Unmet healthcare need, gender, and health inequalities in Canada

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women-only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.

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.

Understanding reasons for unmet health care needs in Korea: what are health policy implications?

BACKGROUND

To ensure equal access to necessary care regardless of an individual's socioeconomic status, it is crucial to understand the factors that act as barriers. Unmet health care needs can arise for a variety of complex reasons, including personal choice, financial barriers, or lack of services, and each of these reasons requires a different policy approach. Researchers have advocated for a more granular measure of unmet health care need for better policy implication. This study aimed to assess various factors associated with different types of unmet health care needs in Korea.

METHODS

The Korean National Health and Nutrition Examination Survey (KNHANES) 2010-2012 was used to analyze responses from 17,610 individuals over age 19. To measure the unmet needs of this population, self-reported experience in the past 1 year was used, and individual's reasons for unmet need were sorted into three distinct categories - availability, acceptability, accessibility. Four different logistic regression models stratified by gender were used to examine the relationship between socioeconomic factors and unmet needs.

RESULTS

While income was not a significant factor for men, women with lower incomes showed a higher likelihood of experiencing unmet need. In addition, women with lower incomes showed higher odds of having acceptability-related unmet needs during the past 1 year compared to men. Education and income levels were associated with accessibility-related unmet needs for both women and men.

CONCLUSION

As unmet health care needs are considered to be a critical indicator of a country's health care system, it is crucial to identify and eliminate any obstacles that prevent access to health care services. Under the current universal health care system in Korea, women, particularly those of lower income and lower educational levels, have limited access to necessary health care services. A gender-specific health care plan is recommended to reduce the higher rate of unmet needs experienced by this group. To reduce accessibility-related unmet needs, increasing available services for younger age groups, reflecting their needs of health services, needs to be considered.

Local Income Inequality, Individual Socioeconomic Status, and Unmet Healthcare Needs in Ohio, USA

Purpose: Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set. Methods: Adults residents of Ohio responding to the 2015 Ohio Medicaid Assessment Survey were included in the analysis. Ohio's 88 counties were classified into quartiles according to the Gini coefficient of income inequality. The primary outcome was a composite of self-reported unmet dental care, vision care, mental healthcare, prescription medication, or other healthcare needs within the past year. Unmet healthcare needs were compared according to county inequality quartile using weighted logistic regression. Results: The analytic sample included 37,140 adults. The weighted proportion of adults with unmet healthcare needs was 28%. In multivariable logistic regression, residents of counties in the highest (odds ratio [OR]=1.13, 95% confidence interval [CI]: 1.01-1.26; p=0.030) and second-highest (OR=1.16, 95% CI: 1.04-1.30; p=0.010) quartiles of income inequality experienced more unmet healthcare needs than residents of the most equal counties. Conclusion: Higher county-level income inequality was associated with individual unmet healthcare needs in a large state survey. This finding represents novel evidence for an individual-level association that may explain aggregate-level associations between community economic inequality and population health outcomes.

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.

Unmet need for referred services as measured by general practice

INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Māori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.

Associations of Generalized Trust and Social Participation at the Individual Level with Unmet Healthcare Needs in Communities with High Mortality

BACKGROUND

The aim of this study was to investigate whether generalized trust and/or social participation at an individual level have negative associations with unmet healthcare needs.

METHODS

Door-to-door interviews were conducted by trained interviewers to collect information. The 8,800 study participants included 220 adults sampled systematically using the resident registration database from 40 sub-municipal-level administrative units in Korea. Unmet healthcare needs were measured subjectively by the following question: "During the past 12 months, was there ever a time when you felt that you needed healthcare (excluding dental care) but did not receive it?" The responses were classified as either "yes" or "no."

RESULTS

The adjusted odds ratios (ORs) for unmet healthcare needs based on one positive response, two positive responses, and three positive responses to the three items of generalized trust compared to no positive responses were 0.92 (95% confidence interval [CI], 0.77-1.09), 0.90 (95% CI, 0.74-1.09), and 0.73 (95% CI, 0.61-0.87), respectively. The adjusted ORs for unmet healthcare needs based on social participation only in informal organizations, only in formal organizations, and in both informal and formal organizations compared to no social participation were 0.83 (95% CI, 0.71-0.98), 0.97 (95% CI, 0.77-1.21), and 0.97 (95% CI, 0.82-1.15), respectively. The covariates included in the multiple logistic regression were sociodemographic variables (gender, age, marital status, educational level, occupation, food security, and administrative unit), self-rated health, and perceived stress.

CONCLUSION

Therefore, generalized trust and social participation in informal organizations can decrease the incidence of unmet healthcare needs.

A narrative systematic review of factors affecting diabetes prevention in primary care settings

BACKGROUND

Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient's primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults.

AIM

To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries.

METHODS

For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data.

RESULTS

A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient's motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals' perception of patient motivations towards change.

CONCLUSION

This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions.

Racial/Ethnic and Gender Disparities in Health Care Use and Access

OBJECTIVE

To document racial/ethnic and gender differences in health service use and access after the Affordable Care Act went into effect.

DATA SOURCE

Secondary data from the 2006-2014 National Health Interview Survey.

STUDY DESIGN

Linear probability models were used to estimate changes in health service use and access (i.e., unmet medical need) in two separate analyses using data from 2006 to 2014 and 2012 to 2014.

DATA EXTRACTION

Adult respondents aged 18 years and older (N = 257,560).

PRINCIPAL FINDINGS

Results from the 2006-2014 and 2012-2014 analyses show differential patterns in health service use and access by race/ethnicity and gender. Non-Hispanic whites had the greatest gains in health service use and access across both analyses. While there was significant progress among Hispanic respondents from 2012 to 2014, no significant changes were found pre-post-health care reform, suggesting access may have worsened before improving for this group. Asian men had the largest increase in office visits between 2006 and 2014, and although not statistically significant, the increase continued 2012-2014. Black women and men fared the worst with respect to changes in health care access.

CONCLUSIONS

Ongoing research is needed to track patterns of health service use and access, especially among vulnerable racial/ethnic and gender groups, to determine whether existing efforts under health care reform reduce long-standing disparities.

Recent im/migration to Canada linked to unmet health needs among sex workers in Vancouver, Canada: Findings of a longitudinal study

Despite universal health care in Canada, sex workers (SWs) and im/migrants experience suboptimal health care access. In this analysis, we examined the correlates of unmet health needs among SWs in Metro Vancouver over time. Data from a longitudinal cohort of women SWs (An Evaluation of Sex Workers Health Access [AESHA]) were used. Of 742 SWs, 25.5% reported unmet health needs at least once over the 4-year study period. In multivariable logistic regression using generalized estimating equations, recent im/migration had the strongest impact on unmet health needs; long-term im/migration, policing, and trauma were also important determinants. Legal and social supports to promote im/migrant SWs' access to health care are recommended.

Healthcare needs and access in a sample of Chinese young adults in Vancouver, British Columbia: A qualitative analysis

Objectives

Immigrants of Chinese ethnicity and young people (between 18 and 30 years of age) are known to access health services less frequently and may be at greater risk for experiencing unmet health needs. The purpose of this study was to examine the health beliefs, health behaviors, primary care access, and perceived unmet healthcare needs of Chinese young adults.

Methods

Semi-structured in-depth interviews were carried out with eight Chinese young adults in Vancouver, Canada.

Results

A content analysis revealed that these Chinese young adults experienced unmet healthcare needs, did not have a primary care provider, and did not access preventive services. Cultural factors such as strong family ties, filial piety, and the practice of Traditional Chinese Medicine influenced their health behaviors and healthcare access patterns.

Conclusion

Chinese young adults share similar issues with other young adults in relation to not having a primary care provider and accessing preventive care but their health beliefs and practices make their needs for care unique from other young adults.

Unmet health care needs among sex workers in five census metropolitan areas of Canada

OBJECTIVES

This paper examines unmet health care needs in one of Canada's most hard-to-reach populations, adult sex workers, and investigates whether their reasons for not accessing health care are different from those of other Canadians.

METHODS

Data gathered in 2012-2013 from sex workers aged 19 and over (n = 209) in five Canadian census metropolitan areas (CMAs) were analyzed to estimate the perceived health, health care access and level of unmet health care needs of sex workers, and their principal reasons for not accessing health care. These data were collected using questions identical to those of the Canadian Community Health Survey (CCHS) Cycle 2.1, 2003. The results were compared with those of residents aged 19 and over in the same CMAs who had participated in the CCHS.

RESULTS

Sex workers reported notably worse perceived mental health, poorer social determinants of health (with the exception of income) and nearly triple the prevalence of unmet health care needs (40.4% vs. 14.9%). Those with the greatest unmet health care needs in both groups were younger, unmarried or single and in poorer health, and reported lower income and a weaker sense of community belonging. Even without these within-group risk factors, sex workers were more likely to report unmet health care needs compared with CCHS respondents. Sex workers were also more likely to identify "didn't get around to it", "too busy", "cost", "transportation problems" and "dislike doctors/afraid" as reasons for eschewing care.

CONCLUSION

Equity policies that reduce cost and transportation barriers may go some way in helping sex workers access needed health care. Qualitative research is needed to better understand the realities of sex workers' personal and work lives, including the degree of freedom they have in accessing health care when they need it, but also their experiences when they do manage to engage with the health care system.

Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Unmet healthcare needs and community health center utilization among the low-income population based on a nationwide community health survey

BACKGROUND

The Korean government has established community health centers (CHC) since the end of the 20th century to improve community public health and access to healthcare. In this study, we investigated the reasons for unmet healthcare needs and the reasons/purposes for using CHC based on income level.

METHODS

We used data from the 2012 Community Health Survey, which was administered by the Korean Centers for Disease Control and Prevention (n=208,399). We performed the χ(2) test to examine differences between unmet healthcare needs and utilization of CHC based on various patient characteristics. Survey logistic regression models were used to examine unmet healthcare needs and utilization of CHC by income level. We also analyzed subgroup models to explain the reasons for the outcome variables.

RESULTS

A total of 22,901 (11.0%) individuals experienced unmet healthcare needs and 75,137 (36.1%) utilized CHC. Results of the survey logistic regression analysis revealed that the lowest-income population had a higher odds ratio (OR) for experiencing unmet healthcare needs (OR=1.61) and utilized CHC more frequently (OR=1.66). Their main reasons for unmet healthcare needs were economic (OR=5.75) and difficulties in transportation (OR=2.17). The lowest-income population visited CHC because of lower costs (OR=1.76) and close proximity to home (OR=1.56). The lowest-income population visited CHC for primary care (OR=1.22) and vaccinations (OR=1.23). In contrast, the highest-income group visited CHC primarily to obtain government-issued documents (OR=0.82).

CONCLUSIONS

Our results indicate different reasons/purposes for unmet healthcare needs and utilization of CHC based on income level. The government should use a management strategy to reduce unmet healthcare needs among the low-income population and redefine the roles of CHC.

Unmet healthcare needs and health status: Panel evidence from Korea

AIMS

Even though basic healthcare services have been considered human rights, studies on optimal level of healthcare utilization have produced mixed results. A growing body of literatures has been using unmet healthcare needs, a subjective survey measure, to find inequity in healthcare. But no studies so far have tried to reveal the association of unmet needs with health outcomes so it was hard to get the public's attention. To answer it, this study tries to reveal the associations between unmet healthcare needs and health outcomes.

METHODS

A 4-year Korean panel dataset of 7,717 persons (31,668 person-years) were analyzed. Unmet healthcare needs were asked (if yes, its reason was also surveyed) if the respondent ever felt healthcare services were needed but could not receive it in the past 12 months. A health-related quality of life instrument (EQ-5D) and self-rated health were used as dependent variables. To avoid simultaneity, 1-year lagged outcome variables were used. And to control for unobserved individual heterogeneity, fixed effects estimation was also run based on Grossman's human capital model.

FINDINGS

Since 2009, more than 14.5% of the study population had reported unmet healthcare needs. When 1-year lagged health outcome variables were regressed on unmet needs, compared to the means, unmet needs were found to associate with 1% decline in EQ-5D and 4.5% decline in self-rated health. Unmet needs due to mild symptoms were not related with outcomes in fixed effects estimation among the elderly.

CONCLUSIONS

Even though causal inference were not found, the association between unmet needs and health outcomes were established. Recognizing demand side determinants of healthcare was a strength of this study.

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.

Gender Inequalities in Access to Health Care among Adults Living in British Columbia, Canada

INTRODUCTION

Existing literature is inconclusive as to whether disparities in access to health care between men and women are mainly driven by socioeconomic or gender inequalities. The aim of this study was to assess whether gender was independently associated with perceived unmet health care needs among a representative sample of British Columbia adults.

METHODS

Using data from the 2011/2012 Canadian Community Health Survey, logistic regression analyses were conducted to investigate the independent effect of gender on perceived unmet health care needs adjusting for potential individual and contextual confounders.

RESULTS

Among 12,252 British Columbia adults (51.9% female), the prevalence of perceived unmet health care needs was 12.0%, with a significantly greater percentage among women compared with men (13.7% vs. 10.1%; p < .001). After adjusting for multiple confounders, women had independently increased odds of perceived unmet health care needs (adjusted odds ratio, 1.37; 95% CI, 1.11-1.68).

DISCUSSION

The current study found that, among a representative sample of British Columbia adults and adjusting for various individual and contextual factors, female gender was associated independently with an increased odds of perceived unmet health care needs.

CONCLUSION

These findings suggest that within Canada's universal health system, gender further explains differences in health care access, over and above socioeconomic inequalities. Interventions within and outside the health sector are required to achieve equitable access to health care for all residents in British Columbia.

Community dental clinics in British Columbia, Canada: examining the potential as health equity interventions

Community dental clinics (CDCs) have emerged to provide oral healthcare for those with low incomes. In British Columbia, the establishment of community clinics has been quite rapid in recent years. However, the expansion has occurred with very little assessment of their impact or effectiveness. While oral health inequities are well recognised, there is limited documentation on healthcare interventions to reduce oral health inequities. This study examines CDCs as health equity interventions from the perspectives of individuals establishing and operating the clinics. The study included interviews with 17 participants--4 dentists, 6 dental hygienists and 7 clinic managers--from 10 clinics operating in British Columbia, Canada in 2008-2009. A thematic analysis of the interview transcripts, explored through a health equity framework, found many ways in which the CDCs exemplify health equity interventions. Although their design and mandates are varied, they potentially enable access to dental treatment, but without necessarily ensuring sustainable outcomes. Moreover, the scalability of CDCs is questionable because frequently they are limited to emergency care and are less responsive to the gradients of needs for populations facing multiple barriers to care. Many of them operate on a charitable base with input from volunteer dentists; however, this foundation probably eases the pressure on dentists and dental hygienists rather than offering a safety net to underserved populations.

Unmet health care needs for persons with environmental sensitivity

Studies of unmet health care needs have shown that women, people with poor health, and people with lower socioeconomic status are more likely to report having unmet health care needs. In this study, we examined the types of and reasons for unmet health care needs in 465 people with environmental sensitivities. A second area of inquiry involved negative reactions to general anesthesia. Results showed that the most common barriers to receiving care were the inability to find a provider who understands environmental sensitivities and a lack of accessibility due to chemical and electromagnetic exposures in health care environments. Lower income and poorer health (longer illness, a worsening or fluctuating course of illness, and a higher level of disability) were significantly correlated with the total number of reported unmet health care needs. Some people with environmental sensitivities reported having negative reactions to anesthesia of long duration; most common were nausea and vomiting, fatigue, and reduced cognitive ability.

Examining the relationship between health-related need and the receipt of care by participants experiencing homelessness and mental illness

BACKGROUND

People experiencing homelessness and mental illness face multiple barriers to care. The goal of this study was to examine the association between health service use and indicators of need among individuals experiencing homelessness and mental illness in Vancouver, Canada. We hypothesized that those with more severe mental illness would access greater levels of primary and specialist health services than those with less severe mental illness.

METHODS

Participants met criteria for homelessness and current mental disorder using standardized criteria (n = 497). Interviews assessed current health status and involvement with a variety of health services including specialist, general practice, and emergency services. The 80th percentile was used to differentiate 'low health service use' and 'high health service use'. Using multivariate logistic regression analysis, we analyzed associations between predisposing, enabling and need-related factors with levels of primary and specialist health service use.

RESULTS

Twenty-one percent of participants had high primary care use, and 12% had high use of specialist services. Factors significantly (p ≤ 0.05) associated with high primary care use were: multiple physical illnesses [AOR 2.74 (1.12, 6.70]; poor general health [AOR 1.68 (1.01, 2.81)]; having a regular family physician [AOR 2.27 (1.27, 4.07)]; and negative social relationships [AOR 1.74 (1.01, 2.99)]. Conversely, having a more severe mental disorder (e.g. psychotic disorder) was significantly associated with lower odds of high service use [AOR 0.59 (0.35, 0.97)]. For specialist care, recent history of psychiatric hospitalization [AOR 2.53 (1.35, 4.75)] and major depressive episode [AOR 1.98 (1.11, 3.56)] were associated with high use, while having a blood borne infectious disease (i.e., HIV, HCV, HBV) was associated with lower odds of high service use.

CONCLUSIONS

Contrary to our hypotheses, we found that individuals with greater assessed need, including more severe mental disorders, and blood-borne infectious diseases had significantly lower odds of being high health service users than those with lower assessed needs. Our findings reveal an important gap between levels of need and service involvement for individuals who are both homeless and mentally ill and have implications for health service reform in relation to the unmet and complex needs of a marginalized sub-population. (

TRIAL REGISTRATION

ISRCTN57595077 and ISRCTN66721740).

Investigating unmet health needs in primary health care services in a representative sample of the Greek population

Unmet health care needs are determined as the difference between the services judged necessary and the services actually received, and stem from barriers related to accessibility, availability and acceptability. This study aims to examine the prevalence of unmet needs and to identify the socioeconomic and health status factors that are associated with unmet needs. A cross-sectional study was conducted in Greece in 2010 and involved data from 1,000 consenting subjects (>18 years old). Multiple binary logistic regression analysis was applied to investigate the predictors of unmet needs and to determine the relation between the socio-demographic characteristics and the accessibility, availability and acceptability barriers. Ninety nine participants (9.9%) reported unmet health needs during the 12 months prior to the research. The most frequently self-reported reasons were cost and lack of time. Youth, parenthood, physician consultations, and poor mental health increased the likelihood of unmet needs. Women were less likely to report accessibility and availability than acceptability barriers. Educational differences were evident and individuals with primary and secondary education were associated with significantly more accessibility and availability barriers compared with those with tertiary education. Unmet health needs pose a significant challenge to the health care system, especially given the difficult current financial situation in Greece. It is believed that unmet health needs will continue to increase, which will widen inequalities in health and health care access.

Geographical variation of unmet medical needs in Italy: a multivariate logistic regression analysis

Background

Unmet health needs should be, in theory, a minor issue in Italy where a publicly funded and universally accessible health system exists. This, however, does not seem to be the case. Moreover, in the last two decades responsibilities for health care have been progressively decentralized to regional governments, which have differently organized health service delivery within their territories. Regional decision-making has affected the use of health care services, further increasing the existing geographical disparities in the access to care across the country. This study aims at comparing self-perceived unmet needs across Italian regions and assessing how the reported reasons - grouped into the categories of availability, accessibility and acceptability – vary geographically.

Methods

Data from the 2006 Italian component of the European Union Statistics on Income and Living Conditions are employed to explore reasons and predictors of self-reported unmet medical needs among 45,175 Italian respondents aged 18 and over. Multivariate logistic regression models are used to determine adjusted rates for overall unmet medical needs and for each of the three categories of reasons.

Results

Results show that, overall, 6.9% of the Italian population stated having experienced at least one unmet medical need during the last 12 months. The unadjusted rates vary markedly across regions, thus resulting in a clear-cut north–south divide (4.6% in the North-East vs. 10.6% in the South). Among those reporting unmet medical needs, the leading reason was problems of accessibility related to cost or transportation (45.5%), followed by acceptability (26.4%) and availability due to the presence of too long waiting lists (21.4%). In the South, more than one out of two individuals with an unmet need refrained from seeing a physician due to economic reasons. In the northern regions, working and family responsibilities contribute relatively more to the underutilization of medical services. Logistic regression results suggest that some population groups are more vulnerable than others to experiencing unmet health needs and to reporting some categories of reasons. Adjusting for the predictors resulted in very few changes in the rank order of macro-area rates.

Conclusions

Policies to address unmet health care needs should adopt a multidimensional approach and be tailored so as to consider such geographical heterogeneities.

Barriers faced by Ugandan university students in seeking medical care and sexual health counselling: a cross-sectional study

BACKGROUND

Meeting the medical and sexual health care needs of young people is crucial for sustainable development. In Uganda, youth are faced with a number of challenges related to accessing medical care and sexual health counselling services. This study sought to investigate the barriers faced by Ugandan university students in seeking medical care and sexual health counselling.

METHODS

This study is part of a cross-sectional survey conducted in 2005 among 980 students at Mbarara University of Science and Technology. Data was collected by means of a self-administered 11-page questionnaire. The barriers encountered by respondents in seeking medical care and sexual health counselling were classified into three categories reflecting the acceptability, accessibility, or availability of services.

RESULTS

Two out of five students reported unmet medical care needs, and one out of five reported unmet sexual health counselling needs. Acceptability of services was the main barrier faced by students for seeking medical care (70.4%) as well as for student in need of sexual health counselling (72.2%), regardless of age, gender, self-rated health, and rural/peri-urban or urban residence status. However, barriers differed within the various strata. There was a significant difference (p-value 0.01) in barriers faced by students originally from rural versus peri-urban/urban areas in seeking medical care (acceptability: 64.8%/74.5%, accessibility: 22.0% /12.6%, availability 13.2%/12.9%, respectively). Students who reported poor self-rated health encountered barriers in seeking both medical care and sexual health counselling that were significantly different from their other counterparts (p-value 0.001 and 0.007 respectively).

CONCLUSIONS

Barriers faced by students in seeking medical and sexual health care should be reduced by interventions aimed at boosting confidence in health care services, encouraging young people to seek early treatment, and increasing awareness of where they can turn for services. The availability of medical services should be increased and waiting times and cost reduced for vulnerable groups.

Prevalence and profiles of unmet healthcare need in Thailand

BACKGROUND

In the light of the universal healthcare coverage that was achieved in Thailand in 2002, policy makers have raised concerns about whether there is still unmet need within the population. Our objectives were to assess the annual prevalence, characteristics and reasons for unmet healthcare need in the Thai population in 2010 and to compare our findings with relevant international literature.

METHODS

A standard set of OECD unmet need questionnaires was used in a nationally-representative household survey conducted in 2010 by the National Statistical Office. The prevalence of unmet need among respondents with various socio-economic characteristics was estimated to determine an inequity in the unmet need and the reasons behind it.

RESULTS

The annual prevalence of unmet need for outpatient and inpatient services in 2010 was 1.4% and 0.4%, respectively. Despite this low prevalence, there are inequities with relatively higher proportion of the unmet need among Universal Coverage Scheme members, and the poor and rural populations. There was less unmet need due to cost than there was due to geographical barriers. The prevalence of unmet need due to cost and geographical barriers among the richest and poorest quintiles were comparable to those of selected OECD countries. The geographical extension of healthcare infrastructure and of the distribution of health workers is a major contributing factor to the low prevalence of unmet need.

CONCLUSIONS

The low prevalence of unmet need for both outpatient and inpatient services is a result of the availability of well-functioning health services at the most peripheral level, and of the comprehensive benefit package offered free of charge by all health insurance schemes. This assessment prompts a need for regular monitoring of unmet need in nationally-representative household surveys.

Access to dental care for low-income adults: perceptions of affordability, availability and acceptability

The objective of this study was to explore access to dental care for low-income communities from the perspectives of low-income people, dentists and related health and social service-providers. The case study included 60 interviews involving, low-income adults (N = 41), dentists (N = 6) and health and social service-providers (N = 13). The analysis explores perceptions of need, evidence of unmet needs, and three dimensions of access--affordability, availability and acceptability. The study describes the sometimes poor fit between private dental practice and the public oral health needs of low-income individuals. Dentists and low-income patients alike explained how the current model of private dental practice and fee-for-service payments do not work well because of patients' concerns about the cost of dentistry, dentists' reluctance to treat this population, and the cultural incompatibility of most private practices to the needs of low-income communities. There is a poor fit between private practice dentistry, public dental benefits and the oral health needs of low-income communities, and other responses are needed to address the multiple dimensions of access to dentistry, including community dental clinics sensitive to the special needs of low-income people.

Overview of lung cancer surgery in Ontario

BACKGROUND

Surgery is the primary curative treatment for lung cancer and thus appropriate surgical resource allocation is critical. This study describes the distribution of lung cancer incidence and surgical care in Ontario, a Canadian province with universal health care, for the fiscal year of 2004.

METHODS

All new lung cancer cases in Ontario between April 1, 2003 and March 31, 2004 were identified in the Ontario Cancer Registry. Incidence rates and surgical procedures were compared by age, health region, neighborhood income, and community size.

RESULTS

Lung cancer incidence was highest in lower income neighborhoods (90.2 cases of 100,000 vs 55.6 in the highest quintile, p < 0.001) and smaller communities (87.1 of 100,000 in communities less than 100,000 vs 56.3 of 100,000 in cities greater than 1.25 million, p < 0.001). Surgical interventions were most common in younger patients (47.4% aged 20 to 54 years versus 30.5% greater than 75 years, p < 0.001), and those in wealthier neighborhoods (43.4% in highest quintile versus 35.8% in the lowest, p < 0.001). Surgical procedures overall and specifically formal resections (20% in cities >1.25 million versus 18% in communities <100,000, p < 0.03) were more common in larger communities (43.4% versus 37.7%, p < 0.001). Pneumonectomy was more common in smaller communities (14.5% vs 9.9%, p = 0.048, whereas more lobar (53.8 vs 45.2%, p = 0.01) and sublobar resections (44.9% vs 31.7%, p < 0.0001) were more common in larger communities. Thoracic surgeons provided the majority of formal resections (51% to 57%) compared with general surgeons (17% to 21%).

CONCLUSIONS

Lung cancer incidence and surgical care vary significantly by health region, income level, and community size. These disparities require further evaluation to meet the needs of patients with lung cancer.