When interpreting the results, it is important to keep some limitations in mind. First, the Divorce in Flanders Survey is a cross-sectional survey in which respondents were asked whether they had contacted a professional health care provider during the past year and whether they had felt a need for care but did not seek professional help during the past year. Because we consider self-rated general health and experiencing depressive symptoms during the week preceding the interview to be predictors of professional health care use and subjective unmet need during the last year, caution is needed when making causal interpretations. Nonetheless, the finding that among divorced singles the odds of using health care and perceiving an unmet need decrease with the elapse of time since the divorce suggests a causal effect of divorce that diminishes over time. The cross-sectional design of the survey also hinders a causal interpretation of the association between health care use and subjective unmet need. However, because we explicitly defined subjective unmet need as perceiving a need without seeking professional help, it seems reasonable to assume that among those who have reported both professional care use and a subjective unmet need, the professional care use either precedes the subjective unmet need or is based on other complaints. Nevertheless, more research based on longitudinal data is required to be able to make causal conclusions.
Second, the indicators of need for care, depressive symptoms, and self-rated health might not capture all of the reasons people might contact a GP, psychiatrist, or psychologist because of social or emotional problems. Yet because we control for depressive symptoms, we do consider the most common mental health problem in Europe [61
]. Moreover, self-rated health is widely used as an indicator of need because it has a good prognostic value [62
], even for mental health [63
Third, as lay people often experience mental health problems as somatic symptoms [65
], a considerable number of visits to health care providers concerning somatic problems that are in fact symptoms of mental health problems are not included when only health care use because of social or emotional problems is considered.
Fourth, we cannot generalize our results to the whole population, because never-married people, widowed people, and people with multiple divorces are excluded and the divorced are overrepresented. Because this study’s focus is on the still-growing group of the divorced, who are substantial consumers of health care, the Divorce in Flanders Survey is well suited to our purposes because it includes large number of divorcees and detailed information on both marital history and health care use.
Because of growing medical costs, financial resources for public health care in Belgium are strained, as they are in most other Western countries. Moreover, the high consumption rates of the growing category of single divorcees place a heavy burden on the public health care system. This raises the question of whether this high level of health care use is equitable. Results show that both health care use and subjective unmet need because of emotional or social problems are strongly associated with being single after divorce.
In line with hypothesis 1a, we find that the divorced singles are more likely to contact a professional health care provider. This seems a consequence of the lack of a partner rather than of the divorce itself, as the repartnered divorced and the continuously married are comparable regarding their health care use. Among men, we find no differences between the continuously married and the repartnered divorced. Among women, we find that the divorced currently living with a new partner are somewhat more likely to have contacted a professional health care provider, but this can be completely attributed to their worse mental health. Hence, hypothesis 1b cannot be confirmed. As divorced singles have the worst performance with regard to various health-related behaviors, like smoking, alcohol intake, physical activity, eating habits, treatment adherence, and so on [66
], it is remarkable that, in accordance with other studies [15
], we find higher rates of health care use than we would expect based on their need for care. A possible explanation may be that these divorced singles have sought help from a professional care provider with regard to problems that most other people can discuss with their partner, or with regard to problems arising from the stress that stems from having the sole responsibility of maintaining the household.
With regard to the prevalence of subjective unmet need, a similar pattern occurs. Disparities between the married and the divorced living without a new partner are pronounced, whereas differences between repartnered divorcees and their married counterparts are less clear cut. Again, no differences are found between repartnered divorced men and their married counterparts. Repartnered women however are somewhat more likely to experience a need for care for which they do not seek professional help. Hence, hypothesis 2b can be confirmed only among women. Congruent with hypothesis 2a, we find that single divorced men and women are much more likely to experience a need for care without seeking this care. Even after considering all predisposing characteristics, enabling factors, depressive symptoms and self-rated health, these disparities remain. This is a remarkable finding, as it has been well illustrated that divorced singles are a vulnerable group, experiencing social and economic disadvantages, which results in higher rates of mental health problems. Apparently, however, this does not completely explain their higher rates of perceived unmet need.
Time elapsed since the divorce seems to matter only among women. However, when considering need for care, the time effect on health care use disappears. Hence, it can be assumed that this negative time effect on health care use reflects the amelioration of mental health with the elapse of time since divorce.
Depressive symptoms are an important correlate of health care use and subjective unmet need. Surprisingly, self-rated health is related to only health care use and not to perceiving a need for care without seeking it. This finding, together with the finding that differences in subjective unmet need between divorced singles and their married counterparts remain after controlling for need for care, shows that the indicator of perceived unmet need captures a need for care as perceived by the respondent that is not related to need indicators such as depressive symptoms and self-rated health. It has been shown that although lay people are well able to estimate their health status [72
], their assessment of their own need for care differs significantly from assessments based on standardized diagnostic scales [73
]. Hence, we argue that it is important to combine both research strategies. Using the subjective approach, we can identify those who perceive a need but do not seek this care. Furthermore, it is important to determine which individuals recognize a need for professional care but fail to seek it, and to examine why they do not seek this care. Research based on the need-adjusted approach helps to identify which groups health care underrepresents.
We find that those who have had non-frequent contact with a health care provider are the most likely to report a need for care without seeking this care. This is of interest because it challenges the assumption of research based on need-adjusted measures of health care use that the needs of people receiving professional health care are being met, and it raises questions about how these high rates of subjective unmet need among health care users can be explained. At a time when concern about cost-effectiveness in health care is increasing, it is important to determine who these people are that so often perceive a need for care without seeking it, and why they fail to do so. A study based on the ESEMeD (European Study on the Epidemiology of Mental Disorders) data has shown that 19% of current and 30% of former mental health care users think that professional help is as bad, or worse, than no help [52
]. One possible explanation for the higher rates of subjective unmet need among non-frequent health care users therefore might be that they are not satisfied with the care received. This dissatisfaction might also be the reason why these non-frequent health care users did not seek professional help more frequently.
We find no apparent effect of income. Nevertheless, we cannot conclude that there are no financial barriers to health care in Flanders, because we did not make a distinction between specialized and non-specialized care. Research has indicated that the poor are more likely to consult non-specialized care providers such as a GP, while those who are financially better off consume more specialized care.
Concerning social support, we find that people who can count on numerous friends and relatives are more likely to contact a health care provider. This finding is in line with the crowding-in hypothesis: Intimates help a person gain insight into personal and emotional problems and encourage a person to seek professional help [19
]. But among women we find that those who can count on numerous intimates are also more likely to perceive a need for care without seeking it. This finding is concordant with the crowding-out hypothesis, as it indicates that women who rely strongly on social networks when they need someone to talk to are more reluctant to seek professional care when perceiving a need. Hence, there are indications that both a crowding-in and a crowding-out process are at work among women.