Elsevier

Health Policy

Volume 65, Issue 2, August 2003, Pages 153-165
Health Policy

Socio-economic differences in the utilisation of health services in Belgium

https://doi.org/10.1016/S0168-8510(02)00213-0Get rights and content

Abstract

Objective: To investigate socio-economic differences in the use of health services in Belgium and to explore to what extent eventual socio-economic inequalities are explained by differences in demographic determinants and health needs. Design: Data was obtained from the 1997 Belgian national Health Interview Survey. In this survey information was collected on the health status, the life style and the medical consumption of a representative sample of the Belgian non-institutionalised population consisting of 8560 Belgian inhabitants aged 15 years and over. Results: Lower socio-economic groups make more often use of the general practitioner and nursing care at home and are more often admitted to hospital than persons with a high socio-economical status. There is, however, no socio-economic gradient when the health status is taken into account. On the opposite, persons with a higher socio-economic status report more often a visit to a specialist, a physiotherapist or a dentist. For the health services for which this was investigated no association was found between socio-economic status and the volume of the use of health services. Conclusions: There are in Belgium still important socio-economic gradients in the use of some health services. These differences may be due to socio-economic inequities but could also indicate that the existing health facilities are not always used in an optimal way. Patient factors may be more important than supply factors in explaining the differential use of health services. Further research needs to focus on socio-economic differences in the reasons, the outcome and the quality of the provided care.

Introduction

Equity in health and equal access to health care among socio-economic groups are among the main objectives in health policy [1], [2] and have been much debated issues during the past 2 decades. Since the Black report [3], published in Britain in 1980, many studies have confirmed the impact of socio-economic factors on health. There is evidence from several industrialised countries, including Belgium, that a shorter life expectancy and higher rates of morbidity are found among lower socio-economic groups and that the health expectancy decreases with a decreasing socio-economic status [4], [5], [6].

The relationship between socio-economic status and health care utilisation is less equivocal and may differ by type of health service under study and by unit of analysis (probability of use or volume of use). Several studies have investigated effects of social class on the utilisation of health services in western European countries [7], [8], [9], [10]. Some research on the relationship between socio-economic status and health care utilisation has also been carried out in Belgium [11], [12]. This research focussed, however, mainly on general practice settings in particular geographic areas.

In 1997 the Scientific Institute of Public Health organised the first National Health Interview Survey. Information on the health status, the health behaviour and the medical consumption was obtained from a representative sample of the population, consisting of more than 10 000 individuals. In this paper data from this survey is used to investigate socio-economic differences in the use of health services in Belgium. This is done for six different types of health services: the general practitioner, the specialist physician, the physiotherapist, the dentist, nursing care at home and hospital care.

An important purpose for studying socio-economic differences in health care utilisation in relation to need factors is to address the issue of equity in health care. Often it is assumed that equity can and should be measured in terms of health care utilisation. This interpretation needs to be considered with caution [14]. ‘Equal access for equal needs’ rather relates to the opportunity to use the needed health services than the actual receipt of care. Differences in the rates of utilisation of certain services by different socio-economic groups do not automatically reflect inequities. For example, a higher rate of hysterectomies in higher income groups, as observed in some countries, may be an indication of unnecessary treatment and one would not want to aim for higher surgery rates for other income groups in such circumstances [15]. In case of unequal utilisation for equal need further study is needed to ascertain why the utilisation rates are different.

A useful model to discuss socio-economic differences in the utilisation of health services has been developed by Anderson [16], and was later refined by Aday and Andersen [17], [18]. In these models explanatory variables are categorised into three groups: variables that predispose towards utilisation (e.g. age, sex and household composition), those that enable utilisation (e.g. income and education) and those that generate utilisation, i.e. need. Although the Aday and Andersen model has been criticised because it obscures the mediating effects of factors such as psychologic distress, locus of control and social support [19], it continues to be relevant in providing a useful analytic framework and starting point for the discussion of the utilisation of health care [20], [21]. The model allows us to explore how enabling factors, such as socio-economic status, are related to the utilisation of health services, taking into account need.

Section snippets

Methods and material

The 1997 Belgian National Health Interview Survey is a cross-sectional survey based on a representative sample of the non-institutionalised population residing in Belgium. The methodology of the Health Interview Survey has been published previously [13], [22], [23]. Sampling was based on a combination of stratification, multistage sampling and clustering. Stratification was done at the regional level and at the level of the provinces, clustering within the municipalities and within the

Results

Table 1 shows the distribution of the study population by age, sex, household type, urbanisation level, educational attainment and equivalent income of the household. The age and sex distribution is similar to the one of the general population in Belgium (source: National Institute of Statistics). The survey results indicate that there is a strong association between socio-economic status and perceived health, the number of chronic diseases and physical functioning. A good or very good

Discussion

The results of this study indicate that in Belgium lower educational groups make more often use of the general practitioner and nursing care at home and are more often admitted to hospital than those with a higher education. Variation in health status explains mostly the observed socio-economic gradients. On the opposite, after adjustment for health status and demographic characteristics persons with a higher socio-economic status report more often a visit with a specialist, a physiotherapist

Conclusions

Although the Belgian health system scores quite well in an international perspective [56] there are still important socio-economic gradients in the use of some health services. These differences may be due to socio-economic inequities but could in some cases also indicate that the existing health facilities are not always used in an optimal way. Further research addressing socio-economic differences in the reasons for contacting a service, the quality of the provided care and health outcomes is

References (56)

  • I. Keskimaki et al.

    Socioeconomic equity in Finnish hospital care in relation to need

    Social Science and Medicine

    (1995)
  • J.P. Mackenbach

    Socio-economic health differences in The Netherlands: a review of recent empirical findings

    Social Science and Medicine

    (1992)
  • P.L. Ritter et al.

    Self-reports of health care utilization compared to provider records

    Journal of Clinical Epidemiology

    (2001)
  • R.O. Roberts et al.

    Comparison of self-reported and medical record healt care utilization measures

    Journal of Clinical Epidemiology

    (1996)
  • F. Beland

    The utilization of health services. Sequence of visits to general practitioners

    Social Science and Medicine

    (1982)
  • G. Dahlgren et al.
  • G. Stronks et al.

    Should equity in health be target number 1

    European Journal of Public Health

    (1993)
  • Department of Health and Social Security. Inequalities in Health: Report of a Working Group Chaired by Sir Douglas...
  • N. Bossuyt et al.

    Espérance de vie en bonne santé selon le statut socio-économique en Belgique

    (2000)
  • R. Balarajan et al.

    Socioeconomic differences in the uptake of medical care in Great Britain

    Journal of Epidemiology and Community Health

    (1987)
  • K. Fernandez de la Hoz et al.

    Self-perceived health status and inequalities in use of health services in Spain

    International Journal of Epidemiology

    (1996)
  • W. Peersman et al.

    Sociaal-economische status en differentieel gebruik van gezondheidszorgvoorzieningen

  • L. De Prins et al.

    Lower educated, more to the General Practitioner

    Huisarts en Wetenschap

    (1998)
  • H. Van Oyen et al.

    The Belgian health interview survey

    Archives of Public Health

    (1997)
  • M. Whitehead

    The concepts and principles of equity and health

    International Journal of Health Services

    (1992)
  • Center for Health Administration Studies. A Behavioral Model of Families’ Use of Health Services. (No. 25), University...
  • L. Aday et al.

    A framework for the study of access to medical care

    Health Services Research

    (1974)
  • R. Andersen et al.

    Societal and individual determinants of medical care utilization in the United States

    Milbank Mem Fund Q

    (1973)
  • Cited by (0)

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