Ethnicity, socio-economic position and gender—do they affect reported health—care seeking behaviour?

Abstract

While the pursuit of equity of access to health care is a central objective of many health care systems, there is evidence that patients of ethnic minority descent, in lower socio-economic position (SEP) or of female gender are less likely than Whites, more affluent groups or men, respectively, to access secondary and tertiary medical care. However, it is unclear at which point in the chain of events leading from perception of need through attendance at primary/emergency care, to referral and receipt of secondary care, this inequality occurs. This study examined the influence of ethnicity, socio-economic position and gender on an individual's perception of the need and urgency for seeking health care. A random sample was selected from two large city General Practices in the UK who were sent postal questionnaires which included two clinical vignettes describing characters experiencing chest pain and discovering a lump in the armpit. The main outcome measure was response to the ‘chest pain’ and ‘lump’ vignettes in terms of immediate health care utilisation. The questionnaire survey (n=1350, response rate 66%) indicated that Black respondents, respondents from lower socio-economic groups and women were at least as likely to report immediate health care seeking in response to the clinical vignettes than White respondents, those from higher socio-economic groups or men. This finding was consistent across all scenarios after adjustment for interpretation of the vignette, access to health services and attitudes to health and health care. For example, those in the lowest SEP group were almost 60% more likely to report immediate care seeking in response to the lump vignette (OR 1.59, 95% CI 1.08–2.33) compared to those in the highest SEP group; and Black respondents 40% more likely (OR 1.41, 95% CI 0.92–2.17). This study suggests inequalities in access to health care by ethnicity, socio-economic position and gender are not related to patients in these groups failing to self-refer to primary or accident and emergency care, barriers must therefore occur at the level of health care provision.

Introduction

There are marked socio-economic gradients for mortality and morbidity, which appear to have worsened over the last few decades (Davey Smith, Bartley, & Blane, 1990; Shaw, Dorling, Gordon, & Davey Smith, 1999). Although it has been argued that health care systems do little to reduce the incidence of health inequalities (Mackenbach, Stronks, & Kunst, 1989; McKeown, Record, & Turner, 1975), there is growing evidence that newer medical technologies can have a major positive impact on life expectancy, case fatality and quality of life (Bunker, Frazier, & Mosteller, 1995; Goldman & Cook, 1984; Tunstall-Pedoe et al., 2000).

While the pursuit of equity of access to health care is a central objective of many health care systems, there is evidence that, although often in greater need, patients of ethnic minority descent or in lower socio-economic position (SEP) are less likely than Whites and more affluent groups, to access secondary and tertiary medical care. This is found both in the UK and USA, despite the NHS in the UK with services free at the point of delivery, and Medicare coverage in the US. Inequalities appear to be particularly prevalent in cardiac treatments (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein, 1993; Ben-Shlomo & Chaturvedi, 1995; Payne & Saul, 1997; Schneider, Zaslavsky, & Epstein, 2002; Whittle, Conigliaro, Good, & Lofgren, 1993), affecting both long-term survival (Whittle et al., 1993) and mortality (Peterson et al., 1997). Similarly, there is evidence to suggest gender inequality in treatment for heart disease, in particular, the under investigation and treatment of women in secondary and tertiary care (Dong, Colhoun, Ben-Shlomo, & Chaturvedi, 1996; Jackson, 1994; Mark, 2000).

Such inequity is not limited to cardiac services. For example, Black people have also been shown to have poorer survival rates for breast cancer than Whites (Bassett & Krieger, 1986), and lower SEP has been associated with later detection of breast cancer and thus preventable deaths (Farley & Flannery, 1989).

These findings increase in significance when compared to the (albeit) limited evidence which suggests that utilisation of primary care services among Black individuals and those from lower socio-economic groups is either equivalent, if not higher, than their White or more well off counterparts after adjustment for crude measures of need (Goddard & Smith, 2001; Haynes, 1991).

A number of possible reasons for such disparities have been suggested, including systematic differences by ethnicity and SEP in (a) interpretation of symptoms and recognition of the importance of receiving early intervention; (b) seeking health care; (c) obtaining a correct primary care diagnosis; (d) referral for specialist treatment, and (e) management at a specialist level. In this study we focused on (a) and (b). Our aim was to investigate the influence of ethnicity and socio-economic position on the perception of urgency in seeking health care in a cross-sectional survey, using responses to case-vignettes and health-care-seeking intentions for an episode of chest pain or a lump discovered in the axilla—both areas known to suffer inequalities in access to health care according to socio-economic position and ethnicity. The division of one vignette into two parts enabled us to examine whether behaviour evolved as symptoms changed. In this way, we have investigated the suggestion that patients of Black ethnicity and lower socio-economic position may receive less specialist care as a result of unwillingness to seek health care or ‘inappropriate’ interpretation of symptoms.