Investigating socio-economic explanations for gender and ethnic inequalities in health

This paper examines inequalities in the self-reported health of men and women from white and minority ethnic groups in the UK using representative data from the Health Survey for England, 1993-1996. The results show substantially poorer health among all minority ethnic groups compared to whites of working-age. The absence of gender inequality in health among white adults contrasts with higher morbidity for many minority ethnic women compared to men in the same ethnic group. The analysis addresses whether socio-economic inequality is a potential explanation for this pattern of health inequality using measures of educational level, employment status, occupational social class and material deprivation. There are marked socio-economic differences according to gender and ethnic group: high morbidity is concentrated among adults who are most socio-economically disadvantaged, notably Pakistanis and Bangladeshis. Logistic regression analyses show that socio-economic inequality can account for a sizeable proportion of the health disadvantage experienced by minority ethnic men and women, but gender inequality in minority ethnic health remains after adjusting for socio-economic characteristics.     

Do minutes count? Consultation lengths in general practice

OBJECTIVE: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. DESIGN: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. SETTING AND SUBJECTS: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. MAIN OUTCOME MEASURES: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. RESULTS: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. CONCLUSIONS: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.     

Use of medical consultations and the occurrence of systemic arterial hypertension in urban and rural areas of Brazil, according to PNAD data 2008

The use of medical consultations is influenced by determinants such as healthcare needs and service characteristics, which depend on whether the environment is urban or rural. The scope was to estimate the proportions of individuals attending medical consultations over the previous 12 months with and without self-reported systemic arterial hypertension (SAH) living in urban and rural areas, and to analyze the patterns of consultation use and associations. This was a sectional study, using PNAD 2008. Logistic regression was performed to obtain crude and adjusted odds ratios (ORs), according to self-reported SAH and household situation. 70.6% of adult Brazilians consult physicians. The association between the presence of SAH and attending medical consultations was 3.63 (OR) times greater in urban areas. The incidence of consultation with physicians was greater among women, individuals using continuous medication or who had health insurance plans or funding for the last consultation, people who reported a disease or restriction in mobility and those with self-reported poor health, in all strata. Multivariate analysis modified the associations of all variables. The differences between the two areas suggested that access policies need to be implemented, with the aim of reducing inequalities.     

Is there equity in access to health services for ethnic minorities in Sweden?

BACKGROUND: This paper addresses the extent to which equity of treatment according to need, as defined by self-reported health status, is received by members of ethnic minorities in Swedish health services. METHODS: The study was based on a multivariate analysis of cross-sectional data from the Swedish Survey of Living Conditions and Immigrant Survey of Living Conditions in 1996 on use of health services, morbidity and socioeconomic indicators. The study population consisted of 1,890 Swedish residents aged 27-60 years born in Chile, Poland, Turkey and Iran and 2,452 age-matched, Swedish-born residents. MAIN RESULTS: Residents born in Chile, Iran and Turkey were more likely to have consulted a physician during the 3 months prior to the interview compared to Swedish-born residents; odds ratios (ORs) 1.4 (95% CI: 1.2-1.7), 1.3 (95% CI: 1.1-1.7) and 1.5 (95% CI: 1.3-1.9) respectively. The higher consultation rate in these ethnic minorities was primarily explained by a less satisfactory, self-reported health status compared to Swedish-born residents. Thirty-eight percent of the minority study groups reported exposure to organised violence in their country of origin, which was associated with a higher level of use of consultations with a physician (OR 1.3, 95% CI: 1.1-1.6). CONCLUSIONS: This study did not indicate any gross pattern of inequity in access to care for ethnic minorities in Sweden. Systems for allocating resources to health authorities need to consider the possibility that ethnic minorities in Sweden and in particular victims of organised violence, use health services more than is suggested by socioeconomic indicators only.     

Knee pain and osteoarthritis in the general population: what influences patients to consult?

BACKGROUND: We examined the relationship between predisposing factors, enabling factors and need-related factors with consultation for knee pain in general practice. METHODS: This was a retrospective review of computerized medical records for knee-related consultations in the 18 months before baseline assessment of individuals aged over 50 years reporting knee pain in the previous 12 months. The association between each factor and consultation for consulters compared to non-consulters was summarized using odds ratios (ORs). Interaction between each variable and chronic pain grade was investigated. The association between knee-related consultation and the number and type of other co-morbid consultations was then determined. RESULTS: In total, 742 participants were assessed. Of these, 209 (28%) had a knee-related consultation in the previous 18 months. Recent onset of pain [OR 3.2; 95% confidence interval (95% CI) 1.8, 5.7] and severity of pain, Grade III/IV (OR 3.4; 95% CI 2.1, 5.6), were associated with knee-related consultation. Those rating their knee problem as a health priority were more likely to consult (OR 3.2; 95% CI 1.6, 6.7). Irrespective of knee pain severity, there was no difference in the median number of co-morbid consultations between knee consulters and knee non-consulters. CONCLUSIONS: Need-related factors appeared to be associated with the decision to consult about knee pain. Neither the presence of self-reported selected co-morbid conditions nor the total number of co-morbid conditions was related to consultations for knee pain. Nevertheless, 50% of those with severely disabling knee pain still did not consult for it. Further investigation of this is important in order to optimize care for patients with knee pain and co-morbid disease.     

Determinants of Women Consulting with a Complementary and Alternative Medicine Practitioner for Pregnancy-Related Health Conditions

The objective of this study was to explore the determinants that are related to women’s likelihood to consult with a complementary and alternative medicine (CAM) practitioner during pregnancy. Primary data were collected as a sub-study of the Australian Longitudinal Study on Women’s Health (ALSWH) in 2010. We completed a cross-sectional survey of 2,445 women from the ALSWH “younger” cohort (n = 8,012), who had identified as being pregnant or had recently given birth in 2009. Independent Poisson backwards stepwise regression models were applied to four CAM practitioner outcome categories: acupuncturist, chiropractor, massage therapist, and naturopath. The survey was completed by 1,835 women (79.2%). The factors associated with women’s consultation with a CAM practitioner differed by practitioner groups. A range of demographic factors were related, including employment status, financial status, and level of education. Women’s health insurance coverage, health status, and perceptions toward both conventional maternity care and CAM were also associated with their likelihood of consultations with all practitioner groups, but in diverse ways. Determinants for women’s consultations with a CAM practitioner varied across practitioner groups. Stakeholders and researchers would benefit from giving attention to specific individual modalities when considering CAM use in maternity care.     

Inequity and inequality in the use of health care in England: an empirical investigation

Achieving equity in healthcare, in the form of equal use for equal need, is an objective of many healthcare systems. The evaluation of equity requires value judgements as well as analysis of data. Previous studies are limited in the range of health and supply variables considered but show a pro-poor distribution of general practitioner consultations and inpatient services and a pro-rich distribution of outpatient visits. We investigate inequality and inequity in the use of general practitioner consultations, outpatient visits, day cases and inpatient stays in England with a unique linked data set that combines rich information on the health of individuals and their socio-economic circumstances with information on local supply factors. The data are for the period 1998-2000, just prior to the introduction of a set of National Health Service (NHS) reforms with potential equity implications. We find inequalities in utilisation with respect to income, ethnicity, employment status and education. Low-income individuals and ethnic minorities have lower use of secondary care despite having higher use of primary care. Ward level supply factors affect utilisation and are important for investigating health care inequality. Our results show some evidence of inequity prior to the reforms and provide a baseline against which the effects of the new NHS can be assessed.     

Health status of older Chinese in Canada: findings from the SF-36 health survey

BACKGROUND: Despite the fact that the Chinese belong to the largest visible minority group in Canada, there is little research findings on their health status, particularly the aging adults. This research aimed at bridging the knowledge gap by examining the health status of this population and comparing the health status between the Chinese aging population and the general aging population in Canada. METHODS: Secondary data analysis of data obtained from a multi-site study, Health and Well Being of Older Chinese in Canada, and from the Medical Outcomes Study 36-item Short Form (SF-36). The SF-36 published scores obtained from the same age cohorts in the Canadian Multicentre Osteoporosis Study were used for comparison purposes. Independent samples t-tests were used to compare the statistical significance of the two groups. RESULTS: Overall, older Chinese-Canadians reported better physical health than all older adults in the Canadian population. However, the older Chinese in all age and gender groups scored lower in the mental component summary (MCS). Despite the age differences, Chinese women reported statistically poorer health than the Chinese men in all of the 8 health domains. CONCLUSION: The data are useful for forming baselines for monitoring the effectiveness of future health interventions for this population. Efforts by service providers to address the health needs of older Chinese-Canadian women, the most vulnerable subgroup in this study, are essential. Interventions are also needed to address the poor mental health status in this ethnic minority group.     

Self-reported morbidity data as an indicator of regional resource requirement.

In this paper five variables are taken from the General Household Survey and the statistical technique of multidimensional scaling is used to estimate the relationships between the standard economic regions of England and Wales in terms of their self-reported morbidity. An estimate is then made of the proportion of resources that must be allocated to each region in order to eliminate the differences found. The five variables measuring longstanding illness; limiting longstanding illness; restricted activity; certificated absence; and general practitioner consultation were standardised, and input to a multidimensional scaling programme. This showed that the English regions were very similar to each other, although a morbidity continuum could be identified which corresponded to the North-South variation in socioeconomic conditions found in England. Wales, however, shows considerable difference from the English regions, a difference which cannot be explained purely in terms of the socioeconomic conditions in the region. For this reason a far more detailed investigation is proposed.     

Factors that Influence Self-reported General Health Status Among Different Asian Ethnic Groups: Evidence from the <Emphasis Type="Italic">Roadmap to the New Horizon: Linking Asians to Improved Health and Wellness</Emphasis> Study

Little is known about the determinants of self-reported general health status among different Asian ethnic subgroups. Using a community-based participatory research approach, we designed, administered, and analyzed a cross-sectional survey of 705 Asians (292 Chinese, 226 Korean, 187 Vietnamese) in the Portland, Oregon region to describe associations between general health status and several sociodemographic and health-related factors in pooled and ethnic-group-stratified samples. Ethnic variation existed in all covariate distributions, except employment, public-service use, language use, health status, visiting healthcare providers, sleep habits, and use of prayer, meditation, yoga or acupuncture. Acculturation measures were strong predictors of poor/fair health in logistic regression models regardless of ethnicity. Ethnic variation in outcome status existed for all remaining covariates. Most health-related research overlooks the heterogeneity within the Asian population. These findings highlight substantial variability in the associations between self-reported general health status and sociodemographic and health-related measures between Asian ethnic groups.     

Characteristics and Outcomes of Ethics Consultations on a Comprehensive Cancer Center’s Gastrointestinal Medical Oncology Service

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database (which includes categorization of the primary issues, contextual ethical issues, and other case characteristics) of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients were identified. The most common primary ethical issue was the DNR order (39%), followed by medical futility (28%). The most common contextual issues were dispute/conflict between staff and family (48%), dispute/conflict intra-family (16%), and cultural/ethnic/religious issues (16%). The majority of ethical issues leading to consultation were resolved (84%); i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning.     

Exploring the determinants of endocrinologist visits by patients with diabetes

Background

Diabetes is today a major public health concern in terms of its financial and social burden. Previous studies have revealed that specialist care for patients with diabetes leads to more positive outcomes than care by general practitioners (GPs) alone. The aim of this study was to estimate the determinants of endocrinologist consultation by patients with diabetes.

Methods

We used a two-part model to explore both the decision to consult and the frequency of consultations. We used claim data collected for 65,633 affiliates of a French social security provider. Patients were aged over 18 and treated for diabetes (types I and II). We controlled for patients’ socioeconomic characteristics, type of diabetes treatment, medical care, and health status. We also controlled for variables, such as the cost of a visit, the distance to the nearest endocrinologist’s office, the density of medical practitioners and the prevalence of diabetes in the area.

Results

The results show that the parameters associated with the decision to consult an endocrinologist were considerably different from factors associated with the frequency of consultations. A marked positive effect of income on the decision to consult was found, whereas travel time to the office had a negative impact on both the decision to consult and the frequency of consultations. Increasing treatment complexity is associated with a higher probability of consulting an endocrinologist. We found evidence of a significant substitution effect between GPs and endocrinologists. Finally, consultation price is a barrier to seeing an endocrinologist.

Conclusion

Given that financial barriers were identified in the relatively wealthy population analysed here, it is likely that this may be even more of an obstacle in the general population.

     

Does Media Use Result in More Active Communicators? Differences Between Native Dutch and Turkish-Dutch Patients in Information-Seeking Behavior and Participation During Consultations With General Practitioners

This study investigates differences between native Dutch and Turkish-Dutch patients with respect to media usage before and patient participation during medical consultations with general practitioners. In addition, the authors assessed the relation between patient participation and communication outcomes. The patients were recruited in the waiting rooms of general practitioners, and 191 patients (117 native Dutch, 74 Turkish-Dutch) completed pre- and postconsultation questionnaires. Of this sample, 120 patients (62.8%; 82 native Dutch, 38 Turkish-Dutch) agreed to have their consultations recorded to measure patient participation. Compared with Turkish-Dutch patients of similar educational levels, results showed that native Dutch patients used different media to search for information, participated to a greater extent during their consultations and were more responsive to their general practitioner. With respect to the Turkish-Dutch patients, media usage was related to increased patient participation, which was correlated with having fewer unfulfilled information needs; however, these relations were not found in the native Dutch patient sample. In conclusion, interventions that enhance participation among ethnic minority patients will better fulfill informational needs when such interventions stimulate information-seeking behavior in that group before a medical consultation.     

Use of health care services by ethnic minorities in The Netherlands: do patterns differ?

BACKGROUND: This article examines the nature of ethnic differences in health care utilisation by assessing patterns of use in addition to single service utilisation. METHODS: Data were derived from the Second Dutch National Survey of General Practice. A nationally representative sample of 104 general practices participated in this survey. Data on health and health service utilisation were collected through face-to-face interviews. Based on a random sample per practice, a total of 12 699 Dutch-speaking people were interviewed, regardless of ethnic background. An additional study among a random sample of 1339 people from the four largest minority groups in The Netherlands was conducted. These four groups comprised people from Turkey, Surinam, Morocco, and The Netherlands Antilles. Multilevel analyses were performed to investigate ethnic differences in health care utilisation, adjusting for socio-economic status, health status, and level of urbanisation. RESULTS: Differences in utilisation patterns were particularly marked for people with a Moroccan, Turkish, or Antillean background. Compared to the other groups, Surinamese were more likely to have had contact with any professional health care service. No evidence was found that the gate keeping role of general practitioners in The Netherlands functions less effectively among the ethnic minority groups as compared to the indigenous population. CONCLUSION: The analysis of patterns of utilisation proved to supply useful information concerning the relationship between ethnicity and use of health care services in addition to figures concerning single service use only.     

Differences in Referral Rates from General Practice

There are many unexplained differences in the rates at whichgeneral practitioners make referrals to other medical specialists.This study investigated 17 586 referrals from 141 general practitionersto specialists in seven specialties in Ringkjøbing countyin Denmark. As an expression of the referral rate, a referralindex was estimated for every general practitioner. The referralindex was the number of referrals to the specialist per 1000patients per year, including children, standardized for ageand sex to the average population in Ringkjøbing county.The following six variables were evaluated in relation to thereferral index: specialists in the local area, doctors per practice,consultations per general practitioner per year, patients registered,consultations per 1000 patients per year standardized for ageand sex, and supplementary procedures per consultation. Stepwisemultiple regression analysis was used. The study showed thatthe referral index rose both with a better access to specialistand with an increasing number of consultations per practitionerper year. The referral index fell with increased numbers ofpatients registered. No correlation was found between the referralindex and number of supplementary procedures per consultation,number of doctors per practice and number of consultations per1000 patients per year.     

Determinants of general practitioner use among women in Australia

This study investigates the use of general practitioner services by women in Australia. Although there is a universal health insurance system (Medicare) in Australia, there are variations in access to services and out of pocket costs for services. Survey data from 2350 mid-age (45-50 years) and 2102 older (70-75 years) women participating in the Australian Longitudinal Study on Women's Health were linked with Medicare data to provide a range of individual and contextual variables hypothesised to explain general practitioner use. Structural equation modelling showed that physical health was the most powerful explanatory factor of general practitioner use. However, after adjusting for self-reported health, out of pocket cost per consultation was inversely associated with use of services. The out of pocket cost was generally lower for women with low socioeconomic status but cost was also directly related to geographical remoteness. Women living in more remote areas had higher out of pocket costs and poorer access to services. Women who reported better access to care were more likely to be satisfied with their most recent general practice consultation and less likely to be sceptical of the value of medical care. These results show the need for health policies that improve the equitable use of general practitioner services in Australia.     

Self-reported Health,Functional Status and Chronic Disease in Community Dwelling Older Adults: Untangling the Role of Demographics

Self-reported health, a widely used measure of general health status in population studies, can be affected by certain demographic variables such as gender, race/ethnicity and education. This cross-sectional assessment of the current health status of older adult residents was conducted in an inner-city Houston neighborhood in May, 2007. A survey instrument, with questions on chronic disease prevalence, health limitations/functional status, self-reported subjective health status in addition to demographic data on households was administered to a systematic random sample of residents. Older adults (>60 years of age) were interviewed (weighted N = 127) at their homes by trained interviewers. The results indicated that these residents, with low literacy levels, low household income and a high prevalence of frequently reported chronic diseases (hypertension, diabetes and arthritis) also reported non-participation in community activities, volunteerism and activities centered on organized religion, thus, potentially placing them at risk for social isolation. Women reported poorer self-reported health and appeared to fare worse in all health limitation indicators and reported greater structural barriers in involvement with their community. Blacks reported worse health outcomes on all indicators than other sub-groups, an indication that skills training in chronic disease self-management and in actively eliciting support from various sources may be beneficial for this group. Therefore, the use of self-reported health with a broad brush as an indicator of “true” population health status is not advisable. Sufficient consideration should be given to the racial/ethnic and gender differences and these should be accounted for.     

Factors associated with health care utilization by the elderly in a public health care system

OBJECTIVE: The objective was to determine the factors associated with the use of health care services by the elderly residing in the community. METHODS: A cross-sectional study on 787 elderly people over 64 years of age from Albacete City (Castilla-La Mancha, Spain). The study was carried out by personal home interviews during a 9-month period. The dependent variables were: health care utilization, and characteristics. The independent variables were: self-reported health status, self-reported morbidity, medication use, functional status, mental health, lifestyle habits, social support, and sociodemographic status. RESULTS: The health care services were used by 74.5% in the last 3 months of which 59.4% were general practitioner visits, 18.4% were to nursing staff, and 16.5% were specialist visits. Laboratory tests were performed in 39.2% and radiological examinations in 24.9%. Emergency visits accounted for 2.4%, and hospitalization, 2.9%. Users of health care services among the elderly population were objectively more ill, although there was a group of healthy individuals who also visited the physician and a large group of elderly with considerable health problems who never saw their physician. In the multivariate analysis, general practitioner utilization was independently associated with a perceived unmet need for care (OR = 3.15), a negative self-reported health status (OR = 2.51), and a lower educational level (OR = 2.41). CONCLUSIONS: Subjective factors as perceived need for care, a negative self-reported health status and lower educational level are important factors that influence in the utilization of health care services.