استفاده از جنسیت و مراقبت های بهداشتی: نقش پریشانی ذهنی و میل به جستجوی کمک
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|34049||2007||15 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Social Science & Medicine, Volume 64, Issue 6, March 2007, Pages 1216–1230
Many studies report higher levels of health care utilization among women. Understanding how gender influences health care utilization is still unresolved. We developed a model that could explain these gender-related differences. The possible pathways assumed by this model that relate gender to utilization, can be summarized as follows: (1) utilization may be influenced by somatic morbidity, mental distress, perceived symptoms, poor subjective health and propensity to use services; (2) women have higher levels of these variables than men (mediating effect); and (3) the direct effects of some of these variables on utililization are moderated by gender, i.e. they are stronger for women than for men (moderating effect). Data were drawn from a community-based sample of adult enrollees of a sickness fund in the Netherlands, who had responded to a mailed health survey (N=8698). This survey contained questions on somatic morbidity, mental distress and other mediating variables. Health care utilization was measured prospectively, using data extracted from a claims database held by the sickness fund that covers all types of general health services except general practitioner consultations. The model was tested using structural equation modelling. Women reported more somatic morbidity and mental distress than men did, as well as elevated levels of other mediating variables, which might explain—at least partly—gender related differences in utilization. Differences in propensity to use services were not found. The expected moderating effect of gender could not be demonstrated. That is, we did not find gender related differences in the strength of the relations between mental distress, other mediating variables and utilization. Mental distress is related to utilization in a way that is not gender specific, however, because women report higher levels of mental distress (as well as somatic morbidity), this results in a greater utilization of somatic health care services.
It is a well-known fact that women use more health care services than men do, even after correcting for the use of health care services that are specific for women, such as gynaecology (Briscoe, 1987; Corney, 1990; Green & Pope, 1999; Ladwig, Marten-Mittag, Formanek, & Dammann, 2000; Svarstad, Cleary, Mechanic, & Robers, 1987). Differences in utilization can partly be explained by differences in somatic morbidity. Women tend to have more minor (transient) illnesses and nonfatal chronic diseases, while men have more fatal chronic diseases and higher mortality rates (Lahelma, Martikainen, Rahkonen, & Silventoinen, 1999; Wingard, Cohn, Kaplan, Cirillo, & Cohen, 1989). These differences in morbidity can be found from early adolescence (Sweeting, 1995). However, whether these differences are consistent across the life span is less clear-cut than is generally assumed (Kandrack, Grant, & Segall, 1991; Macintyre, Hunt, & Sweeting, 1996). A higher frequency of affective disorders or mental distress among women compared to men seems to be a consistent finding (Hankin & Abramson, 2001; Macintyre et al., 1996; Popay, Bartley, & Owen, 1993; Rojas, Araya, & Lewis, 2005; Silverstein, 2002). This might also partly explain the greater use of general health care by women (Koopmans, Donker, & Rutten (2005a) and Koopmans, Donker, & Rutten (2005b)). Several factors have been suggested to explain these gender-related differences in health care utilization and morbidity, such as acquired risks, psychosocial factors and health-reporting behaviour (Verbrugge, 1989). Such factors may exist at different levels in men and women, and the impact of these factors can be different depending on gender. For instance, in a study of Green et al. (Green et al., 2004) the effects of prior depression on health care costs appeared to be stronger for men than for women. Based on findings from the literature, we developed a model that could explain these gender-related differences in health service use. We first describe this model as shown in Fig. 1, then explain and support the proposed mechanisms. Full-size image (46 K) Fig. 1. Conceptual model to predict health care utilization. Note: dotted line means association will be tested, but no association expected. Figure options The possible pathways to utilization that this model assumes can be summarized as follows: 1. utilization may be influenced by physical illness, mental distress, perceived symptoms, poor subjective health and propensity to use services; 2. women have higher levels for these variables than men, especially for mental distress, physical illness and utilization propensity (thus the effect of gender on utilization is mediated by these variables); 3. the effects of some of these variables on utililization are also moderated by gender. That is, they are stronger for women than for men, especially the effects of mental distress on symptom perception and poor perceived health are stronger among women compared to men (gender has a moderating effect on these relations). The model implies that gender does not have a direct relation with utilization, but is indirectly related to utilization through several pathways (mediated by the variables just mentioned). As we do not expect a direct relation between mental distress and utilization, this path is depicted as a dotted line in the diagram. The first pathway linking gender and utilization is through mental distress. We assume no direct link between mental distress and utilization, but assume that it is linked to utilization via poor perceived health (self-rated global health). Mental distress is expected to be more prevalent among women (Hankin & Abramson, 2001; Macintyre et al., 1996; Popay et al., 1993; Rojas et al., 2005; Silverstein, 2002) and is linked to (poor) perceived health in two ways: directly and through symptom perception. Firstly, mental distress has a direct effect on poor perceived health because it is one of the components of health status that is evaluated in the self-assessment of health. Mental distress is further linked through perceived symptoms or complaints, as mental distress raises the awareness of physical symptoms (Gijsbers van Wijk & Kolk, 1997). Both relations are moderated by gender. Firstly, women tend to weigh mental distress more heavily than men in the self assessment of health (Benyamini, Leventhal, & Leventhal, 2000; Corney, 1990; Parslow, Jorm, Christensen, Jacomb, & Rodgers, 2004). For that reason perceived health is a better predictor of mortality among men (Benjamins, Hummer, Eberstein, & Nam, 2004). And secondly, mental distress is more likely to lead to a negative interpretation of physical signs among women. One reason is the greater awareness of physical symptoms among women compared to men (Gijsbers van Wijk & Kolk, 1997) that triggers help seeking in an earlier state or more frequently. Related to this factor is the role of negative affect on the self-assessment of physical symptoms: among women negative affect is more prevalent and more strongly related to a negative interpretation of physical symptoms (Pennebaker & Watson, 1991; Watson & Pennebaker, 1989). The second pathway linking gender and utilization is through physical illness, since female gender will be related to a higher level of somatic morbidity (Lahelma et al., 1999; Wingard et al., 1989). Physical illness is a factor directly related to utilization, but also indirectly through symptom perception, perceived health, and mental distress. The third pathway linking gender and utilization is through utilization propensity, which is supposed to be directly related to utilization and is expected to be higher on average among women. This assumption is based on evidence that men are less likely than women to share their health concerns with significant others, including health care professionals (Gijsbers van Wijk & Kolk, 1997; Tudiver & Talbot, 1999). This tendency leads to a lower utilization propensity of men, i.e. an attitude towards professional medical services that is more reserved and uncomplaining. Of the sociodemographic characteristics that might influence health care utilization, we assume that age is the major factor, related to utilization both directly and indirectly through physical illness. From this model the following hypotheses can be derived: 1. On average women will have a higher utilization of general health care. 2. There will be gender related differences in physical illness, mental distress and utilization propensity that can (at least partly) explain these differences in utilization as these variables are (directly or indirectly) related to utilization. 3. Mental distress is related to utilization indirectly and is mediated by symptom perception and poor perceived health 4. Mental distress is more strongly related to symptom perception and to poor perceived health among women compared to men and is in that way more predictive of utilization among women.