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Open Access Research article

Association between forgone care and household income among the elderly in five Western European countries – analyses based on survey data from the SHARE-study

Andreas Mielck1*, Raphael Kiess1, Olaf von dem Knesebeck2, Irina Stirbu3 and Anton E Kunst3

Author Affiliations

1 Helmholtz Zentrum Muenchen – German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, P.O. Box 1129, 85758 Neuherberg, Germany

2 University Medical Center Hamburg-Eppendorf, Department of Medical Sociology, Martinistr. 52, 20246 Hamburg, Germany

3 Erasmus Medical Center, Department of Public Health, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands

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BMC Health Services Research 2009, 9:52  doi:10.1186/1472-6963-9-52

Published: 23 March 2009

Abstract

Background

Studies on the association between access to health care and household income have rarely included an assessment of 'forgone care', but this indicator could add to our understanding of the inverse care law. We hypothesize that reporting forgone care is more prevalent in low income groups.

Methods

The study is based on the 'Survey of Health, Ageing and Retirement in Europe (SHARE)', focusing on the non-institutionalized population aged 50 years or older. Data are included from France, Germany, Greece, Italy and Sweden. The dependent variable is assessed by the following question: During the last twelve months, did you forgo any types of care because of the costs you would have to pay, or because this care was not available or not easily accessible? The main independent variable is household income, adjusted for household size and split into quintiles, calculating the quintile limits for each country separately. Information on age, sex, self assessed health and chronic disease is included as well. Logistic regression models were used for the multivariate analyses.

Results

The overall level of forgone care differs considerably between the five countries (e.g. about 10 percent in Greece and 6 percent in Sweden). Low income groups report forgone care more often than high income groups. This association can also be found in analyses restricted to the subsample of persons with chronic disease. Associations between forgone care and income are particularly strong in Germany and Greece. Taking the example of Germany, forgone care in the lowest income quintile is 1.98 times (95% CI: 1.08–3.63) as high as in the highest income quintile.

Conclusion

Forgone care should be reduced even if it is not justified by an 'objective' need for health care, as it could be an independent stressor in its own right, and as patient satisfaction is a strong predictor of compliance. These efforts should focus on population groups with particularly high prevalence of forgone care, for example on patients with poor self assessed health, on women, and on low income groups. The inter-country differences point to the need to specify different policy recommendations for different countries.