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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
   children
   – 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
  determinants
• Individualistic and static focus on client need and
  services
• Explains ~20% of variance in use
• 3 categories of determinants
   – Need
   – Enabling
   – Predisposing
                    Need
• 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,
  outcome
• 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
                                                                 HELP
       Environment
 Service System Structure:
         Education
           Health
 Child and Family Services
        Economy                                                                              Service Provision
                                                                                                   Education
                                                               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
                                                                                              Religious/cultural

   Enabling Factors
     Family factors
 Preschool intervention
     School factors
    Social networks
             Applications
• 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
    factors
  – Only small amount of variance explained
  – Perceived need was most significant
  – SES was not explanatory
               Applications
• Variations in treatment for ADHD (Bussing
  2003)
  – School-district level study
  – Stratified sample
  – Teacher and parent screening questionnaires for
    risk
  – 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
     problems
   – 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

				
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