Research has revealed substantial differences in the healthcare use and access of different groups in Switzerland and across European countries, particularly of disadvantaged groups. This phenomenon has been observed through a broad range of healthcare services, including preventive health services. The persistence of differential utilisation and “social gradients” in healthcare use and access highlights the need for innovative methods and theories to help reveal the underlying mechanisms of such disparities.

For example, cross-national comparisons have helped shed light on how particular societal and system arrangements shape healthcare access. National approaches have also made important contributions with longitudinal studies and trend analysis. Health and medical sociologists have increasingly emphasised the need to contextualise health inequalities, accounting for the effect of policies and institutions, for example from the perspective of “institutional theory” or the “diffusion of innovation theory”. They have stressed the importance of macro‐level contexts in shaping the distribution of resources which matter to individuals’ health, and such approach may also apply to healthcare use and access. In other words, the persistence of disparities in healthcare access may be attributed to individual resources such as educational level, income, social capital, health literacy and labour conditions at a micro‐level, and how resources are (re)distributed in a population by institutions such as welfare social policies, healthcare system arrangements, labour markets, or education systems, at a macro level. These may affect individuals’ potential for access to, utilisation of, and adherence towards health services, practices or guidelines. Further research is needed to better understand the dynamics that affect the population and specific groups in their healthcare access. Further theoretical developments supported by empirical evidence to deepen our understanding of the “social determinants of healthcare access” and the multiple factors at play are needed. 

This session invites both theoretical and empirical studies, quantitative and/or qualitative, that research topics on healthcare use, access and inequalities in Switzerland and Europe, from a national or cross-national perspective, and a micro and/or macro approach. 

Research questions: 

• Which mechanisms (re)produce inequalities in access to and use of healthcare services (including preventive health)? What are the logics behind the barriers to healthcare access faced by disadvantaged groups? 
• What drives people towards the over-consumption of healthcare services?
• Which system and social mechanisms, including policy and institutional contexts, contribute to shaping inequalities in healthcare access and use, and how? Which micro- and macro-level factors are at play?
• How does the reproduction of social inequalities into health inequalities relate to the institutional context and (in)effective health promotion policies?

Keywords:Healthcare; Inequalities; Prevention; System; Institutions; Over-consumption

Health state, health behavior and health care use of social assistance recipients in Switzerland – linking survey with administrative data

Marc Höglinger¹ (Presenter), Sarah Heiniger¹, Oliver Hümbelin², Dorian Kessler², Jodok Läser²

¹Zurich University of Applied Sciences, Switzerland

²Bern University of Applied Sciences, Switzerland

Background People living in poverty are more often affected by health problems than people who are financially well off. Health problems make it difficult to work and accumulate assets and, on the other side, poverty itself and its accompanying conditions have negative effects on health. Consequently, people who depend on social assistance benefits are expected to suffer more likely from health impairments. Also, they might be at greater risk for inadequate healthcare use and non-use. However, so far there is no comprehensive knowledge on these questions for Switzerland.  

Objective The aim of our study is to fill in this knowledge gap by addressing the following questions: 

1. How do health state, health behavior, and health care use of social assistance recipients differ from the rest of the population?
2. How does their health state and health care use change at relevant transitions (i.e., exhaustion of unemployment benefits, entry into and exit from social assistance) and during the time they receive social assistance?

Methods Our analyses are based on a unique data set with over 600,000 observations, linking survey data from various sources with administrative data about social assistance receipt and labor market status. The linked dataset allows for a representative analysis for the period 2007 to 2018 and for various subgroup-analysis such as gender, household composition, urban/rural place of residence, or nationality. Survey data covering various self-reported health domains is drawn from the Swiss Health Survey, the Survey on Income and Living Conditions, and the Swiss Labor Force Survey. 

Results Results show for social assistance recipients considerably higher prevalence rates for almost all health related problems under consideration: 18% of social assistance recipients report a (very) poor subjective health (rest of the population: 1%), 45% a chronic condition (rest 21%), 19% restrictions in activities of daily living (rest 2%). Their healthcare use is higher with respect to general practitioner visits, emergency departments, and hospital stays. The only exception is the use of dental services, which is lower compared to the rest of the population.

Conclusions/Relevance Our study provides detailed insights into the health problems and health-related behavior of social assistance recipients. It serves as a reference point for assessing the intervention potential of social assistance agencies regarding health and health care needs of their clients.

Socioeconomic inequalities in the (over)use of antidepressants

Lisa Colman, Department of Sociology, Ghent University, Belgium

Background: Antidepressants are among the most prescribed drugs in Europe. Recent drug utilization studies conducted in Europe suggest a substantial increase in the use of antidepressants over time. Research begins to openly discuss the sharp increase in antidepressants use, linked to debates about their effectives. A more recent, rather unexplored, focus is on the ‘overuse’ of antidepressants. Inappropriate use and the possibility of harm from the overuse of antidepressants has so far not attracted wide attention. Awareness towards the overuse of antidepressants fits within the medicalisation perspective on mental health, stating that mental distress is increasingly medicalised and that structural explanations causing the distress are ignored. This perspective reacts to the biomedical model of ‘illness’, which reduces mental distress to a malfunction in the workings of the body that can be objectively determined, and where antidepressants taking is perceived ‘need-based’. Therefore, the first aim of this research is to analyse if antidepressants use is increasing over time, irrespective of mental health status (i.e., non-need-based). Moreover, the biomedical model doesn’t take into account that there may be people using antidepressants due to their socioeconomic circumstances, rather than their experience of ‘illness’. As such, the medicalisation perspective states that medical therapies are increasingly being promoted to treat milder forms of mental distress, and accordingly changes increase that people with a lower SES, who overall experience more feelings of distress, might be treated by prescribing antidepressants. Therefore, the second aim of this research is to investigate whether people with a lower SES have higher antidepressants use rates compared to people with a higher SES, irrespective of mental health status. Analysing antidepressants use irrespective of mental health status may serve as an indication of non-need-based use, or ‘overuse’.

Methods: Data obtained from the Belgian Health Interview Survey (BHIS) will be used. The BHIS is a repeated cross-sectional survey coordinated by Sciensano, the scientific institute for public health of the federal Belgian State. This study will cover information from 6 successive waves: 1997, 2001, 2004, 2013, 2018. The weighted data will represent a sample of the adult Belgian population (25-85 years). The research aims will be analysed using stepwise Poisson regression models, estimating adjusted prevalence ratios (APRs). Predictor product terms will be added to test time trends.

Preliminary results: (Following results are without the last wave; period 1997-2013). The results reveal that antidepressants use is increasing over time, irrespective of mental health status. Also, people with tertiary education have, irrespective of mental health status, a significantly lower prevalence of antidepressants use compared to people with no or primary education, indicating an educational gradient in antidepressants use. Further analyses reveal that the interaction term between the GHQ-12 scale (used to operationalise mental health status) and survey-wave shows that over time, the prevalence of the use of antidepressants increases for scores on the GHQ-12 scale below the statistical threshold point found by a ROC-analysis between the GHQ-12 scale and antidepressants use, revealing evidence of increasing non-need-based use or ‘overuse’.

When Healthcare System Arrangements Contribute to Health Inequalities: the Case of Gynaecological Cancer Screening in France

Géraldine Bloy, University of Burgundy – LEDi, France; Laurent Rigal, General practice Department, Paris-Saclay University - INSERM CESP 1018, France

In France, it is generally assumed that the care received differs, but fairly slightly according to social status. The global responsibility for social inequalities in health that may be attributable to the health care system and to how health care professionals deliver this care may thus be limited. 

Our presentation will question this assumption. It cross-references epidemiology and sociology in order to examine the social inequalities in gynaecological cancer (cervical and breast) screenings through pap-smears and mammograms in contemporary France. 

The analysis is based on two original surveys1 on preventive practices of French general practitioners (GPs) – from which we draw on information relating to screening for gynaecological cancers – and is backed by a large multidisciplinary literature. 

We measured marked social gradients in both screenings (larger ones for cervical cancer). We then related these gradients to the last prescriber of the screening, who could be a medical gynecologist (member of a specifically French specialty), a GP, or an organized screening program for breast cancer. The contextualization of the prescription, with the different professional groups and institutions at play, shows a precise ecology of interlinked but poorly coordinated actors responsible for the screenings. The suboptimal division of tasks that ensues directly contributes to shape social inequalities in healthcare access. 

This results from a specific story, that has framed professional logics and women’s socially differentiated expectations or habits relating to gynaecological care, without raising concern about social inequalities. In French women rights history, medical gynaecologists have often been considered as women’s “favourite” doctors. Meanwhile, GPs have been discredited or marginalized as gynaecological caregivers: due to a limited investment in gynaecology, most of them risk a progressive loss of clinical competences in this area and don’t feel comfortable in examining women’s physical intimacy. 

Although France is supposed to have one of the greatest healthcare systems, with cancer screening free-of-charge for patients, such a dysfunctional arrangement has not been regulated by health policy. On the contrary, recent decisions relating to medical gynaecology have increased tensions in the access to gynaecological care, with less specialist doctors available, higher fees required, and no competent relay constituted among GPs for gynaecological screenings. However, the set-up of an organized screening program for cervical cancer and the recent contribution of midwives to this screening could help reduce the social gradients. 

Mixing quantitative and qualitative methods in social sciences, and crossing approaches in the same case study produce more systemic and contextualized analysis in the complex area of social inequalities in health.

1 Prev Quanti was an epidemiological survey based on cross-sectional observations in the practices of 52 volunteer training supervisors — private GPs who train students in their offices — at two medical schools. Seventy patients (35 men and 35 women) aged 40 to 74 years were selected at random from the patient list of each doctor (n=3640). Information on the main preventive care measures was collected from the patients and separately abstracted from their medical files. Prev Quali, was a qualitative sociological survey carried out by semi-structured interviews of a diversified sample of 99 GPs. It dealt with the same preventive practices and screenings as those in the quantitative survey. 

The impact of the residence status regularization on access to healthcare for undocumented migrants in Switzerland: a panel study

Julien Fakhoury⁽¹⁾⁽²⁾, Idris Guessous³, Delphine Courvoisier⁴, Claudine-Burton Jeangros², Yves Jackson³

¹Swiss NCCR “LIVES – Overcoming Vulnerability: Life Course Perspectives”, University of Geneva, Switzerland; ²Institute of sociological research, University of Geneva, Switzerland; ³Division of Primary Care Medicine, Geneva University Hospital and University of Geneva; ⁴Division of Rheumatology, University Hospital of Geneva, Switzerland

Switzerland has a universal healthcare system. Yet, undocumented migrants face barriers at different levels that hinder their access to health services. The aims of this study are 1) to identify barriers at the undocumented migrants’ level and 2) to assess whether the regularization of the residence status improves their healthcare utilization. 

Methods

We used two-wave panel data collected at one-year intervals from the Parchemins study, a multidisciplinary study taking place in Geneva and evaluating the impact of regularization on undocumented migrants’ health and well-being. The sample consisted of undocumented migrants living in Geneva for at least 3 years. We categorized them into two groups according to their status at baseline: those who had been newly regularized (<3 months) vs. those ineligible or unwilling to apply for regularization. Using the number of medical consultations over the past 12 months to measure healthcare utilization, we conducted multivariable regression analyses to identify impeding factors. In a second step, we estimated first-difference panel models to assess change in healthcare utilization due to regularization. Models were adjusted for demographic characteristics and health-related variables. 

Preliminary Results

Of the 310 participants, 68 (22%) belonged to the regularized group and 111 (36%) suffered from comorbidity at the beginning of the follow-up. At baseline, significant factors hindering healthcare utilization included male gender (Risk ratio: 0.62; 95% confidence interval: 0.46-0.85) and not having a regular family doctor (RR: 0.67, 95% CI: 0.52-0.86). Prior to regularization, migrants in the regularized group did not significantly differ from undocumented ones in terms of healthcare utilization (RR: 0.94; 95% CI: 0.71-1.25). However, after regularization, they were more likely to consult than those who remained undocumented (RR: 1.65; 95% CI: 1.23-2.21), suggesting a positive impact of regularization on healthcare utilization. Results from the first-difference panel models seemed to confirm that residence status regularization might have driven migrants’ healthcare utilization (β coefficient: 1.00; 95% CI: 0.29-1.79). 

Conclusions

Public policies aiming at granting undocumented migrants residence authorizations might improve healthcare utilization for this population. More research is needed to understand the mechanisms through which regularization improves undocumented migrants’ use of healthcare services.