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Inequalities in Health Services Usage in a National Health System Scheme: The Case of a Southern Social European Region

Morteruel, Maite; Rodriguez-Alvarez, Elena; Martin, Unai; Bacigalupe, Amaia

doi: 10.1097/NNR.0000000000000256
HEALTH EQUITY RESEARCH SERIES
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Background Health services can reduce inequalities caused by other determinants of health or increase them due to the effect of the inverse care law—the principle that the availability of good quality care tends to vary inversely with the need for it in the population served.

Objective The purpose of the research was to describe inequalities in the use of nursing services, medical services in primary care, specialist care, and services not fully covered by the Basque public health system in Spain.

Methods A cross-sectional study of adults aged at least 25 years who completed the 2013 Basque Health Survey (N = 10,454) was conducted. Age-standardized prevalence and prevalence ratios for use of services that are covered and noncovered in the health system were computed. The association of health services usage with socioeconomic variables was estimated using a Poisson regression model with robust variance. The relative index of inequality (RII) was used to measure the magnitude of socioeconomic status inequalities in health service use. All analyses were carried out separately for men and women.

Results Individuals with lower socioeconomic status were more likely to use primary care (RII = 0.87, 95% CI [0.79, 0.97]) and less likely to use specialist services (RII = 0.82, 95% CI [0.75, 0.89]). Across noncovered health services, inequalities between the highest and lowest social groups were significant in all cases and especially marked in men’s use of physiotherapists (RII = 0.46, 95% CI [0.35, 0.61]) and podiatrists (RII = 0.24, 95%CI [0.15, 0.38]).

Discussion There are significant inequalities in primary and specialist health service use based on individual socioeconomic status, particularly for services that are not provided free of charge within the existing health system. This suggests that health service systems that are not explicitly designed to provide universal access may actually amplify preexisting social and health inequalities within their target populations.

Maite Morteruel, PhD, is Researcher in the Department of Nursing I and Member of the OPIK-Research Group for Social Determinants of Health and Demographic Change, and Elena Rodriguez-Alvarez, PhD, is Professor in the Department of Nursing I and Member of the OPIK-Research Group for Social Determinants of Health and Demographic Change, University of the Basque Country (UPV/EHU), Leioa, Spain.

Unai Martin, PhD, is Assistant Professor in the Department of Sociology 2 and Member of OPIK-Research Group for Social Determinants of Health and Demographic Change, and Amaia Bacigalupe, PhD, is Assistant Professor in the Department of Sociology 2 and Member of the OPIK-Research Group for Social Determinants of Health and Demographic Change, University of the Basque Country (UPV/EHU), Leioa, Spain.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (www.nursingresearchonline.com).

Accepted for publication October 4, 2017.

This study was supported by the Basque Government Research Fund to consolidate research groups (Ref. IT977-16).

Editorial Note: This paper was accepted under the editorship of Susan J. Henly.

The authors have no conflicts of interest to declare.

Corresponding author: Elena Rodriguez-Alvarez, Department of Nursing I, University of the Basque Country (UPV/EHU), Sarriena s/n, 48940 Leioa, Bizkaia, Spain (e-mail: elena.rodriguez@ehu.eus).

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