Factors influencing intentional non-utilization of healthcare: a study using the Andersen model.

Morbidity increases with age and enhances the burden of health problems that result in new challenges to meet additional demands. In the ageing population, health problems, and health care utilization should be assessed carefully and addressed. This study aimed to identify chronic morbidities, health problems, health care seeking behaviour and health care utilization among the elderly. We conducted a community based, cross-sectional study in urban areas of the Sunsari district using face-to-face interviews. A total of 530 elderly participants were interviewed and selected by a simple proportionate random sampling technique. About half, 48.3%, elderly were suffering from pre-existing chronic morbidities, of which, 30.9% had single morbidity, and 17.4% had multi-morbidities. This study unfurled more than 50.0% prevalence of health ailments like circulatory, digestive, eye, musculoskeletal and psychological problems each representing the burden of 68.7%, 68.3%, 66.2%, 65.8% and 55.7% respectively. Our study also found that 58.7% preferred hospitals as their first contact facility. Despite the preferences, 46.0% reported visiting traditional healers for treatment of their ailments. About 68.1% reported having difficulty seeking health care and 51.1% reported visits to a health care facility within the last 6 months period. The participants with pre-existing morbidity, health insurance, and an economic status above the poverty line were more likely to visit health care facilities. Elderly people had a higher prevalence of health ailments, but unsatisfactory health care seeking and health care utilization behaviour. These need further investigation and attention by the public health system in order to provide appropriate curative and preventive health care to the elderly. There is an urgent need to promote geriatric health services and make them available at the primary health care level, the first level of contact with a national health system.

BackgroundMorbidity increases with age and enhances the burden of health problems that result in new challenges to meet additional demands. In the ageing population, health problems, and health care utilization should be assessed carefully and addressed. This study aimed to identify chronic morbidities, health problems, health care seeking behaviour and health care utilization among the elderly.MethodsWe conducted a community based, cross-sectional study in urban areas of the Sunsari district using face-to-face interviews. A total of 530 elderly participants were interviewed and selected by a simple proportionate random sampling technique.ResultsAbout half, 48.3%, elderly were suffering from pre-existing chronic morbidities, of which, 30.9% had single morbidity, and 17.4% had multi-morbidities. This study unfurled more than 50.0% prevalence of health ailments like circulatory, digestive, eye, musculoskeletal and psychological problems each representing the burden of 68.7%, 68.3%, 66.2%, 65.8% and 55.7% respectively. Our study also found that 58.7% preferred hospitals as their first contact facility. Despite the preferences, 46.0% reported visiting traditional healers for treatment of their ailments. About 68.1% reported having difficulty seeking health care and 51.1% reported visits to a health care facility within the last 6 months period. The participants with pre-existing morbidity, health insurance, and an economic status above the poverty line were more likely to visit health care facilities.ConclusionElderly people had a higher prevalence of health ailments, but unsatisfactory health care seeking and health care utilization behaviour. These need further investigation and attention by the public health system in order to provide appropriate curative and preventive health care to the elderly. There is an urgent need to promote geriatric health services and make them available at the primary health care level, the first level of contact with a national health system.

Racial and ethnic disparities in healthcare utilization among children in U.S. foster care: Recommendations to challenge the status quo based on a scoping review

Transgender and gender-independent individuals (TGI) encounter myriad barriers to accessing affirming healthcare. Healthcare discrimination and erasure exposure among TGI individuals is vital to understanding healthcare accessibility, utilization behaviors, and health disparities in this population. Exposure to gender identity-related healthcare discrimination and erasure in childhood may contribute to TGI adults’ healthcare utilization behaviors. The commonality of childhood exposure to gender identity-related healthcare discrimination and its relationship to healthcare avoidance during the early months of the COVID-19 pandemic among TGI adults were explored. TGI adults aged 18 to 59 (N = 342) in the United States were recruited online during the summer of 2020. Among individuals who reported childhood exposure to gender identity-related healthcare discrimination, 51% reported experiencing two or more distinct forms of discrimination. Hierarchical logistic regression indicated that exposure to healthcare discrimination in childhood significantly increased the odds of healthcare avoidance during the early months of the COVID-19 pandemic, after accounting for demographic factors and self-reported COVID-19 symptoms (odds ratio = 1.30, 95% confidence interval = 1.10, 1.54). These findings suggest that childhood exposure to gender identity-related healthcare discrimination is a prominent barrier to the utilization of healthcare for TGI adults, even during a global pandemic.

ABSTRACTBackground: Prior studies show an association between drug use and health care utilization. The relationship between specific drug type and emergent/urgent, inpatient, outpatient, and behavioral health care utilization has not been examined. We aimed to determine if multiple drug use was associated with increased utilization of behavioral health care. Methods: To assess health care utilization, we conducted a retrospective cohort study of patients who accessed health care at a safety-net medical center and affiliated clinics. Using electronic health records, we categorized patients who used stimulants, opioids, or multiple drugs based on urine toxicology screening tests and/or International Classification of Diseases, 9th Revision (ICD-9). Remaining patients were categorized as patients without identified drug use. Health care utilization by drug use group and visit type was determined using a negative binomial regression model. Associations were reported as incidence rate ratios. Utilization was described by rates of health care–related visits for inpatient, emergent/urgent, outpatient, and behavioral health care among patients who used drugs, categorized by drug types, compared with patients without identified drug use. Results: Of 95,198 index visits, 4.6% (n = 4340) were by patients who used drugs. Opioid and multiple drug users had significantly higher rates of behavioral health care visits than patients without identified drug use (opioid incidence rate ratio [IRR] = 7.2; 95% confidence interval [CI]: 3.8–13.8; multiple drug use IRR = 5.6, 95% CI: 3.3–9.7). Patients who used stimulants were less likely to use behavioral health services (IRR = 1.3, 95% CI: 0.9–2.0) when compared with opioid and multiple drug users, but were more likely to use inpatient (IRR = 1.6, 95% CI: 1.4–1.8) and emergent/urgent care (IRR = 1.4, 95% CI: 1.3–1.5) services as compared with patients without identified drug use. Conclusions: Integrated medical and mental health care and drug treatment may reduce utilization of costly health care services and improve patient outcomes. How to capture and deliver primary care and behavioral health care to patients who use stimulants needs further investigation.

BackgroundThe COVID-19 pandemic has profoundly impacted healthcare systems worldwide, with China presenting a unique case. As the first country to report COVID-19 cases and the last to lift its stringent Zero-COVID policy, China presents a distinctive context for understanding the long-term effects of the pandemic on healthcare utilization. This study provides a comprehensive analysis of healthcare utilization trends in China over more than four years of the pandemic, focusing on how different phases, including the Zero-COVID policy and its cessation.Methods and findingsWe conducted an interrupted time-series analysis of monthly healthcare utilization data from January 2015 to April 2024, including outpatient visits and inpatient discharges, across Mainland China, controlling for underlying secular trends and patterns. Hospital-based healthcare utilization data were sourced from the National Health Commission of China, and daily Policy Stringency Indices (higher values indicating stricter control policies) were obtained from Oxford’s COVID-19 Government Response Tracker. We modeled changes in healthcare utilization using negative binomial regression, comparing actual outcomes with counterfactual estimates based on pre-COVID trends. We assessed healthcare utilization during key pandemic phases, including the post-Zero-COVID period. Healthcare utilization in China experienced substantial declines during the pandemic, with an estimated reduction of 1.21 billion (7%) outpatient visits and 140.9 million (13%) inpatient discharges compared to expected levels from January 2020 to April 2024. The most pronounced declines occurred during the initial pandemic waves and coincided with periods of stringent Zero-COVID measures. Negative associations between the Policy Stringency Index and healthcare utilizations were observed. Before the lifting of the Zero-COVID policy, a 10-point increase in the Policy Stringency Index was associated with a 7.2 percentage point decrease in outpatient visits and a 6.2 percentage point decrease in hospitalizations. Although healthcare utilization gradually rebounded following the cessation of the Zero-COVID policy, as of April 2024, utilization remained below expected levels in 20 (65%) of the 31 regions for outpatient visits and in 23 (74%) for inpatient discharges. Regional disparities were evident, with more developed areas, such as Shanghai and Beijing, experiencing the largest absolute reductions after adjusting for population size. In Shanghai, outpatient visits declined by 4,997 and hospitalizations by 241 per 1,000 people. In contrast, the largest relative reductions occurred in less developed regions, where outpatient visits dropped by 16% in Guizhou and hospitalizations declined by 27% in Shanxi. Use of aggregated routine health system data limited individual-level analyses, assessment of care quality, and disentangling of causal pathways.ConclusionsThe COVID-19 pandemic and Zero-COVID policies were associated with substantial and enduring disruptions to healthcare utilization in China, characterized by slow recovery and regional disparities in access. These findings underscore the importance of strengthening healthcare systems to enhance resilience and better balance public health interventions with the maintenance of essential healthcare services in anticipation of future public health crises. Continued targeted efforts are needed to address the delayed recovery, particularly in regions with already strained healthcare infrastructure, and to ensure equitable healthcare access across the country.

Utilization and costs of health care and early support services in Germany and the influence of mental health burden during the postnatal period

Association between mental health and self-care behavior among older adults with diabetes according to Behavioral Risk Factor Surveillance System 2019

To describe the sociodemographic differences among Mexican American children (first, second, and third generation), non-Hispanic black children, and non-Hispanic white children; to compare the health status and health care needs of Mexican American children (first, second, and third generation) with those of non-Hispanic black children and non-Hispanic white children; and to determine whether first-generation Mexican American children have poorer health care access and utilization than do non-Hispanic white children, after controlling for health insurance status and socioeconomic status. The Third National Health and Nutrition Examination Survey was used to create a sample of 4372 Mexican American children (divided into 3 generational groups), 4138 non-Hispanic black children, and 4594 non-Hispanic white children, 2 months to 16 years of age. We compared parent/caregiver reports of health status and needs (perceived health of the child and reported illnesses), health care access (usual source of health care and specific provider), and health care utilization (contact with a physician within the past year, use of prescription medications, physician visit because of earache/infection, and hearing and vision screenings) for different subgroups within the sample. More than two thirds of first-generation Mexican American children were poor and uninsured and had parents with low educational attainment. More than one fourth of first-generation children were perceived as having poor or fair health, despite experiencing similar or better rates of illnesses, compared with other children. Almost one half of first-generation Mexican American children had not seen a doctor in the past year, compared with one fourth or less for other groups. Health care needs among first-generation Mexican American children were lower, on the basis of reported illnesses, but perceived health status was worse than for all other groups. After controlling for health insurance coverage and socioeconomic status, first-generation Mexican American children and non-Hispanic black children were less likely than non-Hispanic white children to have a usual source of care, to have a specific provider, or to have seen or talked with a physician in the past year. Of the 3 groups of children, Mexican American children had the least health care access and utilization, even after controlling for socioeconomic status and health insurance status. Our findings showed that Mexican American children had much lower levels of access and utilization than previously reported for Hispanic children on the whole. As a subgroup, first-generation Mexican American children fared substantially worse than second- or third-generation children. The discrepancy between poor perceived health status and lower rates of reported illnesses in the first-generation group leads to questions regarding generalized application of the "epidemiologic paradox." Given the overall growth of the Hispanic population in the United States and the relative growth of individual immigrant subgroups, the identification of subgroups in need is essential for the development of effective research and policy. Furthermore, taking generational status into account is likely to be revealing with respect to disparities in access to and utilization of pediatric services.

To review literature on the impact of The Food and Drug Administration (FDA) drug risk communications on medication utilization, health care services use, and health outcomes. The authors searched MEDLINE and the Web of Science for manuscripts published between January 1990 and November 2010 that included terms related to drug utilization, the FDA, and advisories or warnings. We manually searched bibliographies and works citing selected articles and consulted with experts to guide study selection. Studies were included if they involved an empirical analysis evaluating the impact of an FDA risk communication. We extracted the drug(s) analyzed, relevant FDA communication(s), data source, analytical method, and main outcome(s) assessed. Of the 1432 records screened, 49 studies were included. These studies covered 16 medicines or therapeutic classes; one third examined communications regarding antidepressants. Most used medical or pharmacy claims and a few rigorously examined patient-provider communication, decision making, or risk perceptions. Advisories recommending increased clinical or laboratory monitoring generally led to decreased drug use, but only modest, short-term increases in monitoring. Communications targeting specific subpopulations often spilled over to other groups. Repeated or sequential advisories tended to have larger but delayed effects and decreased incident more than prevalent use. Drug-specific warnings were associated with particularly large decreases in utilization, although the magnitude of substitution within therapeutic classes varied across clinical contexts. Although some FDA drug risk communications had immediate and strong impacts, many had either delayed or had no impact on health care utilization or health behaviors. These data demonstrate the complexity of using risk communication to improve the quality and safety of prescription drug use, and suggest the importance of continued assessments of the effect of future advisories and label changes. Identifying factors that are associated with rapid and sustained responses to risk communications will be important for informing future risk communication efforts.

Using three waves of the Chinese Longitudinal Healthy Longevity Survey in 2005, 2008–2009, and 2011–2012, this study investigates the effect of health insurance on health care utilization and health behaviors of older people in China. Enrollment in a health insurance program represents the main explanatory variable, while total health expenditures (THE), out-of-pocket expenditures (OOP), smoking, drinking and physical inactivity represent outcomes of interest. This study finds that health insurance is associated with an increase in THE and a reduction in OOP, suggesting that insurance enhances access to health services while reducing financial burden. The effects of insurance on health behaviors are complex, associated with increased probabilities of smoking and drinking and a decreased probability of physical inactivity. Results vary across age, education and residential location groups and across time, due to the fact that the health insurance system changed significantly during the study period.

BackgroundSupplemental private health insurance (PHI) plays a crucial role in complementing China’s social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system.MethodsData from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences.ResultsAmong UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities.ConclusionThe findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes.

In the United States, 1 in 6 women report a lifetime prevalence of sexual assault. Few population-based studies have examined the association between sexual assault victimization on health care utilization and unhealthy behaviors. To assess the relationship between experiencing sexual assault and health care utilization and unhealthy behaviors among a state-wide representative sample of Connecticut adults. Cross-sectional study of 4183 Connecticut residents who responded to sexual assault questions in the 2005 telephone-based Connecticut State Behavioral Risk Factor Surveillance System (CT-BRFSS). Health care utilization and unhealthy behaviors among residents reporting sexual assault. Approximately one out of eleven Connecticut adults (9.4%) experienced sexual assault at some point in their life. Among adults aged 65 years and older, 4.3% reported sexual assault compared to 11.2% of adults aged 18-34 years, (p < 0.001). Among men, 3.7% reported sexual assault victimization versus 14.6% of women, (p < 0.001). After controlling for sociodemographic factors, victims of forced sexual assault were less likely to have seen a physician in the previous 12 months for a routine checkup (Odds ratio [OR]: 1.49, 95%: 1.07-2.07) and more likely to report being unable to see a doctor because of cost (OR: 2.72, 95% CI: 1.70-4.34). Victims were more likely to currently smoke (OR: 2.01, 95% CI: 1.34-3.00) and drink heavily (OR: 3.30, 95% CI: 2.01-5.42) than those reporting no sexual assault. For Connecticut adults, sexual assault victimization was associated with infrequent usage of some primary care health services and higher risks of unhealthy behaviors. Increased community-level interventions and public health outreach programs are needed to provide health-care services to this high-risk group.

Transgender older adults in the United States (US) experience significant disparities in behavioral healthcare access and utilization. However, the specific facilitators that contribute to positive or adequate behavioral healthcare experiences among this vulnerable aging population remain uncertain. Understanding the unique facilitators that shape positive behavioral healthcare experiences for transgender (trans hereafter) older patients can assist medical practitioners in integrating these lessons into their practices, thereby promoting cultural responsiveness in care. In this qualitative study, we aim to address the question: What factors facilitate positive behavioral healthcare access and treatment among transgender older adults in the US? Between September 2021 and January 2022, the first author conducted 47 semi-structured, individual interviews with transgender adults aged 65 or older residing in the US. Analyses focused on the behavioral healthcare access and utilization experiences of interview respondents. Data analyses were conducted collaboratively by the authors using NVivo (Release 1.6) software inductively using a grounded theory approach. Findings suggest opportunities for enhancing behavioral health support and resources for transgender older communities. Four main themes emerged from the data: (1) engaging with behavioral healthcare practitioners who offer compassionate, patient-centered care; (2) utilizing culturally tailored peer-support services; (3) ensuring equitable access to gender-affirming medical interventions; and (4) addressing financial and logistical barriers to behavioral healthcare access. These insights highlight opportunities for enhancing behavioral health support and resources for transgender older communities while emphasizing the importance of incorporating these factors into behavioral healthcare research and practice to promote cultural responsiveness in care for this vulnerable aging population.

This study aimed to examine how trust in institutions and changes in household finances were associated with healthcare utilization and preventive behaviors during and immediately after the COVID-19 pandemic. The COVID-19 pandemic worsened health disparities, ignited distrust in healthcare systems, and contributed to household economic shifts for many United States (US) residents. To examine these issues, we surveyed a nationally representative sample of US residents in July 2020 (n = 1,085) and May 2023 (n = 2,189). These repeated cross-sectional surveys enabled investigation of how trust in key stakeholders (e.g., federal government, the healthcare system) and household finances were linked with various types of healthcare utilization (e.g., annual preventive visits, receipt of pharmacy-based healthcare), preventive health care (e.g., influenza vaccination), and preventive behaviors (e.g., exercise, healthy eating). In 2023, the likelihoods of using some types of healthcare (annual health check and pharmacy-based healthcare) and engaging in preventive health behaviors increased relative to 2020. Improved household finances were associated with greater odds of healthy eating, exercising, and receiving annual preventive visits. Trust in the healthcare system was positively associated with all healthcare use types examined including preventive care such as influenza immunization and the individual prevention behavior of healthy eating but not exercise. Findings highlight the important role healthcare systems can have as trusted entities in potentially supporting healthcare utilization and prevention in the post-pandemic environment. Policy implications of these findings include increased efforts by payers and healthcare systems to facilitate positive health behaviors for US residents via specific strategies, such as making annual preventive health checks more accessible. At the same time, it is critical to support maintaining and building trust in healthcare systems to promote appropriate healthcare utilization.