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