Models of Use of Health Care Services

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Models of Use of Health Care Services Powered By Docstoc
					Variation in Health Service Use in Childhood:
             Explanatory Models

 • Large variation in use of health services by
   – 21- 48% don’t use services
   – 12% high users

 • Patterns are stable through adulthood
 • Health status accounts for only 16% of variance
Determinants of Use of Health Care Services
 • Economic                   • Socio-psychological
   –   Insurance                 – Perceived threat
   –   Income                    – Knowledge of disease
   –   Cost                      – Social network support
   –   Availability
                              • Socio-cultural
 • Sociodemographic              – Family structure
   –   Age                       – Social networks
   –   Gender
   –   Education              • Organisational
   –   Religion                  – Quality of care
   –   Ethnicity                 – Quantity of services
   –   Socioeconomic status      – Accessibility
Historical Models of Utilization

                      Pescosolido et al, 1995
       Explanatory Models
• Organise many different explanatory factors
• Focus of models
  – Volume of use
  – Types of use
  – Outcomes of use

• Two important models
  – Health Belief Model
  – Socio-Behavioral Model
          Health Belief Model
Evaluation of the decision-making process
 to use professional health care
•   Perceived susceptibility
•   Perception of benefits
•   Evaluation of potential barriers
•   General health motivations
      Socio-Behavioral Model
• Andersen 1968
• Prediction of utilisation by patterns of
• Individualistic and static focus on client need and
• Explains ~20% of variance in use
• 3 categories of determinants
   – Need
   – Enabling
   – Predisposing
• Evaluated
• Perceived
  – Interaction between biology and health beliefs
    and experience
• Strongest relationship with use
    Predisposing Factors
• Social structure              • Demographic
   –   Maternal mental health     – Age
   –   Single parent              – Gender
   –   Family size                – Medical history
   –   Education
   –   Religion
   –   Ethnicity
   –   Mobility

• Beliefs
   – Health locus of control
   – Values about health
   – Knowledge about illness
        Enabling Factors
• Family
  – SES
  – Insurance
  – Social supports

• Community
  – Urban/rural
  – Region
       Network-Episode Model
• Entry in health service system is a function of:
   – Choice
   – Coercion
   – Muddling through

• Users are not simply rational decision-makers
• “Muddling through”
   – Influenced by circumstances
   – Engage in successive limited comparisons between alternatives

• Dynamic nature of system entry, repeat use, adherence,
• Community-based and process model
                                           Pescosolido 1991, 1992
    Gateway Provider Model
• Adaptation of NEM
• Adult “gateway providers” influence child
  service use
• Informal: friends, family
• Formal: mental health specialists, GPs,
  teachers, child welfare, juvenile justice
                              Stiffman et al, 2004
      Gateway Provider Model
Influences on GPs:
• Recognition of need
    – Primary health care providers miss 46-86% of
      existing mental health problems and diagnoses
•   Knowledge of predisposing factors
•   Identification of problem
•   Knowledge of service system
•   Interorganisational relationships
Conceptual Model of Help Seeking and
          Service Delivery
                              PROBLEM RECOGNITION          DECISION TO SEEK                SERVICES/SUPPORT
 Service System Structure:
 Child and Family Services
        Economy                                                                              Service Provision
                                                               Gateway Provider             Diagnostic assessments
                                       Need              Perceptions and Knowledge of      Special education services
                                  Perceived need     Service resources Neurodevelopment      Accommodations
                                  Evaluated need:          Parental/teacher attitudes               Health
 Predisposing factors            Learning disorders                                             Health services
       Gender                      Comorbidities                                             Therapeutic services
    Medical history                                                                                 Informal
       Ethnicity                                                                               Support services
                                                                                               Advocacy groups

   Enabling Factors
     Family factors
 Preschool intervention
     School factors
    Social networks
• Ontario Child Health Study
  – Woodward et al, Pediatrics 1988
  – Explanation of variance in ambulatory medical
    care use for ON children age 4-16 during a 6
    month period
  – Examined need and predisposing/enabling
  – Only small amount of variance explained
  – Perceived need was most significant
  – SES was not explanatory
• Variations in treatment for ADHD (Bussing
  – School-district level study
  – Stratified sample
  – Teacher and parent screening questionnaires for
  – Home interviews for service assessment
  – High risk families assessed for help-seeking steps
  – Children with diagnosed ADHD and no treatment
    assessed for barriers to care
                  ADHD study
• Results for rates of evaluation for high-risk kids:
   – Lowest evaluation rates when no routine source of
     paediatric care
   – Boys 5x more likely to be evaluated
   – Better for older children with more behavioural
   – Whites 2x more likely to be evaluated than Blacks
   – Higher SES more likely to be treated
   – Special ed children more likely to be treated
              ADHD study
• Parents had high recognition rates
• Parental barrier perspectives
  – Unsure where to go for help
  – Problem got better by itself
  – No perceived need
  – Negative expectations
  – Stigma
  – Financial barriers