Social capital, community size and utilization of health services: a lagged analysis

Objectives

We examine the relationship between social capital, community size and GP visits, and conceptualize social capital as a stock variable measured at a prior point in time.

Methods

Data from the 2002 Canadian Community Health Survey and the 2001 Canadian Census are merged with GP visit data from the Ontario Health Ministry. Negative binomial regression is used to measure the impact of community-level (CSC) and individual-level social capital (ISC) on GP visits. CSC is measured with the Petris Index using employment levels in religious and community-based organizations, and ISC is measured along multiple dimensions.

Results

The effect of social capital varies by community size. A one standard deviation increase in the Petris Index in larger communities (population > 100,000) leads to a 2.6% decrease in GP visits with an annual offset in public spending of $66.4M. Tangible social support—a measure of ISC—also exhibited large effects on GP visits. In smaller communities (population 10,000-100,000), only increased ISC exhibited an impact on GP visits. Age had no effect on the association between social capital and GP visits.

Conclusions

Each form of social capital likely operates through different mechanisms and impact differs by community size. Stronger CSC likely obviates some physician visits in larger communities that involve counseling/caring services while some forms of ISC may act similarly in smaller communities.     

Access to general practitioner services: the disabled elderly lag behind in underserved areas

BACKGROUND: Several studies have shown that people living in areas underserved in physicians have reduced odds of consulting. However, beyond the magnitude of this effect averaged for the whole population, policymakers need to know whether specific subgroups faced with transportation difficulties, such as the elderly and especially the disabled elderly, have a particularly restricted access to physicians when residing in underserved areas. METHODS: The study sample, representative of the French population aged 18-75 in 1999, comprised 12 405 individuals. Multilevel Poisson models were used to investigate the impact of the area-level density of general practitioners (GPs) on the number of GP consultations reported over the previous 12 months. RESULTS: The mean number of GP consultations over the previous 12 months was 3.8 (S.D.=4.9). Multivariate analyses indicated that living in areas underserved in GPs lead to a greater reduction in primary care utilization for the elderly, and especially for the disabled elderly, than for younger age groups. The disabled elderly had 244% more GP consultations (95% CI:+79%, +562%) when they lived in areas with high versus low GP density (defined with the 10th and 90th percentiles as cut-offs). CONCLUSION: If further research confirms our findings, this increasingly disturbing public health issue in industrialized countries where populations are ageing will require priority policy measures. Ensuring that elderly people living in underserved areas have adequate access to primary care may prevent future hospitalizations, use of home care services and institutionalization.     

Influenza vaccine uptake in the elderly population: Individual and general practitioner’s determinants in Central Italy,Lazio region, 2016–2017 season

BackgroundElderly people are a priority target group for influenza vaccination and their decision to be vaccinated might partly depend on advice received from general practitioners (GP). This study aims to investigate the association between influenza vaccine uptake in the elderly residents in the Lazio region of Italy and the demographic and professional characteristics of their GPs, taking simultaneously into account the elderly’s individual characteristics.MethodsWe used data retrieved from different administrative sources to retrospectively analyse the cohort of 1,255,657 elderly residents aged ≥65 years who were alive and registered in the regional healthcare service at the beginning of the 2016–2017 influenza vaccination campaign (1 Oct. 2016–31 Jan. 2017). We assessed influenza vaccine uptake at the end of the vaccination campaign and evaluated its association with both individual and GP-related characteristics through a multilevel Poisson regression models accounting for clustering at physician level.ResultsOverall, vaccination coverage at the end of vaccination campaign was 50.6%. Elderly residents who were male, older, vaccinated in the previous seasons, living in smaller provinces, and spending more money for specialist medical care showed a significantly increased probability to be vaccinated. Vaccine uptake was also significantly higher in the elderly residents assisted by GPs who got master’s degree more recently, assisted a relatively high proportion of elderly patients, received influenza vaccination, had a computer assistant, and were associated with other physicians.ConclusionsOur results indicate that influenza vaccination coverage in the elderly residents of the Lazio region is still unsatisfactorily low. We identified several determinants of influenza vaccine uptake, related to both individual and GP characteristics. Understanding how GP characteristics affected influenza vaccine uptake in the elderly population might provide insight on GPs’ attitudes and concerns regarding influenza vaccination, allowing the implementation of targeted evidence-based interventions to sensitise GPs and increase vaccination coverage.     

Contextual social capital as a risk factor for poor self-rated health: a multilevel analysis

In this study, we critically examine whether contextual social capital (CSC) is associated with self-rated health, with an emphasis on the problem of confounding. We also examine different components of CSC and their association with self-rated health. Finally, we look at differences in susceptibility between different socio-demographic groups. We use the cross-sectional base line study of the Stockholm Public Health Cohort, conducted in 2002. A postal questionnaire was answered by 31,182 randomly selected citizens, 18-84 years old, in Stockholm County. We used four measures of social capital: horizontal (civic trust and participation), vertical (political trust and participation), cognitive (civic and political trust) and structural (civic and political participation). CSC was measured at parish level from aggregated individual data, and multilevel regression procedures were employed. We show a twofold greater risk of poor self-rated health in areas with very low CSC compared with areas with very high CSC. Adjustments for individual socio-demographic factors, contextual economic factors and individual social capital lowered the excess risk. Simultaneous adjustment for all three forms of confounding further weakened the association and rendered it insignificant. Cognitive and structural social capital show relatively similar associations with self-rated health, while horizontal CSC seems to be more strongly related to self-rated health than vertical CSC. In conclusion, whether there is none or a moderate association between CSC and self-rated health, depends on the extent to which individual social capital is seen as a mediator or confounder. The association with self-rated health is similar independent of the measure of CSC used. It is also similar in different socio-demographic groups.     

社会资本对农村户籍老年人健康的影响与性别差异研究

[目的]了解不同类别社会资本(人际信任、社会支持、社会参与)对我国农村户籍老年人健康的影响及性别差异.[方法]基于2017-2018年中国老年健康影响因素跟踪调查(CLHLS)数据对9068名60岁以上农村户籍老年人进行分析.[结果]社会参与(正式和非正式)和人际信任对农村户籍老年人健康状况的积极影响显著,有社会参与的...     

Suicide Stigma in Online Social Interactions: Impacts of Social Capital and Suicide Literacy

ABSTRACT

This study examined whether and when people are more likely to conform to stigmatizing views on suicide in online social interactions. Two key factors in the study included characteristics of individuals’ social capital and suicide literacy. Study 1 analyzed national survey data to explore the relationships, and Study 2 involved a vignette to gauge the extent to which people conform to stigmatizing attitudes toward suicidal people under group pressure. Results showed that those emphasizing social networks demonstrated higher levels of suicide stigma, while those with more interpersonal trust showed lower levels of stigma. However, in relation to interpersonal trust, suicide literacy played a moderating role in that those with lower levels of interpersonal trust showed significantly less conformity when they had high suicide literacy.     

健康相关社会资本对中老年社区居民抑郁症状的影响

目的 研究中老年社区居民群体健康相关社会资本对抑郁症状的影响,为提升其心理健康水平提供依据。方法 采用多阶段分层整群抽样的方法,抽取成都市中老年居民1432人进行问卷调查。抑郁症状采用流调中心抑郁水平评定量表（CES-D）,健康相关社会资本由自编社会资本量表测量。应用多因素logistic回归分析中老年居民社会资本对其抑郁症状的影响。结果 中老年社区居民抑郁症状发生率为25.4%。不同性别、婚姻状况、文化程度、工作状况、健康状况的中老年人社会资本不同（P<0.05）;在控制人口学特征、健康危险因素等变量的情况下,家庭关系较好的中老年人产生抑郁症状的可能性较低（OR=0.555, 95%CI: 0.429~0.720）、社区信任与归属感得分较高的老年人产生抑郁症状的可能性较低（OR=0.726, 95%CI: 0.553~0.952）。结论 家庭关系、社会归属与信任感是影响社区中老年居民心理健康的主要社会资本因素,应对影响居民抑郁症状的因素采取有针对性的措施进行干预。     

The market for paid sick leave

In many countries, general practitioners (GPs) are assigned the task of controlling the validity of their own patients’ insurance claims. At the same time, they operate in a market where patients are customers free to choose their GP. Are these roles compatible? Can we trust that the gatekeeping decisions are untainted by private economic interests? Based on administrative registers from Norway with records on sick pay certification and GP-patient relationships, we present evidence to the contrary: GPs are more lenient gatekeepers the more competitive is the physician market, and a reputation for lenient gatekeeping increases the demand for their services.     

Measuring dimensions of social capital: evidence from surveys in poor communities in Nicaragua

A dominant perspective in social capital research emphasizes a "structural" dimension of social capital, consisting of network connections, and a "cognitive" dimension, consisting of attitudes toward trust. Correspondingly, membership in organizations (i.e., membership density) and general trust in people (i.e., social trust) are two indicators commonly used to relate structural and cognitive social capital, respectively, to a variety of health and other outcomes. This study analyzed relationships between membership density, social trust and a more comprehensive set of household-level social capital indicators as well as selected civic and health behaviors in the context of Nicaragua. The sample of respondents was drawn from 6 communities and interviews were conducted with 482 heads of households, resulting in data on 2882 individuals. Factor analyses suggest that membership density loaded strongly (loading=0.81) onto an "organizational participation" factor which contained a number of qualitative characteristics of involvement, including bridging social capital. Further, this structural dimension of social capital appears to be a construct consisting of more than just informal social networks. However, factor analyses suggest that distinctions between levels of trust are warranted in Nicaragua: social trust loaded weakly (loading=0.32) onto a factor characterized by institutional trust in a factor analysis of trust items, and well below 0.30 in a factor analysis of both structural and cognitive dimensions of social capital. A nuanced understanding of these household-level indicators of structural and cognitive social capital held implications for civic and health behaviors. While membership density and institutional trust were positively related to an index of political engagement, social trust was either not related or negatively associated (among urban respondents). Similarly, social trust was associated with over 50% reduced odds of an additional childhood vaccinations whereas institutional trust was associated with increased odds (OR=1.7) of an additional vaccination. The findings highlight the complexity of social capital and the importance of exploring more comprehensive indicators.     

A multilevel analysis of social capital and self-rated health: Evidence from China

We investigate relationship between social capital and self-rated health (SRH) in urban and rural China. Using a nationally representative data collected in 2005, we performed multilevel analyses. The social capital indicators include bonding trust, bridging trust, social participation and Chinese Communist Party membership. Results showed that only trust was beneficial for SRH in China. Bonding trust mainly promoted SRH at individual level and bridging trust mainly at county level. Moreover, the individual-level bridging trust was only positively associated with SRH of urban residents, which mirrored the urban–rural dual structure in China. We also found a cross-level interaction effect of bonding trust in urban area. In a county with high level of bonding trust, high-bonding-trust individuals obtained more health benefit than others; in a county with low level of bonding trust, the situation was the opposite.     

General practitioners’ perspectives on primary care consultations for suicidal patients

Little is known about general practitioners’ (GPs’) perspectives, management of and interactions with suicidal patients prior to the patient's suicide. The aims of the study were to explore GPs’ interpretations of patient communication and treatment in primary care leading up to suicide and to investigate the relationship between GPs and mental health services prior to a patient's suicide. Thirty‐nine semi‐structured interviews with GPs of people who had died by suicide were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using a thematic approach. The following themes emerged from GP interviews: (i) GP interpretations of suicide attempts or self‐harm; (ii) professional isolation; and (iii) GP responsibilities versus patient autonomy. GPs recruited for the study may have different views from GPs who have never experienced a patient suicide or who have experienced the death of a patient by suicide who was not under the care of specialist services. Our findings may not be representative of the rest of the United Kingdom, although many of the issues identified are likely to apply across services. This study highlighted the following recommendations for future suicide prevention in general practice: increasing GP awareness of suicide‐related issues and improving training and risk assessment skills; removing barriers to accessing therapies and treatments needed in primary care; improving liaison and collaboration between services to provide better patient outcomes; and increasing awareness in primary care about why patients may not want treatments offered by focusing on each individual's situational context.     

Social Support and the ‘Left Behind’ Elderly in Rural China: A Case Study from Jiangxi Province

This study examines the living situation of elderly people in rural China whose children have left to work in other areas [the ‘left behind’ elderly (LBE)] and explores policy implications associated with their care. Based on survey data and interviews conducted in three villages in Jiangxi Province, China, we compare the living situation of the LBE and the ‘non-left behind’ elderly (NLBE). The data reveal that the LBE are relatively more isolated and that they spend less time interacting with neighbors and more time watching television. The study shows that the LBE have a much greater need for care services than income maintenance. Also, the LBE group has less social capital than the NLBE group. Based on our findings, it is clear that the proposal to use social capital and informal care cannot effectively meet all the needs of the LBE group. Instead, it is recommended that a comprehensive system of social support is developed.     

Increasingly inequitable distribution of general practitioners in Australia, 1986-96

OBJECTIVE: To document trends in the distribution of general practitioners (GPs) in Australia between 1986 and 1996, adjusted for community need. METHODS: Data on the location of GPs, population size and crude mortality in statistical divisions (SD) were obtained from the Australian Bureau of Statistics Census of Population and Housing in 1986 and 1996. From these data, we calculated measures of distribution equality (number of people sharing each GP in each SD) and distribution equity (number of people sharing each GP divided by the crude mortality rate; the Robin Hood Index), and analysed temporal changes in the distribution of GPs. RESULTS: Nationally, the number of people sharing each GP fell 11% from 1,038 in 1986 to 921 in 1996. However, in 41 of 57 SDs (72%, p=0.01) the number of people sharing a GP actually increased over this time, and the average Robin Hood Index across SDs fell from 0.943 to 0.783 (p=0.004), indicating increasingly inequitable distribution. Comparing the Robin Hood Index values of all SDs ranked in pairs, the value fell in 53 of 57 (93%, p<0.001) paired SDs over the decade. These patterns demonstrate increasing inequity over the decade. The number of people sharing each GP was consistently and substantially lower in the capital city SDs and the Robin Hood Index values were consistently and substantially higher (overserved) compared with country SDs. CONCLUSIONS: Despite there being more GPs per capita in Australia, their distribution became increasingly unequal and inequitable between 1986 and 1996, such that rural and remote areas became increasingly poorly served.     

性别视角下社会资本对老年人认知能力的影响

目的 分析社会资本对老年人认知能力影响的性别差异。方法 基于2015年中国健康与养老全国追踪调查(China Health and Retirement Longitudinal Study, CHARLS)数据,选取4 751例老年人为研究对象,以社会信任、社会支持、社会参与、互惠度量社会资本,以心智状况和情景记忆度量认知能力,利用广义线性回归分析社会资本对认知能力影响的性别差异。 结果 男性认知水平高于女性(P＜0.001),男女心智状况和情景记忆得分均有统计学差异(P＜0.001);男性高社会信任和有经济支持的比例均高于女性(χ2 = 1.1×103,P＜0.001和 χ2 = 58.695,P＜0.001)。老年男性中有经济支持(β = 0.302,P = 0.011)、社会参与(β = 0.605,P＜0.001)者的心智状况更好;老年女性的心智状况除受经济支持(β = 0.508,P＜0.001)、社会参与(β = 0.410,P＜0.001)的影响,还受照料支持(β = 0.292,P = 0.008)的影响。老年男性中有经济支持(β = 0.199,P = 0.010)、照料支持(β = 0.182,P = 0.017)、社会参与(β = 0.363,P＜0.001)和互惠(β = 0.233,P = 0.032)者的情景记忆更好,社会信任与其情景记忆负相关(β = - 0.238,P = 0.010);老年女性的情景记忆受经济支持(β = 0.269,P＜0.001)、社会参与(β = 0.167,P = 0.018)、互惠(β = 0.461,P＜0.001)的影响。结论 社会资本对老年人认知能力的影响具有性别差异。     

Market reforms in English primary medical care: medicine, habitus and the public sphere

Drawing on interviews with English primary care doctors (GPs), this paper examines GP responses to reforms intended to introduce a market in primary health care. GPs' reactions are conceptualised in terms of a GP habitus, which takes for granted the superiority of 'public' providers ( i.e . GP partnerships) in the provision of care. GPs are actively involved in the defence of the public sphere, which is neither a neo-liberal minimalist market state, nor a wholly altruistic state, responding to consumers' wants. The public sphere they defend is one in which boundaries are drawn about entitlements and GPs are actively engaged in defining and policing these boundaries. The GP habitus can be seen as shaping responses in ways which serve GP interests. In the context of struggles involving various social actors ( e.g . private providers, third-party payers, patients) with different stakes in the field of general medical practice; this public service orientation may enable GPs to reap cultural capital. At the same time, the habitus constrains action in a way which limits resistance to reforms threatening GPs' interests, with GPs responding by coping, rather than downing tools or engaging in active confrontation.     

Familiarity with a GP and patients' evaluations of care. A cross-sectional study

BACKGROUND: Personal continuity is considered a core feature of general practice care. Nowadays, another important concept for general practice may be patients' familiarity with a GP. OBJECTIVES: We studied the extent to which patients see a familiar GP, and how this matches their preferences. Furthermore we studied the impact of knowing the GP on patients' evaluations of consultations. METHODS: A cross-sectional design was used and 2400 patients visiting 17 general practices (30 GPs) in The Netherlands for a consultation were approached; 2152 patients completed the questionnaire. The main outcome measures were: i) the extent to which patients saw a familiar GP in relation to the reason for encounter, perceived seriousness of symptoms, and concern about symptoms; and ii) the impact of 'knowing the GP' on patients' overall satisfaction with the consultation, feeling of being helped to move forwards, trust in the GP, and perceived clearness of treatment plans. RESULTS: Patients saw a familiar GP to a high extent, regardless of the reason for encounter, perceived seriousness of symptoms and worries. Higher levels of familiarity with a GP were associated with higher levels of satisfaction, with increased feelings of being helped forward, with more trust in the GP, and with the perception of clearer treatment plans made. A multivariate model including the variable 'knowing the GP' explained 11% of the observed variance in patients' evaluations of consultations. CONCLUSION: Familiarity with a GP improves patients' assessment of general practice care. Also in the future, personal continuity should be promoted.     

Paying doctors by salary: a controlled study of general practitioner behaviour in England

The study aim was to evaluate the impact of the experimental introduction of salaried contracts in England on general practitioner (GP) behaviour and the quality of care. A controlled before-and-after design was implemented involving ten practices of standard contract GPs, paid largely by capitation and fee-for-service, and ten salaried GP practices. Diaries and routinely available data were used to assess GP workload, and patient assessments of the quality of care were obtained by postal questionnaire. GPs in salaried practices spent less time on practice administration but more working out-of-hours and in direct patient care, allowing more patients to be seen. Total list sizes were smaller in salaried compared with standard contract practices, but lists per GP were higher because of staffing policies. Salaried GPs tended to provide shorter consultations compared with standard contract GPs, prescribe in fewer consultations, but referral rates were similar. Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practices and two in standard contract practices. However, none of these differences were statistically significant. To conclude, salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided.     

Factors affecting general practice collaboration with voluntary and community sector organisations

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients’ “wicked problems”. This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived‐experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP‐VCS collaborations were unique to their local context. The identified factors affecting GP‐VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the “negotiation” of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration—especially more holistic and integrated approaches—becomes systematically embedded into practice.     

Social differences in postponing a General Practitioner visit in Flanders,Belgium: which low‐income patients are most at risk?

One of the main goals of primary care is providing equitable health‐care, meaning equal access, equal treatment and equal outcomes of healthcare for all in equal need. Some studies show that patients from lower socioeconomic groups visit a GP more often, while other studies show that they are more likely to postpone a visit to a GP. In this study, we want to explore within the social group of low‐income patients living in Flanders, Belgium, which patients have a higher risk of postponing a visit to a GP. A face‐to‐face questionnaire was administered among 606 low‐income users of Public Social Services. The questionnaire consisted of questions on socioeconomic and demographic characteristics, social networks, health and healthcare use. A multivariate logistic regression model was built to study the relationship between postponing or cancelling a GP visit which respondents thought they needed and variables on health, socio‐demographic background. The multivariate regression indicates that depression, self‐rated health and trust in the GP independently predict postponing a visit to a GP. Low‐income people with a low trust in the GP, people with a poor self‐rated health and people suffering from a severe depression are more likely to postpone or cancel a GP visit they thought they needed compared to other people on low incomes. This might indicate that the access to health‐care for low‐income people might be hindered by barriers which are not directly linked to the cost of the consultation.