Doctoral
Thesis: General practitioner utilisation
among women in Australia
Supervisors: Professor
Annette Dobson & Dr Julie Byles
University:
Research Centre for Gender and Health, University of
Newcastle, Australia
The
purpose of this thesis is to explore the determinants
of the use of general medical practitioners among women
in Australia. General practice is the first point of
contact for the provision of health care services in
Australia and is the gateway to more intensive and specialised
services. Despite the existence of a national health
insurance scheme (Medicare) there is growing debate
about the equity of access to health services, especially
for people living in rural and remote areas of Australia.
This
study examined the use of general practitioner (GP)
services during 1995 and 1996. The framework for the
study was the behavioural model of health service utilisation
developed by Andersen, Newman and Aday and others which
includes measures of medical need and other individual
and societal factors that may predispose, enable or
impede use of services. Survey data for 20,000 participants
in the Australian Longitudinal Study on Women's Health
were linked with data from the Health Insurance Commission
(HIC) which administers Medicare. The survey data included
a range of questions designed to explore social and
environmental aspects of women's lives as well as the
psychological and biological determinants of health
and health care utilisation. The HIC data provided measures
of GP utilisation for each woman and the out of pocket
cost associated with each consultation.
Using
the linked database, the demographic characteristics,
medical history and health service utilisation of very
frequent attenders and non-attenders to general practice
were described. These data provided insights into the
use of GP services that could not be determined from
either source alone. Although some findings were consistent
across age groups, the profile of frequent attenders
differed according to life stages such as pregnancy
and menopause. A few case studies highlighted the difficult
personal and social circumstances of some women and
demonstrated the importance of considering the context
in which use of health services took place.
A
third source of data for the research was a sub-study
to provide additional measures of individual and environmental
determinants of health service use and satisfaction
with GPs among a sample of almost 5,000 women participating
in the longitudinal study. This sub-study provided strong
quantitative evidence to support the qualitative reports
of the problems faced by women living in country areas.
The availability, accessibility and affordability of
services were rated lower by women living in rural and
remote areas than by women living in urban areas. These
substudy results complimented the administrative data
from the HIC which revealed inequities in the out of
pocket costs of services and in the availability of
female GPs.
Many
studies have adapted the behavioural model to examine
the utilisation of a variety of types of health services,
but the model requires more complex analysis than the
traditional statistical techniques employed by most
researchers. Insights were gained by using structural
equation modelling, in addition to multiple linear regression
and Poisson regression modelling, and by including out
of pocket costs in the model.
The
use of GP services was shown to be determined primarily
by medical need. Also the out of pocket cost per visit
tended to be lower for women with lower socioeconomic
status. These findings suggest that the system is equitable
in these dimensions. However the out of pocket cost
for GP services increased with distance from urban centres,
which shows that the charges imposed by GPs are not
equitable across place of residence. Higher cost was
associated with lower use of services, even among women
considered to have high levels of need for care.
The
findings from these cross-sectional data suggest a need
to regulate the costs of GP services to patients, particularly
in rural areas. The study also highlights the need to
improve the delivery of GP services especially in rural
and remote areas. The long-term impact of the geographical
inequity in services on health outcomes for women remains
to be determined. Policy implications are discussed
and recommendations for future research and monitoring,
using cohorts in the longitudinal study, are proposed.
To Contact Anne:
Anne Young
Womens health Australia
Research Centre for Gender Health and Ageing
University of Newcastle
University Drive
Callaghan NSW 2308
Australia
Email:
anne.young@newcastle.edu.au
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