Socioeconomic aspects of unmet healthcare needs and health outcomes - Economic conditions, social capital, unmet healthcare needs, healthcare providers and mortality

Socioeconomic status (SES) differences in health are well known. Both material and psychosocial hypotheses regarding these SES differences have been forwarded. Social capital (trust, social participation) may be seen as a contextual and social extension of this debate with access to healthcare as one of the four hypothesized mechanisms between high social capital and health. This thesis investigates material, psychosocial and social capital factors and SES with regard to unmet health care needs, choice of primary care (PC) provider and mortality in ecological and individual level studies. In paper I, social capital (measured as trust), relative income (Gini index) and absolute income (GNP/capita) were examined in models regarding infant mortality rate (IMR), adult mortality rate (25-64 years) and life expectancy (LE), analyzed in models for all countries (23), and 11 rich and 12 poor separately. Social capital contributed little to the information content (adjusted R2) of the models for all health outcomes, while Gini index had a high information content for IMR in rich countries and BNP/capita for LE in all countries. This suggests that material factors rather than social capital affect health outcomes in this ecological study.In paper II, socioeconomic differences regarding unmet healthcare needs were investigated using the Public Health Survey in Skåne, 2012, including 28,029 respondents aged 18-80. SES was significantly associated with unmet healthcare needs. There was a clear gradient for unmet healthcare needs among the SES groups, where higher non-manual employees had lower levels of unmet healthcare needs than all other employed groups. Only retired persons had lower unmet healthcare needs than the higher non-manual employees. The unemployed, those on long-term sick leave and unskilled manual workers reported particularly high levels of unmet needs. The SES differences in unmet needs were attenuated when economic stress, trust and self-rated health were introduced in the multiple analyses.In paper III unmet healthcare needs were investiged with regard to primary care (PC) provider. In Sweden, the prevalence of private PC providers has risen dramatically since the reform in 2010, and private providers now constitute approximately 40% of all PC providers. The study-population consisted of respondents from the Public Health Survey in Skåne, 2012, aged 18-80. Differences in unmet healthcare needs were small between public and private providers. The initial lower unmet need in favor of private PC providers, particularly for women, disappeared after adjusting for SES and self-rated health. The SES distribution between the PC types differed, with a higher prevalence of higher non-manual employees and old-age pensioners registered with private PC providers. These two SES groups demonstrated the lowest unmet healthcare needs of all SES groups in paper II. In paper IV the association between unmet needs at baseline and mortality at follow-up 5 years later was investigated. The study population consisted of the respondents from the Public Health Survey Skåne 2008, aged 18-80 (N=28,198). Mortality data was obtained from the National Board of Health and Welfare (Socialstyrelsen). There were 946 deaths during the five-year follow-up period. People with unmet healthcare needs had higher hazard rate ratios (HRRs) of mortality from cancer and from other causes of deaths than cancer and CVD, while no association was seen for CVD. Particularly the older part of the population, 65-80, had higher HRRs if they had presented unmet healthcare needs at baseline