Korean National Health Insurance system imposes a 30% coinsurance for outpatient medical care and prescription drugs; however, at the age of 65, the coinsurance model changes to a copayment model that offers lower fees for the elderly. Thus, this study aimed to investigate the influence of the copayment model for outpatient visits and prescription drugs on healthcare utilization among the Korean elderly. We compared total outpatient visits, total prescriptions, and out-of-pocket expenses between a case group with copayment reduction (65 years or older) and a control group without any reduction (64 years or younger). We obtained secondary data collected from seven waves of the Korea Health Panel Survey (2010-2016). Outpatient visits increased exclusively in the case group among those with lower income. After adjusting for covariates, the results of the difference-in-differences analysis showed that, compared to the control group, there was a significant increase in outpatient visits among individuals with lower income in the case group. Our study shows that cost sharing changes affect Korean patients with different income levels in different ways.

Differences in the Potential Accessibility of Home-Based Healthcare Services among Different Groups of Older Adults: A Case from Shaanxi Province, China

With the increase of the aging population and the lack of family care, home-based healthcare services have gradually become the main model to cope with aging, so local governments have invested heavily in the construction of home-based healthcare services. However, healthcare services still have problems such as low resource utilization and imbalanced development. The reason is that the supply and demand of healthcare services are not matched and the potential accessibility is low. Therefore, based on the supply and demand of healthcare services, this article pulls out the spatial and social factors that affect the potential accessibility, and tests the influence of individual factors on the potential accessibility among different groups of older adults. It is found that the perceived vulnerability of the older adults will reduce the potential accessibility of healthcare services. The psychosocial status, income and education level with the willingness to use healthcare services of the older adults are directly proportional, while residence has a negative impact on the potential accessibility. Finally, based on this finding, this article puts forward feasible suggestions from the perspective of policy content, publicity, and implementation.

Patient-physician communication about financial problems: A cross-sectional study among over-indebted individuals

Background

About every tenth household across Europe is unable to meet payment obligations and living expenses on an ongoing basis and is thus considered over-indebted. Previous research suggests that over-indebtedness reflects a potential cause and consequence of psychosomatic health problems and limited access to care. However, it is unclear whether those affected discuss their financial problems with general practitioners. Therefore, this study examined patient-physician communication about financial problems in general practice among over-indebted individuals.

Methods

We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017. We assessed the prevalence of patient-physician communication about financial problems and its association with patient characteristics using descriptive statistics and logistic regression analysis. Of 699 individuals who returned the questionnaire (response rate:50.2%), we included 598 respondents enrolled in statutory health insurance with complete outcome data in the analyses.

Results

Conversations about financial problems with general practitioners were reported by 22.6% (n = 135) of respondents. Individuals with a high educational level were less likely to report such conversations than those with medium educational level (aOR 0.11; 95%CI 0.01–0.83) after adjustment for other sociodemographic characteristics, health status and measures of financial distress. Those without a migrant background(aOR 2.09; 95%CI 1.32–3.32), the chronically ill(aOR 1.90; 95%CI 1.16–3.13) and individuals who reported high financial distress(aOR 2.15; 95%CI 1.22–3.78) and cutting on necessities to pay for medications(aOR 1.86; 95%CI 1.12–3.09) were more likely to discuss financial problems than their counterparts.

Conclusions

Few over-indebted individuals discussed financial problems with their general practitioner. Patients’ health status, coping strategies and perception of financial distress might contribute to variations in disclosure of financial problems. Thus, enhancing communication and screening by routine assessment of financial problems in clinical practice can help to identify vulnerable patients and promote access to health care and social services and well-being for all.

Depression in middle-aged and older first generation migrants in Europe: Results from the Survey of Health, Ageing and Retirement in Europe (SHARE)

Objective

To determine the prevalence of depression in migrants aged 50 years or older in comparison to residents without a history of migration in 11 European countries.

Methods and subjects

The Survey of Health, Ageing and Retirement in Europe (SHARE), a cross-national, multidisciplinary, household-based panel survey using nationally representative probability samples (n = 28,517) of 11 European countries of the non-institutionalized population aged 50 years and older. Depression was measured using the EURO-D scale, and odds ratios (OR) were estimated for migration status. Effects of sociodemographic variables, somatic comorbidities, functional impairment, cognitive function, geographic region, and time lived in current country of residence were assessed in multivariate logistic regression analysis.

Results

Adjusting for confounds, the OR for depression in migrants was 1.42 (95% CI, 1.28–1.59). The influence of migration status on the prevalence of depression was significantly greater in Northern (OR, 1.85; 95% CI, 1.39–2.46) and Western Europe (OR, 1.38; 95% CI, 1.22–1.57), compared to Southern Europe (OR, 1.16; 95% CI, 0.79–1.70) (p < 0.05 for the interaction).

Conclusion

We found a higher prevalence of depression in first-generation migrants aged 50 years or older, together with relevant geographical variation. This difference was not due to other known predictors of depression in older age.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

The short-term effects of the earned income tax credit on health care expenditures among US adults

OBJECTIVE

To test the hypothesis that the earned income tax credit (EITC)-the largest US poverty alleviation program-affects short-term health care expenditures among US adults.

DATA SOURCES

Adult participants in the 1997-2012 waves of the US Medical Expenditure Panel Survey (MEPS) (N = 1 282 080).

STUDY DESIGN

We conducted difference-in-differences analyses, comparing health care expenditures among EITC-eligible adults in February (immediately following EITC refund receipt) with expenditures during other months, using non-EITC-eligible individuals to difference out seasonal variation in health care expenditures. Outcomes included total out-of-pocket expenditures as well as spending on specific categories such as outpatient visits and inpatient hospitalizations. We conducted subgroup analyses to examine heterogeneity by insurance status.

PRINCIPAL FINDINGS

EITC refund receipt was not associated with short-term changes in total expenditures, nor any expenditure subcategories. Results were similar by insurance status and robust to numerous alternative specifications.

CONCLUSIONS

EITC refunds are not associated with short-term changes in health care expenditures among US adults. This may be because the refund is spent on other expenses, because of income smoothing, or because of similar refund-related variation in health care expenditures among noneligible adults. Future studies should examine whether other types of income supplementation affect health care expenditures, particularly among individuals in poverty.

The impact of intimate partner violence on forgone healthcare: a population-based, multicentre European study

BACKGROUND

To examine the relationship between forgone healthcare and involvement in intimate partner violence (IPV) as victims, perpetrators or both.

METHODS

This cross-sectional multicentre study assessed community non-institutionalized residents (n = 3496, aged 18-64) randomly selected from six European cities: Athens, Budapest, London, Östersund, Porto, Stuttgart. A common questionnaire was used, including self-reports of IPV and forgone healthcare ('Have you been in need of a certain care service in the past year, but did not seek any help?'). Odds ratios (ORs), 95% confidence intervals (CIs) were computed fitting logistic regression models adjusted for city, chronic disease, self-assessed health status and financial strain.

RESULTS

Participants experiencing past year IPV (vs. no violence) reported more often to forgone healthcare (n = 3279, 18.6% vs. 15.3%, P = 0.016). IPV experienced as both a victim and perpetrator was associated with forgone healthcare (adjusted OR, 95%CI: 1.32, 1.02-1.70).

CONCLUSION

IPV was associated with forgone healthcare, particularly for those experiencing violence as both victims and perpetrators. Results suggest that preventing IPV among adults may improve timely healthcare uptake.

No unmet needs without needs! Assessing the role of social capital using data from European social survey 2014

This paper examines the determinants of unmet healthcare needs in Europe. Special emphasis is put on the impact of social capital. Data come from the European Social Survey, 2014. Our study includes 32,868 respondents in 20 countries. Because unmet needs are observed only in those individuals who are exposed to, and recognise, the need of medical care, sample selection can be an issue. To address it, we analyse the data using the bivariate sample selection model. When there is no need, there is no assessment of access to healthcare. Accordingly, in this situation, our model assumes that unmet need is unobserved. The magnitude and statistical significance of the error correlation support our modelling strategy. A high proportion (18.4%) of individuals in need in Europe reported unmet needs. Informal connections seem to mitigate barriers to access as well as trust in other people and institutions, particularly in health services. Financial strain still is a strong predictor of unmet needs. Other vulnerable groups include informal carers, minorities and individuals feeling discriminated. Unmet needs might also arise due to persistent needs of healthcare as it seems to be the case of individuals with lower health status and chronic conditions. A result that merits further research concerns the positive impact of civic engagement on unmet needs.

Employment Status and Self-Reported Unmet Healthcare Needs among South Korean Employees

We aimed to examine the association between employment status and self-reported unmet healthcare needs and to identify factors influencing self-reported unmet healthcare needs by employment status. Nationally representative data from the 2012 Korea National Health and Nutrition Examination Survey were used. Participants were classified by employment status as either permanent or precarious workers. Explanatory variables included sociodemographic, labor-related, and health-related factors. Multivariate logistic regression ascertained the association between employment status and self-reported unmet healthcare needs and explanatory factors associated with self-reporting of unmet healthcare needs. Precarious workers had a higher prevalence of self-reported unmet healthcare needs than permanent workers, with a statistically significant odds ratio (OR) (1.74; 95% confidence interval (CI), 1.19–2.54). Male precarious workers working >40 h per week were more likely to self-report unmet needs than male precarious workers working <40 h (OR, 3.90; 95% CI, 1.40–10.87). Female precarious workers with a lower household income were about twice as likely to self-report unmet needs. Working hours and household income were significantly influential factors determining self-reporting of unmet healthcare needs, especially among precarious workers. Policy interventions to improve access to healthcare for precarious workers are needed.

Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage

Objectives

In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people—vulnerable groups for the burden of illness—in countries with UHC.

Design

Longitudinal observational cohort study.

Setting

Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC.

Participants

Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178).

Main outcome measures

Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression.

Results

Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR≤0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR≥1.12).

Conclusions

UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

Direct healthcare costs associated with device assessed and self-reported physical activity: results from a cross-sectional population-based study

Background

Physical inactivity (PIA) is an important risk factor for many chronic conditions and therefore might increase healthcare utilization and costs. This study aimed to analyze the association of PIA using device assessed and self-reported physical activity (PA) data with direct healthcare costs.

Methods

Cross-sectional data was retrieved from the population based KORA FF4 study (Cooperative Health Research in the Region of Augsburg) that was conducted in southern Germany from 2013 to 2014 (n = 2279). Self-reported PA was assessed with two questions regarding sports related PA in summer and winter and categorized into “high activity”, “moderate activity”, “low activity” and “no activity”. In a subsample (n = 477), PA was assessed with accelerometers and participants were categorized into activity quartiles (“very high”, “high”, “low” and “very low”) according to their mean minutes per day spent in light intensity, or in moderate-vigorous PA (MVPA). Self-reported healthcare utilization was used to estimate direct healthcare costs. We regressed direct healthcare costs on PA using a two-part gamma regression, adjusted for age, sex and socio-demographic variables. Additional models, including and excluding potential additional confounders and effect mediators were used to check the robustness of the results.

Results

Annual direct healthcare costs of individuals who reported no sports PA did not differ from those who reported high sports PA [+€189, 95% CI: -188, 598]. In the subsample with accelerometer data, participants with very low MVPA had significantly higher annual costs than participants with very high MVPA [+€986, 95% CI: 15, 1982].

Conclusion

Device assessed but not self-reported PIA was associated with higher direct healthcare costs. The magnitude and significance of the association depended on the choice of covariates in the regression models. Larger studies with device assessed PA and longitudinal design are needed to be able to better quantify the impact of PIA on direct healthcare costs.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5906-7) contains supplementary material, which is available to authorized users.

Forgone care among middle aged and elderly with chronic diseases in China: evidence from the China Health and Retirement Longitudinal Study Baseline Survey

OBJECTIVE

In general, published studies analyse healthcare utilisation, rather than foregone care, among different population groups. The assessment of forgone care as an aspect of healthcare system performance is important because it indicates the gap between perceived need and actual utilisation of healthcare services. This study focused on a specific vulnerable group, middle-aged and elderly people with chronic diseases, and evaluated the prevalence of foregone care and associated factors among this population in China.

METHODS

Data were obtained from a nationally representative household survey of middle-aged and elderly individuals (≥45 years), the China Health and Retirement Longitudinal Study, which was conducted by the National School of Development of Peking University in 2013. Descriptive statistics were used to analyse sample characteristics and the prevalence of foregone care. Andersen's healthcare utilisation and binary logistic models were used to evaluate the determinants of foregone care among middle-aged and elderly individuals with chronic diseases.

RESULTS

The prevalence of foregone outpatient and inpatient care among middle-aged and elderly people was 10.21% and 6.84%, respectively, whereas the prevalence of foregone care for physical examinations was relatively high (57.88%). Predisposing factors, including age, marital status, employment, education and family size, significantly affected foregone care in this population. Regarding enabling factors, individuals in the highest income group reported less foregone inpatient care or physical examinations compared with those in the lowest income group. Social healthcare insurance could significantly reduce foregone care in outpatient and inpatient situations; however, these schemes (except for urban employee medical insurance) did not appear to have a significant impact on foregone care involving physical examinations.

CONCLUSION

In China, policy-makers may need to further adjust healthcare policies, such as health insurance schemes, and improve the hierarchical medical system, to promote reduction in foregone care and effective utilisation of health services.

Inner-city green space and its association with body mass index and prevalent type 2 diabetes: a cross-sectional study in an urban German city

OBJECTIVE

The accessibility of green space is an important aspect of the urban residential environment and has been found to be beneficial for health and well-being. This study investigates the association between different indicators of green space and the outcomes body mass index (BMI) and prevalent type 2 diabetes in an urban population.

DESIGN

Population-based cross-sectional study.

SETTING

Dortmund, a city located in the industrial Ruhr area in Western Germany.

PARTICIPANTS

1312 participants aged 25-74 years from the Dortmund Health Study.

METHODS

The participants' addresses were geocoded and shapefiles of statistical districts, road network and land use, as well as data on neighbourhood characteristics were obtained at baseline. Three indicators of green space were constructed using geographical information systems: proportion of green space, recreation location quotient (RLQ) weighted by population and distance to the next park or forest. Multilevel linear and logistic regression analyses on the association of green space with BMI and type 2 diabetes were performed, adjusted by individual-level characteristics and neighbourhood unemployment rate.

RESULTS

The multilevel regression analyses showed no association between green space and BMI. In contrast, the three indicators of green space were significantly associated with type 2 diabetes. Residents of neighbourhoods with a low RLQ had a 2.44 (95% CI 1.01 to 5.93) times higher odds to have type 2 diabetes compared with residents of high RLQ neighbourhoods. Likewise, residing more than 0.8 km away from the nearest park or forest increased the odds of type 2 diabetes (OR 1.71, 95% CI 1.05 to 2.77).

CONCLUSIONS

This study indicates that green space and its spatial accessibility might play a role in the development of type 2 diabetes. Further research is needed to clarify this association.

Predictors of unmet health care needs in Serbia; Analysis based on EU-SILC data

Unmet health care needs have been designated as an indicator of equality in access to health care, which provides insight into specific barriers faced by respondents when they need medical services. The purpose of this research was to analyze demographic, socioeconomic, regional characteristics and perception of the health status; and identify predictors of unmet health care needs and consequently determine the size of inequalities in the availability, accessibility and acceptability of health care. The cross-sectional study obtained data from the Survey on Income and Living Conditions in the Republic of Serbia in 2014, based on a sample of 20,069 respondents over 16 years. Data was collected by using a household questionnaire and a questionnaire for individuals. Multivariate logistic regressions were applied. Almost every seventh citizen (14.9%) reported unmet health care needs. Predictors of unmet needs, for overall reasons, which increase the likelihood of their emergence included: self-perceived health status as very bad (OR = 6.37), divorced or widower/widow (OR = 1.31), living in the Sumadija region or Western Serbia (OR = 1.54) and belonging to the age group of 27 to 44 (OR = 1.55) or 45 to 64 years (OR = 1.52). The probability for those least reporting unmet health care needs included female patients (OR = 0.81), those with higher education (OR = 0.77), those who belong to the richest quintile (OR = 0.46) and who are unemployed (OR = 0.64). Reasons for unmet needs that indicate the responsibility of the health system amounted to 58.2% and reasons which represent preferences of the respondents amounted to 41.7%. The most frequent reason for unmet needs was financial (36.6%), and the wish to wait and see if the problem got better on its own (18.3%). Health policy should adopt a multidimensional approach and develop incentives for the appropriate use of health services and should eliminate barriers which restrict the accessibility and availability.

Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.

Socioeconomic Inequalities in Health and Perceived Unmet Needs for Healthcare among the Elderly in Germany

Research into health inequalities in the elderly population of Germany is relatively scarce. This study examines socioeconomic inequalities in health and perceived unmet needs for healthcare and explores the dynamics of health inequalities with age among elderly people in Germany. Data were derived from the Robert Koch Institute's cross-sectional German Health Update study. The sample was restricted to participants aged 50-85 years (n = 11,811). Socioeconomic status (SES) was measured based on education, (former) occupation, and income. Odds ratios and prevalence differences were estimated using logistic regression and linear probability models, respectively. Our results show that self-reported health problems were more prevalent among men and women with lower SES. The extent of SES-related health inequalities decreased at older ages, predominantly among men. Although the prevalence of perceived unmet needs for healthcare was low overall, low SES was associated with higher perceptions of unmet needs in both sexes and for several kinds of health services. In conclusion, socioeconomic inequalities in health exist in a late working age and early retirement but may narrow at older ages, particularly among men. Socially disadvantaged elderly people perceive greater barriers to accessing healthcare services than those who are better off.

Healthcare renunciation among young adults in French higher education: A population-based study

Healthcare renunciation has been a recent focus of the public health debate, but large-scale investigations of healthcare renunciation are scarce. The goal of this study was to examine healthcare renunciation among young adults at French universities. It investigated prevalence of and reasons for healthcare renunciation and identified subgroups of vulnerable youths. Data were collected in the 2013 triennial study conducted by the French National Observatory of Student Life. That study had a sample of 35,810 18- to 25-year-old participants. Measures included healthcare renunciation, reasons for healthcare renunciation, demographics, cultural and socioeconomic background, health and social outcomes, healthcare system-related variables, and markers of adulthood. The results showed that the prevalence of healthcare renunciation was 27.2%. The most common reasons for healthcare renunciation were refusal renunciation (self-care, 12.7%; wait for improvement, 15.5%) and barrier renunciation (financial reasons, 12.1%; lack of time, 10.2%). Therefore, healthcare renunciation is linked not only to financial constraints but also to individuals' subjective needs and ways of facing illness. Overall, disadvantaged youths and youths transitioning to adulthood were likelier to renounce care, especially for financial reasons. To conclude, there are social inequalities in the use of healthcare by emerging adults in higher education in France. Emerging adulthood appears to be a risky period in which people are likely to renounce healthcare for multiple reasons. Support should be provided for vulnerable youths to prevent them from becoming increasingly vulnerable.

[Social disparities in outpatient and inpatient care: An overview of current findings in Germany]

There is controversy about social disparities in healthcare services in Germany, but a differentiated analysis regarding various dimensions of healthcare is lacking. This narrative review intends to summarize conceptually the current state of research and draw subsequent conclusions. Separated into access, utilization and quality, the findings of social inequality in outpatient and inpatient care in Germany are summarized. Besides the common individual indicators of socioeconomic status (SES), regional deprivation and health insurance status are also included. Despite methodical diversity, the results show that healthcare inequalities due to SES exist, but not universally. Furthermore, there is a differentiated pattern respecting separate dimensions of healthcare. Concerning access (e.g. waiting times, co-payments) lower status groups and patients covered by statutory health insurance are deprived. Higher utilization becomes apparent among higher status groups and privately insured patients in terms of specialist consultations and prevention services. The findings regarding quality of process and outcome differ depending on quality indicator and disease. In different dimensions of medical healthcare, social disparities still exist, though the impact on health remains unclear for some types of healthcare inequalities. Moreover, it is often difficult to conclude from unequal outcome quality the inequalities of healthcare. Depending on access, utilization and quality, separate interventions for reducing these disparities are to be introduced.

Do We Reap What We Sow? Exploring the Association between the Strength of European Primary Healthcare Systems and Inequity in Unmet Need

Access to healthcare is inequitably distributed across different socioeconomic groups. Several vulnerable groups experience barriers in accessing healthcare, compared to their more wealthier counterparts. In response to this, many countries use resources to strengthen their primary care (PC) system, because in many European countries PC is the first entry-point to the healthcare system and plays a central role in the coordination of patients through the healthcare system. However it is unclear whether this strengthening of PC leads to less inequity in access to the whole healthcare system. This study investigates the association between strength indicators of PC and inequity in unmet need by merging data from the European Union Statistics on Income and Living Conditions database (2013) and the Primary Healthcare Activity Monitor for Europe (2010). The analyses reveal a significant association between the Gini coefficient for income inequality and inequity in unmet need. When the Gini coefficient of a country is one SD higher, the social inequity in unmet need in that particular country will be 4.960 higher. Furthermore, the accessibility and the workforce development of a country's PC system is inverse associated with the social inequity of unmet need. More specifically, when the access- and workforce development indicator of a country PC system are one standard deviation higher, the inequity in unmet healthcare needs are respectively 2.200 and 4.951 lower. Therefore, policymakers should focus on reducing income inequality to tackle inequity in access, and strengthen PC (by increasing accessibility and better-developing its workforce) as this can influence inequity in unmet need.

Socioeconomic Status and Use of Outpatient Medical Care: The Case of Germany

Background

Socially disadvantaged people have an increased need for medical care due to a higher burden of health problems and chronic diseases. In Germany, outpatient care is chiefly provided by office-based general practitioners and specialists in private practice. People are free to choose the physician they prefer. In this study, national data were used to examine differences in the use of outpatient medical care by socioeconomic status (SES).

Methods

The analyses were based on data from 6,754 participants in the Robert Koch Institute’s German Health Interview and Examination Survey for Adults (DEGS1) aged between 18 and 69 years. The number of outpatient physician visits during the past twelve months was assessed for several medical specializations. SES was determined based on education, occupation, and income. Associations between SES and physician visits were analysed using logistic regression and zero-truncated negative binomial regression for count data.

Results

After adjusting for sociodemographic factors and health indicators, outpatients with low SES had more contacts with general practitioners than outpatients with high SES (men: incidence rate ratio [IRR] = 1.25; 95% confidence interval [CI] = 1.08–1.46; women: IRR = 1.20; 95% CI = 1.07–1.34). The use of specialists was lower in people with low SES than in those with high SES when sociodemographic factors and health indicators were adjusted for (men: odds ratio [OR] = 0.68; 95% CI = 0.51–0.91; women: OR = 0.56; 95% CI = 0.41–0.77). This applied particularly to specialists in internal medicine, dermatology, and gynaecology. The associations remained after additional adjustment for the type of health insurance and the regional density of office-based physicians.

Conclusion

The findings suggest that socially disadvantaged people are seen by general practitioners more often than the socially better-off, who are more likely to visit a medical specialist. These differences may be due to differences in patient preferences, physician factors, physician-patient interaction, and potential barriers to accessing specialist care.

Are health care inequalities unfair? A study on public attitudes in 23 countries

Background

In this article we focus on the following aims: (1) to analyze national and welfare state variations in the public perception of income-related health care inequalities, (2) to analyze associations of sociodemographic, socioeconomic, health-related, and health care factors with the perception of health care inequalities.

Methods

Data were taken from the International Social Survey Programme (ISSP), an annually repeated cross-sectional survey based on nationally representative samples. 23 countries (N = 37,228) were included and assigned to six welfare states. Attitude towards income-related health care inequalities was assessed by asking: “Is it fair or unfair that people with higher incomes can afford better health care than people with lower incomes?” with response categories ranging from “very fair” (1) to “very unfair” (5). On the individual level, sociodemographic (gender, age), socioeconomic (income, education) health-related (self-rated health), and health care factors (health insurance coverage, financial barriers to health care) were introduced.

Results

About two-thirds of the respondents in all countries think that it is unfair when people with higher incomes can afford better health care than people with lower incomes. Percentages vary between 42.8 in Taiwan and 84 in Slovenia. In terms of welfare states, this proportion is higher in Conservative, South European, and East European regimes than in East Asian, Liberal, and Social-Democratic regimes. Multilevel logistic regression analyses show that women, people affected by a low socioeconomic status, poor health, insufficient insurance coverage, and foregone care are more likely to perceive income-related health care inequalities as unfair.

Conclusions

In most countries a majority of the population perceives income-related health care inequalities as unfair. Large differences between countries were observed. Welfare regime classification is important for explaining the variation across countries.

Forgone care among chronically ill patients in Germany-Results from a cross-sectional survey with 15,565 individuals

The decision not to seek health care although one feels that care is needed (forgone care), is influenced by various factors. Within the study "Responsiveness in ambulatory care" 15,565 chronically ill (coronary heart disease and/or type 2 diabetes) patients in Germany were surveyed in 2013. The survey included questions on forgone care, perceived discrimination when seeking care, net-income, subjective health status and subjective socioeconomic status (subSES). Survey data were linked on patient-level with administrative claims data by a German sickness fund. We applied multivariate binomial logistic regression analyses to assess the association between age, sex, comorbidities, living area, subjective health status, subSES, experienced discrimination, net-equivalent income and reported forgone care. The majority in the sample are men (71.4%), the average age is 69.4 (SD: 10.2) years and 14.1% reported forgone care. In the multivariate model, we find that younger age, female gender, perceived discrimination, depression, and a poor subjective health status increase the odds of reporting forgone care. Overall, our results suggest that a negative experience with the health care system, i.e. perceived discrimination/unfair treatment, are strong predictors of forgone care among the chronically ill.

Direct costs in impaired glucose regulation: results from the population-based Heinz Nixdorf Recall study

OBJECTIVE

For the first time, this population-based study sought to analyze healthcare utilization and associated costs in people with normal fasting glycemia (NFG), impaired fasting glycemia (IFG), as well as previously undetected diabetes and previously diagnosed diabetes linking data from the prospective German Heinz Nixdorf Recall (HNR) study with individual claims data from German statutory health insurances.

RESEARCH DESIGN AND METHODS

A total of 1709 participants of the HNR 5-year follow-up (mean age (SD) 64.9 (7.5) years, 44.5% men) were included in the study. Age-standardized and sex-standardized healthcare utilization and associated costs (reported as € for the year 2008, perspective of the statutory health insurance) were stratified by diabetes stage defined by the participants' self-report and fasting plasma glucose values. Cost ratios (CRs) were estimated using two-part regression models, adjusting for age, sex, sociodemographic variables and comorbidity.

RESULTS

The mean total direct healthcare costs for previously diagnosed diabetes, previously undetected diabetes, IFG, and NFG were €2761 (95% CI 2378 to 3268), €2210 (1483 to 4279), €2035 (1732 to 2486) and €1810 (1634 to 2035), respectively. Corresponding age-adjusted and sex-adjusted CRs were 1.53 (1.30 to 1.80), 1.16 (0.91 to 1.47), and 1.09 (0.95 to 1.25) (reference: NFG). Inpatient, outpatient and medication costs varied in order between people with IFG and those with previously undetected diabetes.

CONCLUSIONS

The study provides claims-based detailed cost data in well-defined glucose metabolism subgroups. CRs of individuals with IFG and previously undetected diabetes were surprisingly low. Data are important for the model-based evaluation of screening programs and interventions that are aimed either to prevent diabetes onset or to improve diabetes therapy as well.

Health system characteristics and unmet care needs in Europe: an analysis based on EU-SILC data

Using survey data from the 2009 wave of the European Union Statistics on Income and Living Conditions, this study examines the determinants of unmet needs for medical and dental care in European countries. Special emphasis is put on the impact of health system characteristics. Four factors are taken into account: the density of doctors or dentists, the rules governing access to practitioners, the method of paying primary care physicians, and the amount of out-of-pocket payments. The analysis is carried out using multilevel logistic regression models. Separate regressions are estimated for medical and dental services. The dependent variable is whether respondents reported that, at least once in the last 12 months, they needed care but did not receive it. The estimation results show that the probability of experiencing unmet medical or dental needs varies noticeably across countries. This inter-country variability seems to be partly explained by the differences in the financing of health care. Indeed, a positive link is found between the share of households' out-of-pocket payments in total health expenditure and the probability of unmet needs. The other contextual factors do not seem to play a significant role.

Association of neighbourhood unemployment rate with incident Type 2 diabetes mellitus in five German regions

AIM

To analyse the association of neighbourhood unemployment with incident self-reported physician-diagnosed Type 2 diabetes in a population aged 45-74 years from five German regions.

METHODS

Study participants were linked via their addresses at baseline to particular neighbourhoods. Individual-level data from five population-based studies were pooled and combined with contextual data on neighbourhood unemployment. Type 2 diabetes was assessed according to a self-reported physician diagnosis of diabetes. We estimated proportional hazard models (Weibull distribution) in order to obtain hazard ratios and 95% CIs of Type 2 diabetes mellitus, taking into account interval-censoring and clustering.

RESULTS

We included 7250 participants residing in 228 inner city neighbourhoods in five German regions in our analysis. The incidence rate was 12.6 per 1000 person-years (95% CI 11.4-13.8). The risk of Type 2 diabetes mellitus was higher in men [hazard ratio 1.79 (95% CI 1.47-2.18)] than in women and higher in people with a low education level [hazard ratio 1.55 (95% CI 1.18-2.02)] than in those with a high education level. Independently of individual-level characteristics, we found a higher risk of Type 2 diabetes mellitus in neighbourhoods with high levels of unemployment [quintile 5; hazard ratio 1.72 (95% CI 1.23-2.42)] than in neighbourhoods with low unemployment (quintile 1).

CONCLUSIONS

Low education level and high neighbourhood unemployment were independently associated with an elevated risk of Type 2 diabetes mellitus. Studies examining the impact of the residential environment on Type 2 diabetes mellitus will provide knowledge that is essential for the identification of high-risk populations.

Understanding healthcare practices in superdiverse neighbourhoods and developing the concept of welfare bricolage: Protocol of a cross-national mixed-methods study

Background

Diversity in Europe has both increased and become more complex posing challenges to both national and local welfare state regimes. Evidence indicates specific barriers for migrant, faith and minority ethnic groups when accessing healthcare. However, previous studies of health in diverse cities in European countries have mainly adopted an ethno-national focus. Taking into account the new complexity of diversity within cities, a deeper and multi-faceted understanding of everyday health practices in superdiverse contexts is needed to support appropriate healthcare provision.

Methods/Design

This protocol describes a mixed method study investigating how residents in superdiverse neighbourhoods access healthcare. The study will include participant observation and qualitative interviewing as well as a standardised health survey and will be carried out in eight superdiverse neighbourhoods – with varying deprivations levels and trajectories of change – in four European countries (Germany, Portugal, Sweden and UK). In each neighbourhood, trained polylingual community researchers together with university researchers will map formal and informal provision and infrastructures supportive to health and healthcare. In-depth interviews with residents and healthcare providers in each country will investigate local health-supportive practices. Thematic analysis will be used to identify different types of help-seeking behaviours and support structures across neighbourhoods and countries. Using categories identified from analyses of interview material, a health survey will be set up investigating determinants of access to healthcare. Complex models, such as structural equation modelling, will be applied to analyse commonalities and differences between population groups, neighbourhoods and countries.

Discussion

This study offers the potential to contribute to a deeper understanding of how residents in superdiverse neighbourhoods deal with health and healthcare in everyday practices. The findings will inform governmental authorities, formal and informal healthcare providers how to further refine health services and how to achieve equitable access in diverse population groups.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany

Background

The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES).

Methods

The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity.

Results

We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12–1.64) as well as for obesity (OR 1.14; 95% CI 1.02–1.26). Further analyses showed that these associations were relatively similar for both men and women.

Conclusions

Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Forgone care and financial burden due to out-of-pocket payments within the German health care system

BACKGROUND

The amount of out-of-pocket (OOP) payments within the German health care system has risen steadily within the last years. OOP payments aim to strengthen patients' cost awareness and try to restrict the demand on medical necessary treatments. However, besides the intended decline of non-induced health care services there's a risk that people also forgo necessary treatments because the utilization of health care services depends not only on need-factors but also on the ability to pay for it. Therefore, this paper aims to analyze the determinants of the total amount of OOP payments, the financial burden caused by OOP payments and the relinquishment of health care services due to OOP payments.

DATA AND METHODS

The empirical analysis is based on cross-sectional data of the German subsample (n = 2851) of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a representative panel study among private households with persons above the age of 50 years and covers a wide range of topics, e.g. health behavior, health status and information about the socio-economic status. The analysis of the independent variables "total amount of OOP payments", "financial burden due to OOP payments" and "forgone care" is carried out by the means of descriptive as well as multivariate regression methods.

RESULTS

Individuals with low income as well as people suffering from chronic illnesses face a higher financial burden and forgo health care services more frequently at the same time. E.g. the financial burden of people who belong to the lowest income quintile is about eight times higher compared to individuals who belong to the highest quintile. The probability of forgone care for this group is about 5.6 percentage points higher [95% CI: 5.2 - 6.0].

CONCLUSION

Especially for the group of people with chronic illnesses and low-income earners it cannot be ruled out that they also forgo necessary medical treatments due to the relatively high financial burden they face. Hence, it is required to facilitate the access to necessary care for these groups.

Treatment pattern of type 2 diabetes differs in two German regions and with patients' socioeconomic position

Background

Diabetes treatment may differ by region and patients' socioeconomic position. This may be particularly true for newer drugs. However, data are highly limited.

Methods

We examined pooled individual data of two population-based German studies, KORA F4 (Cooperative Health Research in the Region of Augsburg, south), and the HNR (Heinz Nixdorf Recall study, west) both carried out 2006 to 2008. To ascertain the association between region and educational level with anti-hyperglycemic medication we fitted poisson regression models with robust error variance for any and newer anti-hyperglycemic medication, adjusting for age, sex, diabetes duration, BMI, cardiovascular disease, lifestyle, and insurance status.

Results

The examined sample comprised 662 participants with self-reported type 2 diabetes (KORA F4: 83 women, 111 men; HNR: 183 women, 285 men). The probability to receive any anti-hyperglycemic drug as well as to be treated with newer anti-hyperglycemic drugs such as insulin analogues, thiazolidinediones, or glinides was significantly increased in southern compared to western Germany (prevalence ratio (PR); 95% CI: 1.12; 1.02–1.22, 1.52;1.10–2.11 respectively). Individuals with lower educational level tended to receive anti-hyperglycemic drugs more likely than their better educated counterparts (PR; 95% CI univariable: 1.10; 0.99–1.22; fully adjusted: 1.10; 0.98–1.23). In contrast, lower education was associated with a lower estimated probability to receive newer drugs among those with any anti-hyperglycemic drugs (PR low vs. high education: 0.66; 0.48–0.91; fully adjusted: 0.68; 0.47–0.996).

Conclusions

We found regional and individual social disparities in overall and newer anti-hyperglycemic medication which were not explained by other confounders. Further research is needed.

Healthcare-seeking behaviour in rural Ethiopia: evidence from clinical vignettes

OBJECTIVES

To investigate the determinants of healthcare-seeking behaviour using five context-relevant clinical vignettes. The analysis deals with three issues: whether and where to seek modern care and when to seek care.

SETTING

This study is set in 96 villages located in four main regions of Ethiopia. The participants of this study are 1632 rural households comprising 9455 individuals.

PRIMARY AND SECONDARY OUTCOME MEASURES

Probability of seeking modern care for symptoms related to acute respiratory infections/pneumonia, diarrhoea, malaria, tetanus and tuberculosis. Conditional on choosing modern healthcare, where to seek care (health post, health centre, clinic and hospital). Conditional on choosing modern healthcare, when to seek care (seek care immediately, the next day, after 2 days, between 3 days to 1 week, a week or more).

RESULTS

We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult-related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non-Government Organization (NGO) clinics as opposed to health posts. Delays in care-seeking behaviour are apparent mainly for adult-related conditions and among poorer households.

CONCLUSIONS

The analysis suggests that the lack of healthcare utilisation is not driven by the inability to recognise health problems or due to a low perceived need for modern care.