Willoq: Un caso de turismo vivencial

There is also an extensive literature looking at children’s health care use or families similarities regarding the use of health care services. Parents serve as role models for the next generation of health care users as well as initiate a child's use of health care. Children are not small adults; they have special health needs related to their developmental status. Children require health care that emphasizes

preventive services such as immunizations and continuous monitoring of physical and psychosocial growth and development.

The study of children’s health care use is interesting because children depend upon their carers, usually parents, to seek, consent to, and pay for health care.

In general one in eight children is usually classified as a high user (falling in the top one third on a distribution of use), while similar numbers of children are classified as low users (falling in the bottom one third on a distribution of use; Starfield et al, 1979, 1985). Longitudinal research has shown that these patterns of use among children are relatively stable and consistent across time (Starfield et al, 1979). A study by Cardol and colleagues (2006) considered whether family similarity in contact frequency with general practice can be explained as a result of shared circumstances, through socialisation, or through homogeneity of background characteristics. Overall, the study showed that resemblances in contact frequencies within families can be best explained by spending more time together (socialisation), and parents and children consulting a general practitioner simultaneously (circumstances of the moment).

Socio-financial models

Family income, type of insurance, or maternal utilisation, other variables like parental education, ethnicity, and age/gender of the child are examples of financial and socio-demographic predictors which have been found to be significantly associated with the type of provider (private versus public) used as well as the frequency of visits.

The socio-behavioural model developed by Aday & Andersen

The use of the Aday & Andersen (1975) model in the paediatric population remains limited, since it was originally conceived with an adult population in mind. However, it is possible to categorise factors associated with child health care utilisation into predisposing, enabling and need determinants.

1. Predisposing factors a) Parental education

Regarding parental education, parents who have higher levels of education tend to have children who are seen more frequently by health care providers (Guendelman & Schwalbe, 1986; Newacheck, 1992). It is hypothesised that the relationship between parental education attainment and their child’s health care use could be due to a higher income, better access to health care, and so a more comprehensive diagnosis and treatment plan, an

increased awareness of the child’s health problems, seeking care earlier in a child’s illness episode and more appropriately (general practitioner versus emergency room), and seeking more preventive care (Starfield & Budetti, 1985).

b) Age, gender, and ethnicity

The age, gender and ethnicity of the child have been shown to be associated with a child’s use of health care. Higher use tends to be associated with younger children, and decreases as childhood progresses (Newacheck, 1992). This may be due to the increased number of scheduled preventive visits for young children, parental inexperience, or a parent’s perception of greater child vulnerability at early ages.

In addition, boys have been found to use more care; Starfield and Budetti (1985) reported that boys have had increasingly higher rates of activity limitation than girls. This is maybe correlated with the fact that boys have higher morbidity and mortality rates in all age groups throughout infancy and childhood due to risky behaviour and the fact they are more active and harder to control. For example, ratios for mortality rates among boys versus girls between the ages of two to five include: ages one through four, 1.32:1 and ages five to 14, 1.72:1 (Starfield & Budetti, 1985).

White children are more likely to use health care services than any other ethnic group. Newacheck (1992) found that White children were twice as likely to be high users compared with Black children, probably due to the lower rates of health insurance among Black families.

c) Family structure and functioning

Characteristics of family structure influence a child’s use of health care. There is evidence that children from large families or who have mothers working outside the home use less health care (Newacheck, 1992; Newacheck & Halfon, 1986; Wolfe, 1980).

Children who live in single-parent families may be in an environment of increased family stress, increased social disruption and less parental supervision. Thus, these children may face an increased risk of physical injury (Starfield & Budetti, 1985) and tend to have more physician visits than other children when other factors including need, insurance status, and other demographic characteristics are held constant (Halfon et al, 1995).

Therefore, when examining use of health care by children, assessing both the numbers of adults and children within a family is important. It may be that family

structure serves as a proxy measure for other enabling factors such as time to appointment, waiting time, and convenience of services.

Life events such as divorce, illness or death of a parent, can also disturb the family balance and subsequently generate more contacts with general practice, and also a poor living environment can partly explain why some families present more illnesses than others (Dowrick, 1992; Litman, 1974). The influence of family functioning on pediatric health care utilisation has been investigated in some studies. Two retrospective analyses (Riley et al, 1993; Weimer, Hatcher, & Gould, 1983) found that greater levels of family conflict, as measured by the Family Environment Scale, predicted greater child health care utilisation.

Family functioning also appears to indirectly affect utilisation through its impact on other variables. Black and Jodorkovsky (1994) found that greater levels of family support reduced the influence of parenting stress and contributed to lower utilisation of pediatric services relative to families with lower self ratings of support and high parenting stress.

In 1996 Ward and Pratt used a prospective cohort study to examine the influence of psychosocial factors on the use of general practitioners over a six-month period by 271 children (aged four to nine years) and their mothers. They hypothesised that if parents had a propensity to use health care and viewed it as a valued alternative for assistance, then parental stress played a role in increasing paediatric utilisation. The authors also thought that while parents were able to cope with a problematic parent–child relationship when their stress was low, increased stress decreased their ability to cope without professional assistance (Ward & Pratt, 1996).

2. Enabling factors a) Financial factors

Availability of insurance coverage increases children's use of ambulatory health care, especially parent's use of preventive health care for their child (Riley et al, 1993). Children with health insurance coverage were approximately 50 percent more likely than children without coverage to be higher users of physician services (Newacheck, 1992). A study completed in Ontario, Canada, found no relationship between children's health care use and socioeconomic variables such as income below the poverty level or the receipt of social assistance (Woodward et al, 1988). The researchers reported that this finding might suggest the universal insurance provided by the Ontario Health Insurance Plan has been effective in removing financial barriers to ambulatory medical care.

The total family income also shows a strong association with the number of visits made to a health care provider. Children living in poverty generally are under- immunized, experience delayed entry to care (Halfon et al, 1995), and are less likely to see a provider over a one year period (Wolfe, 1980).

In a study that analyzed approximately 30,000 children, maternal, and child ambulatory utilisation patterns from the 1978 National Health Interview Survey (NHIS), family income was found to be a significant predictor of utilisation

(Newacheck & Halfon, 1986). Using data from the 1976-1978 NHIS, Muller found that those in the lowest income group had 47% fewer visits than those in the highest group (Muller, 1986). In another study which used the 1988 NHIS, children who lived below the poverty line were more likely to be low users (no physician contacts during past year) of health care (Newacheck, 1992).

Given these findings and results of the study conducted by Woodward and colleagues (1988) in Canada, it appears that the effect of family income on children's health care use is moderated by the presence of a health care plan. However, economically disadvantaged families, who do not have a health plan, may be disinclined to seek and utilise health services due to other severe and complex social problems associated with poverty (Halfon et al, 1995). Many families living at or below the poverty line must deal with other environmental and access barriers such as transportation difficulties and safety concerns.

3. Need factors

a) Children’s health status

Children who experience more health problems are more likely to be high users of health services (Newacheck & Halfon, 1986; Riley et al, 1993; Starfield et al, 1985). In regards to children’s health, both the presence of chronic health conditions (Hankin et al, 1984; Wolfe, 1980) and parental perceptions of poor child health (Newacheck & Halfon, 1986) are related to greater frequency of utilisation.

Recently, children’s mental health also has received a lot of attention and the use of psychiatric services (Hankin et al, 1984; Starfield et al, 1985), the use of child mental health treatment (Kelleher & Starfield, 1990), and the use of counselling services (Riley et al, 1993), have all been found to predict a high volume of total health care visits. However, these findings could not be generalised, as other studies failed to find a relationship between mental health and health care use (Ward & Pratt, 1996).

b) Maternal use of health care services

A strong parental predictor of children’s health care utilisation is the maternal use of health care services, with greater maternal use of health care services consistently linked to greater use of health care services by children. This relationship has been found with utilisation categorised as the total volume of use

(Starfield et al, 1985) and as use versus nonuse of services (Newacheck & Halfon, 1986; Wolfe, 1980). The findings are consistent with research presented earlier (Cardol et al, 2006) that has shown that levels of health care use cluster in families.

2.7.4 Discussion

Common sense would suggest that people who seek medical help have more severe symptoms than those who do not seek help. However, as previously presented, people’s interpretation of their symptoms and their help-seeking behaviour is determined by many factors aside from physiological activity and symptom severity.

The utilisation of health care is a clearly defined concept in the literature; it is an outcome indicator by which realized access can be evaluated (Aday & Andersen, 1975).

Studying an outcome such as utilisation can provide the basis for policy decisions regarding future funding, effectiveness and appropriateness of resources, and the organization of health care.

This section presented different socio-behavioural and psychological models regarding health care utilisation in adults or children. The models can explain variations in help seeking behaviour, but they describe how help seeking

behaviour decisions should be made in theory, rather than how they actually are made in practice.

According to the Aday & Andersen model, researchers have examined the effects of many different variables on adults or children’s health care use. This is a double- edged sword since others wanting to conduct utilisation studies have evaluated which variables to use, but few have consistently discussed the strong

predictive power of utilisation. Without model replication, researchers wanting to study utilisation of health care must take into account many variables since it is not yet clear which variables account for a large amount of variation. Although Andersen’s model has been criticised because it does not

emphasise the mediating effects of factors such as psychological distress, locus of control and social support (Arling, 1985), it continues to be relevant in providing a useful analytic framework and starting point for the discussion of the utilisation of health care (Andersen, 1995; Newbold, Eyles, & Birch, 1995).

Previous research regarding adults’ and children’s health care utilisation has been limited by its methodology and its scope. Few studies have used a population- based sample (Thompson, Aria, Basile & Desai, 2002; Sachs-Ericsson, Blazer, Plant & Arnow, 2005). This is important because clinically based samples are more prone to selection biases that may give inaccurate estimates and these samples are not representative of the population as a whole.

Regarding children’s health care use, studies done in the past have shown that the child's age and health status have consistently predicted high use of health care. In all of the studies, there was higher utilisation of care if the child was young in age (Newacheck, 1992; Wolfe, 1980; Woodward et al,

1988). In addition, the more diagnoses or illnesses a child had, the more the child visited a doctor. However, age and health status of a child cannot solely account for high utilisation rates. Other studies have shown the influence of one or more of the following variables: mother's patterns of use, parental education, family structure, and family functioning on the utilisation of children's health care (Newacheck, 1992; Newacheck & Halfon, 1986; Riley et al, 1993; Starfield et al, 1985; Wolfe, 1980; Woodward et al, 1988). Further, the existing studies have a set of variables which can explain a maximum of 33% of the variation in use (Riley et al, 1993). The amount of variation that remains unexplained (67%) suggests that there are other variables, such as aspect of parental behaviour and family functioning which may warrant further study.

Without adequate commitment to the well-being of the child from his/her family, a child is at a higher risk for poor social (i.e. ability to develop and maintain social relationships) and emotional health outcomes (Schor, 1995).

None of the past studies incorporated parenting attitudes as a variable in their utilisation studies. Parental attitudes can be thought of as filters that indirectly affect parental behaviour and thereby reflect the child's environment (Holden & Edwards, 1989). It is the parental behaviour which plays a major role in children's health as well as their use of health care. However, it is not known how much parent/family factors contribute to the variation in children's health care utilisation rates. The relationship between parent/family factors and a child's use of health care is hypothesized to have some affect over and above sociodemographic/financial factors and a child's health status.

In summary, both in adults and children the need factors represented mainly by health status are associated with health care utilisation, therefore the number of hospital admission or general practitioner visits, outcome variables used later in this thesis, could be considered reasonable proxies for physical health.

Also, there is some evidence among the studies reviewed which suggest an association between poor parenting and later life health problems. The evidence is however less consistent for an association between childhood maltreatment and health care utilisation. Further on, it seems there are still gaps in understanding not necessarily why (as research in developmental psychology and neurobiology offers plausible explanations) but how much the family life, and in particular the quality of parent-child relationship could affect the use of health care in childhood and in later life.