Original Articles
Low education, high gp consultation rates: the effect of psychosocial factors

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Abstract

The purpose of this study was to estimate the contribution of psychosocial factors to the increased use of a general practitioner (GP) among those with a lower level of education. The use of GP services was elicited from survey data from 2867 respondents from the Dutch Longitudinal Study on Socio-Economic Differences in the Utilization of Health Services (LS-SEDUHS) using a simple “Yes/No” format. Psychosocial variables included long-term stressful conditions, social support, external locus of control, coping styles, and tendency to consult (a measure of people's propensity to go to a doctor with health problems). People with primary education used the GP services more than people with higher vocational training or a university degree (OR 1.87, p<0.05), adjusted for health status and health insurance. Only tendency to consult partially explained this difference (OR: 1.74, p>0.05). Most psychosocial factors do not seem very important in explaining high GP utilization rates among those with a low socioeconomic status. Alternative explanations are discussed.

Introduction

Socioeconomic differences in the use of health care systems has been widely reported 1, 2, 3, 4. Evidence from The Netherlands and the United Kingdom suggests that groups with a lower educational attainment or social class use the general practitioner services more than those with a higher educational qualification or those in the higher social class categories, even if the less favorable health status of those with a low socioeconomic status is taken into consideration 5, 6, 7, 8. Furthermore, when potentially important information about health insurance is taken into account, substantial socioeconomic differences remain [9]. The question then arises as to what other factors apart from health status and health insurance might be contributing to the socioeconomic differences in the use of general practitioner services?

To study health services utilization, Andersen formulated a widely used behavioral model describing the use of health services as a function of medical need, and enabling and predisposing characteristics of an individual [10]. The need component reflects the urge to seek medical care because of the individual's objective or subjective health status. The enabling component suggests that people, in addition to their medical need, must have the means (e.g., health insurance) to use health care facilities. The predisposing component involves characteristics existing prior to the onset of disease, which reflect a person's propensity to use health care services.

One group of predisposing characteristics is psychosocial factors. To understand the differences in the pattern of use of general practitioner services among different groups, it is useful therefore to determine the contribution of psychosocial factors. This understanding could be important when targeting interventions, both to help patients and perhaps also to find ways of reducing the workload for the general practitioner, especially in deprived areas.

In this study, we report the results of a cross-sectional analysis concerning the explanation of differences by level of education in consultation rates with the general practitioner in The Netherlands, controlling for health status and health insurance. We used data from a questionnaire that had elicited a response of approximately 72%. Explanatory variables used were long-term stressful conditions, social support, locus of control, coping styles, and attitudes toward health and health care. We tested the hypothesis that differences in the use of general practitioner services according to education remained after controlling for health status and health insurance and that the differences can be attributed to these psychosocial characteristics.

Our study was carried out in The Netherlands, but its results may have implications for other health systems that share certain characteristics with the Dutch health care system, such as the aim of universal access and the central role of the general practitioner in primary care.

Section snippets

Study population

We used cross-sectional data from the Longitudinal Study on Socio-Economic Differences in Utilization of Health Services (LS-SEDUHS). The LS-SEDUHS is part of the GLOBE study, a longitudinal study on inequalities in health in The Netherlands that began in Spring 1991 with a postal survey. The design and objective of this study have been described elsewhere [11]. The sample of the GLOBE study was based on a cohort of noninstitutionalized Dutch nationals aged 15–74 years. The highest and lowest

Results

Results of the associations between education and the explanatory factors are displayed in Table 2. Because so many associations and overall contributions of education in Table 2 were statistically significant, all coefficients of education are displayed in Table 3. Long-term stress was only statistically significantly more prevalent among the lower educated with respect to situational problems. Both types of social support did not significantly differ according to educational level, although

Discussion

In this study, we tested whether psychosocial factors contributed to explaining the higher general practitioner consultation rates among those in the lower socioeconomic strata, controlling for health status and health insurance. Analyses were carried out on cross-sectional Dutch survey data of 2867 mainly chronically ill persons. Tendency to consult was the only psychosocial factor that explained the socioeconomic differential partially. Therefore, our hypothesis has to be rejected because the

Acknowledgements

Acknowledgments—This project was supported by a grant from the Health Insurance Council (Ziekenfondsraad). It was part of the GLOBE study (Gezondheid en LevensOmstandigheden Bevolking Eindhoven en omstreken), a large-scale research project on health and living conditions of the population of Eindhoven and surroundings. The GLOBE study was conducted by the Department of Public Health, Erasmus University Rotterdam, in collaboration with the Community Health Services of the city of Eindhoven, the

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