Research paperAddictive behaviors and healthcare renunciation for economic reasons in a French population-based sample
Introduction
Healthcare renunciation for economic reasons, i.e., forgoing care due to financial reasons although clearly perceiving the need for it, is a major health concern in health inequality research. Vulnerable people are especially a focus because people in situations of deprivation and high-risk populations (e.g., those with chronic illnesses) are more likely to forgo care for economic reasons worldwide (Bodenmann et al., 2014; Guessous, Gaspoz, Theler, & Wolff, 2012; Pampel, Krueger, & Denney, 2010; Röttger, Blümel, Köppen, & Busse, 2016; Wolff, Gaspoz, & Guessous, 2011). Previous studies have mainly focused on the relationships of forgone care with socioeconomic status, demographics, and perceived health status. Studies found consistent associations of healthcare renunciation for economic reasons of having low income or job position, being older, being female, having dependent children, being divorced or single, and having bad health outcomes in different countries (Bodenmann et al., 2014, Guessous et al., 2012, Pampel et al., 2010, Röttger et al., 2016, Wolff et al., 2011).
Another part of the literature on the utilization of health care services highlighted that drug users constitute a vulnerable population in need of medical care. In several countries, drug users have been described as having an important lack of access to primary care (Myers, 2012) and are considered medically underserved (Metsch et al., 2002), although addiction is associated with adverse medical consequences. Studies have mostly focused on high-risk drug users’ unmet healthcare needs, such as injecting drug users (Al-Tayyib, Thiede, Burt, & Koester, 2015; Chitwood, McBride, French, & Comerford, 1999; Metsch et al., 2002; Robbins, Wenger, Lorvick, Shiboski, & Kral, 2010) and methamphetamine users (Powelson et al., 2014). This population has a large burden of unmet health needs and is more likely to visit hospital emergency departments (Vu et al., 2015). However, information on associations of occasional or recreational drug use and other addictive behaviors such as gambling with unmet health care in the general population is lacking. Some studies reported that, in the general population, unhealthy substance use was a risk factor for not receiving preventive healthcare, such as breast-cancer screening, flu vaccination, and control visits to general practitioners (Chitwood, Sanchez, Comerford, & McCoy, 2001; Lasser et al., 2011), but investigations on the relationship between forgone care and experimental or recreational drug use are needed.
Overall, if healthcare renunciation is a topic of growing interest, to our knowledge, no study has focused specifically on the association between addictive behaviors and healthcare renunciation in the general population. Because drug users are likely to have unmet healthcare needs, they are susceptible to be a high-risk population for healthcare renunciation. For example, Guessous et al. (2012) reported that current smokers were more likely to renounce care than non-smokers, and Guessous et al. (2014) reported that current smokers were more likely to renounce dental care than nonsmokers. However, these studies did not report other substance use, and no information on the addictive level of tobacco use was available.
This study aimed to fill this gap and investigated associations of healthcare renunciation for economic reasons and addictive behaviors (alcohol, tobacco, cannabis, other illicit drug use, and gambling) in a population-based sample of French adults. France has a universal health system, with a national public health insurance based on income. It includes significant cost sharing (approximately 30% of health care costs). Cost sharing is eliminated for individuals with several specified chronic conditions and low-income individuals (in 2017, the upper limit for cost sharing elimination is 727€ [$778] for one person, 1090€ [$1167] for two persons). It is also lowered or eliminated for highly effective prescription drugs (Schoen et al., 2010). However, out-of-pocket expenditures may affect even low-income individuals (e.g., one single person having more than 727€ per month). Most French citizens buy private complementary insurance that covers cost sharing (Pierre & Jusot, 2017). Data on healthcare renunciation are scarce in France.
Section snippets
Participants and procedure
Data were collected using the 2014 Health Barometer, a French cross-sectional survey conducted among a random representative sample of the French population aged 15–75 years between December 2013 and May 2014. It is conducted using computer-assisted telephone interviews. Telephone numbers of households (landlines and cell phones) were randomly generated, and individuals in households were randomly selected among eligible household members: having a member between 15 and 75 years old, speaking
Results
Descriptive statistics and bivariate associations are reported in Table 1. A total of 25.0% of the participants had renounced care for financial reasons at least once in the previous twelve months. More precisely, 16.4% renounced dental care, 11.1% renounced eye care, 7.1% renounced a medical appointment, and 9.5% renounced other another form of health care, with an average of 1.76 ± 0.97 dimensions of forgoing care among those who renounced care.
Demographics were associated with healthcare
Discussion
This study investigated associations of healthcare renunciation for economic reasons and addictive behaviors among a population-based sample of people living in France with Universal Health Coverage.
First, a total of 25.0% of the participants renounced care at least once in the previous twelve months, regardless of the kind of renunciation (dental care, eye care, medical appointments, and other kinds of health care). This prevalence rate is higher than those previously reported in France (15.4%
Conflict of interest
The authors declare no conflict of interests.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors.
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2019, International Journal for Equity in Health