This study examined the factors associated with the use of healthcare in a large Brazilian city with the objective of discerning which factors affect the use of health services and their intensity. The findings showed that some inequalities exist in health service utilization, but that the groups traditionally considered most disadvantaged were not always those who had the worst access: women and the elderly had the greatest predisposition to visit a doctor, but educational level was not a significant predictor of use. Instead, health needs appear to be among the most important factors determining the use and intensity of doctor visits. Being enrolled in a private health insurance plan and being able to identify a doctor as a usual source of care also influenced the use of services, while the number of doctor visits was not associated with access to private insurance. The Hurdle model was able to show that many of the factors associated with any use differed from those associated with greater subsequent utilization.
If one of the principal objectives of health policy is a reduction of inequities, then health systems need to promote horizontal equity: the principal that individuals with the same health needs have the same level of access to health care, independent of their socioeconomic status, geographic location, or other non-health-related factors.3
Various international studies have evaluated healthcare inequities by comparing health needs with the use of health services. Analysis of population surveys conducted in Canada evaluated utilization trends from 1978 to 2003, and concluded that people with worse health status generally had more doctor visits than healthy individuals, and that those who were poor and had less education were less likely to have had any doctor visits overall. The poor who did gain access had a greater number of doctor visits once they initiated care.25
A study based on Netherlands Health Interview Surveys (1990–1998) showed that lower socioeconomic groups use more healthcare services partly because they suffer from more illnesses.26
Another study used data from a sample of Spanish subjects and concluded that there is inequity in GP visits favoring the lower socioeconomic groups, probably representing an overuse of public healthcare services.27
In the present study, residents of disadvantaged areas had more health needs and fewer facilitating factors for the use of health services. This was to be expected, given the nature of the HVI used to assess the level of area vulnerability. Even so, as with other international studies, after adjusting for health needs and other factors, education level (our main measure of socioeconomic status) was not associated with getting an initial doctor visit; moreover, among those who had one or more doctor visits, those with the highest levels of education had lower utilization rates.
The HVI measure of the local environment was associated with initial doctor visits: residents of areas with the highest level of vulnerability had more difficulty in obtaining it, but once they accessed care, characteristics of the area of residence were not associated with the intensity of healthcare utilization. One possible explanation for this discrepancy might be socioeconomic differences in the use of preventive and routine care, which might be lower in populations living in poorer areas. It has been argued elsewhere that the use of preventive services is more associated with predisposing and enabling factors, while the use of curative services is more associated with health needs.28
If multiple doctor visits are an indicator of health need, then those who live in vulnerable areas and who have the highest health needs are the ones who actually use health services most frequently—a potential indicator of horizontal equity, which seems to be in the process of expanding in the municipality under study. Furthermore, some health services are strongly associated with ability to pay, such as dental services.29
However, the ability to pay is not an issue for the type of medical care discussed here since public services are available to all Brazilian citizens free of charge, and the public system is used exclusively by over two-thirds of the population.
Among the predisposing factors for the use of health services considered in this study, age and female gender were independently associated both with obtaining an initial consultation and the number of doctor visits. The association of age with greater utilization of services is widely known30
and is explained at least in part by increased prevalence and incidence of chronic diseases at older ages, an association that persisted even after adjusting for health needs. Women used more health services than men, which is an observation consistent with other studies.31
In the present study, women were more likely than men to have had at least one doctor visit and much more likely to have greater overall levels of utilization. One intriguing observation was the existence of an interaction between gender and the use of health services in areas of medium and high vulnerability, indicating that women living in disadvantaged areas were more likely than men to overcome barriers to obtaining at least one yearly doctor visit. The explanations for this finding are not obvious, and further investigations are necessary for a better understanding of these trends. The finding that those who were married or living with someone were more likely users of services—perhaps due to greater social support—is observed in other Brazilian studies.32,33
As expected, the component of health needs most strongly associated with the utilization of services was poorer health status, given that those who considered themselves to be in the worst mental and physical health had 36% more doctor visits then those in the best health. In addition, adults with less healthy behaviors consulted a doctor less often in the prior year and, among those who had initial contact with services, the intensity of consultations was lower. These results are consistent with studies carried out in other countries5
and in the south of Brazil,34
demonstrating a relationship—usually inverse—between these unhealthy behaviors and the use of health services. This is a worrisome situation, because in addition to being more frequently exposed to situations that are harmful to health, these individuals are less likely to receive health promotion education and advice since they access care less frequently.
One of the principal findings of this study was the strong relationship between having a regular doctor and having had a doctor visit in the past year, demonstrating that this, in fact, is a facilitating factor for utilization. It is known that having a personal physician tends to generate greater utilization because the professional encourages routine and follow-up visits.35
This association may be explained by the fact that this variable is also measuring unobserved needs. For example, people who are in need of care are more likely to seek it out and are thus more likely to have contact and identify with a specific family doctor. On the other hand, people without a regular doctor may not have one because of limited availability, which would then reduce their likelihood of visiting a doctor. Despite these possible explanations, this finding suggests that health policies and models of organizing services that foster the doctor–patient relationship can have a positive effect on the healthcare system in terms of equity and improved access.
This study has strengths and limitations. Its principal strength is the large population base of the study, which is representative of all the adult residents of one of Brazil’s largest cities. The large sample size permits identification of intraurban differences in health status and in the distribution of predisposing factors influencing the use of health services, as well as examination of the influence of these factors on the use of health services.
On the other hand, the principal limitation of this study is its cross-sectional nature, which does not permit the analysis of temporal relationships between the independent variables and the use of health services. Nevertheless, it is unlikely that the results presented here are due to reverse causation, as it is probably not reasonable to assume that the use of health services has led to worse health conditions or worse health behaviors as measured in this study. To further protect against this possibility, we did not include the presence of chronic disease as an indicator of health status, although this information was available in the database. It was not incorporated into the health needs index because morbidity attributed to chronic diseases is based on previous medical diagnosis, and this information is influenced by the use of health services, or in other words, the greater the utilization, the greater the probability of diagnosis.36
Health needs were measured by general health conditions, and some residual confounding is a possibility that cannot be excluded. In this case, our results are likely to err on the side of being more conservative. Finally, this study was based on the number of doctor visits and did not include measures of quality, the reason for the visit, or whether the visit resulted in resolving the health problem for which the patient sought care. We were not able to differentiate between access to different types of outpatient services, and use of hospital services (which might show a very different pattern) were not available for analysis. Another factor only partially addressed in this study is the question of supply. Demand for services is not always translated into utilization because it depends on other factors such as the availability of services (hours of operation and transportation), the interpersonal communication style of the healthcare personnel, and the ability of an individual to navigate the healthcare system.37
These themes will be addressed in future publications.