Abstract
BackgroundKnowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach.MethodsData on participants (N = 22,997) aged 16–84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization.ResultsJoint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40–9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67–5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56–6.19), but with no significant horizontal inequity – by gender, education, or their combination – remaining after needs adjustment.ConclusionThis study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.
Highlights
Knowledge remains scarce about inequities in health care utilization between groups defined, by single, but by multiple and intersecting social categories
The results paint a picture of primary and secondary care in Northern Sweden delivered according to needs when it comes to educational disparities, and with gender inequities disfavouring men remaining in primary care, Table 2 Estimating intersectional inequalities and horizontal inequities in General Practitioner (GP) utilization in Northern Sweden
The study suggests that whereas utilization of specialist care in Northern Sweden roughly follows the principle of horizontal equity along and across these two axes of inequality, men seem to be disadvantaged when it comes to primary care utilization given their health care needs
Summary
Knowledge remains scarce about inequities in health care utilization between groups defined, by single, but by multiple and intersecting social categories. The present study seeks to contribute to this line of inquiry by examining complex or intersectional inequities in health care utilization in Northern Sweden by gender and education, two central and stable dimension of inequity. Most health care policy and research has given focus to horizontal equity, which is the provision of equal health care to those with equal health care needs regardless of any other factors, such as socioeconomic position, gender, racial/ethnic differences or place of residence [9, 10]. These principles are clearly formulated in Swedish legislation and policies. Specialist care is mostly restricted to hospitals present in the larger towns, and is accessed almost exclusively by referral from the primary health care doctor
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