| Frequent attenders in primary health care: A cross-sectional study of frequent attenders’ psychosocial and family factors, chronic diseases and reasons for encounter in a Finnish health centre | ||
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Research on the utilization of health care services is of increasing value because of the high and still rising expenditure in health care. Such research is associated with the medical, social and behavioral sciences and also with health economics (Purola 1971, Purola 1972). The use of health services has been explained by patients’ personal factors (health or illness, symptoms, knowledge, beliefs, experiences, feelings of threat, needs, coping factors etc.), social factors (sociodemographic factors, family factors, social support etc.) and factors related to the health care system (geographic distance, availability, accessibility, costs etc.).
The users of health care services perceive themselves as less healthy, fewer of them have attempted self-treatment and more of them report personal problems and stress than non-users (Anderson et al. 1977). Previous use of health care services is more strongly related to current use of health care services than are measures of previous health status (Eve 1988). In a review of health care utilization studies, McKinlay concludes that factors relating to family life, perception of needs, childhood habits and relationships with service personnel are important determinants of utilization behaviour (McKinlay 1972). The utilization of health care services is related to age, gender, education, religion, ethnicity, socioeconomic status, social support, etc. (McKinlay 1972, Mechanic 1979, Kouzis & Eaton 1998). The rate of utilization is generally lower among males than females and increases with age (McKinlay 1972, Mechanic 1976). Medical needs explain the use of health services among both older and younger patients (Evashwick et al. 1984, Hibbard & Pope 1986). Mental health status is a powerful predictor of patient-initiated utilization of health services among the elderly (Hibbard & Pope 1986). Differences in social welfare and social security systems affect the attendance rates greatly (Schrire 1986).
Various conceptual models have been developed to operationalize the complex and multi-dimensional issue of health care utilization. These multifactorial models offer some theoretical frameworks to be used in the research on the use of health care services to explain utilization.
Andersen and Laake (1987) have developed a conceptual model, called the behavioral model of utilization, for determining the use of health services. According to Andersen’s model, physician contacts are determined by three factors: predisposing factors, enabling factors and need factors. According to the authors, predisposing factors include gender, age and social status. Enabling factors include conditions that facilitate or inhibit the use of physician services, e.g. the distance to the health centre, the type of municipality, working time and family size. Need variables include chronic diseases, disability days, new illness conditions and psychological well-being. The need variables seem to explain best the number of visits to physicians. (Kronenfeld 1980, Andersen & Laake 1987.) Only a few studies have analyzed the context of health care by including both environmental and provider-related variables of utilization (Phillips et al. 1998).
In the model developed by Purola, the basic setting for the use of health care services is, firstly, the disease in the medical sense and, secondly, the perceived illness as an originator of behavioral reactions. Thirdly, the predisposing and enabling factors act as modulators of the person’s behavioral reactions. (Purola 1971, Purola 1972.)
Antonovsky’s model of utilization includes host characteristics, characteristics of the medical institutions and characteristics of the larger sociocultural environment. This model takes into account the fact that medical care constitutes a small social system, which may be used to deal with diffuse social and psychological needs when the system is available, when its use is socially encouraged, and when it is receptive to peoples’ needs and orientation. (Antonovsky 1972.)
The health behavior of a population can also be explained using the health belief model originally conceptualized by Becker (Janz & Becker 1984). In this model, the person’s reactions to symptoms of illness are modified by various factors, e.g. motivation, the experienced threat of illness and coping factors. The model includes an interesting concept, “cue to action”, which means that different cues, information or recommendations may act as the final stimulus to the behavior carried out, e.g. an encounter with a physician. (Leavitt 1979.)
The biopsychosocial model originally introduced by Engel (1977) has not been used, until now, as a conceptual basis of research on health care utilization. The biopsychosocial model is based on the general systems theory of Von Bertalanffy (1968), which implies that all levels of an organization or system, beginning from molecules and cells and ending up with society or biosphere, are linked to each other in a hierarchical relationship, so that a change in one effects changes in the others.
Theoretically, as Engel pointed out, systems theory provides a conceptual approach suitable not only for the proposed biopsychosocial concept of disease but also for studying disease and medical care as interrelated processes (Engel 1977). Thus, the biopsychosocial approach would benefit the research on health care utilization, which aims to understand more thoroughly the relationships between various explanatory factors (e.g. somatic diseases, psychological factors and social environment, such as family) of health care utilization.
About 86% of the Finnish population visit a physician at least once a year (Vohlonen et al. 1991). The average number of visits to GPs in health centres in 1998 was about 2.1 visits per year in the whole country, and this means a total of about 10.8 million visits per year (SOTKA Statistics, Stakes, Finland). The private medical sector comprises about 4.9 million visits to physicians per year (Tapani Niskanen, Stakes, personal communication). According to Häkkinen, the mean number of visits to physicians was 3.4 in 1987, of which 2.3 were GP visits and 1.1 were visits to medical specialists. Of all visits to physicians, including outpatient visits to hospitals, 44% were visits to GPs in health centres. (Häkkinen 1991.) In an interview study of the Finnish population, about 7% of men and 9% of women visited a GP more often than eight times a year (Berg et al. 1990).
The use of health services increases with age and with the increasing number of chronic diseases. Women use more health care services than men, and the use of health care services is higher in the lower social classes (Berg et al. 1990, Häkkinen 1991). Moreover, in cities the use is higher than in rural areas (Nyman 1982). Divorced and widowed persons visit GPs more often than married or single persons (Berg et al. 1990).