Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Where the Health Belief and Theory Of Reason Action Models Fail: Why Universal Access Will Not Fix The Disparities In Health – Preet Ghuman

Since World War II, as Europe began to rebuild and the United States began to heal its wounded, healthcare across the industrialized world began to take shape. Most European nations began to fully develop single payer nationalized systems; fortifying their belief that healthcare was an innate right of its citizenry. The United States saw its own transformation after WWII ended, as a system of “insurance” arose across the country, beginning with indemnity insurance and leading to what is now managed care. This stark divide in the paths between the European nations and the United States is the subject of harsh criticism by proponents of universal healthcare in this country.
Reports on the 2005 census have shown that as many as 46.6 million Americans lack health insurance coverage, 11.2 percent of which are children (1). This number is predicted to rise to approximately 56 million by 2013 (2). Socioeconomic gaps have formed in healthcare access, utilization, and delivery since WWII. This disparity is even more prevalently in minority groups across the country, due to lower level of education and low-income levels (3). Much of the socioeconomic disparities in health are blamed on this lack of access to many essential health services. Many researchers go a step further and make the claim that providing full access to healthcare will eliminate the socioeconomic and racial disparities in health, implying and arguing that access will lead to utilization across the country (4)(5). This, as many new students in the Boston University School of Public Health are learning, is the crutch of the public health problem: intention does not always lead to behavior and more importantly access does not always lead to utilization.
Increased research on the overall effects of universal care is beginning to show that access is only the metaphorical “tip of the iceberg”; with many arguing that there are a number of underlying social/behavioral factors that will limit overall utilization of the system among minorities and inner-city populations. Other socioeconomic factors such as race and income level need to be addressed before any universal system can be successful.
Decades Old Dogma – Universal Coverage Will Fix All Socioeconomic Health Woes
Imagine a United States where healthcare was not only free but open to access by anyone, anywhere in the country. Imagine minorities and whites, people of all levels of income receiving the same coverage and same quality of care across the country. Strong proponents of universal healthcare say we can achieve this by simply giving access to healthcare to all residents and delivering it to them at a level affordable to all. It is a decades old public health dogma that began forming after managed care could not control spiraling health costs across the nation during the 1980s. Large amounts of research dollars have poured into the subject, ultimately culminating in the Clinton Universal Healthcare Plan of 1997, which sought to create universal coverage based on regional risk pools across the United States (6).
Some of the earliest and most cited studies have simply examined the role of access in improving individual health, especially among minorities and the poor. The model of many of these studies, based upon theory and implication, was that “...medical treatments create healthy populations” (7). This model was used widely for healthcare reform in this country and abroad in 1980s and 1990s. A 1981 study examined economic status with access and utilization, and showed that “the poor continue to experience illness at a much greater rate than do the nonpoor” due lack of utilization caused by little or no access to a physician (8). The study concluded that if access could be extended to those who were uninsured, especially minorities, then overall health among these populations would generally increase. Those who go uninsured and without access to essential medical care face: higher medical bills, unsatisfactory care, and access problems (9). Many argue that universal access will alleviate many problems among the poor, and overcome copayment barriers. As Freeman Et. Al. states, “...access is determined largely by insurance status”(10).
Many similar studies also examined the types of barriers that would exist for poorer and minority populations (vulnerable groups) even if they had access to medical services. A key study performed by Bierman et. al. identified barriers within healthcare systems that must be removed for universal access to be successful, such as navigating through the health care bureaucracy as a patient. This study, while taking steps towards identifying the causes and solutions for underlying causes of health disparities, only examined barriers regarding the actual system itself (while ignoring the many other social and economic issues which can cause health disparities). It concluded that if these barriers could be removed, universal access to care could easily bridge age, gender, social, and economic gaps. Lack of insurance coverage (and access) was commonly found to be the single biggest cause of racial disparities between whites and Hispanics, and whites and African American (11)(12)(13).
It is also long believed in public health that the lack of access to care leads to lower health outcomes in minorities than the rest of general public. Proponents argue, citing these studies, by removing the perceived barrier of limited access more minorities will access and use their primary care physician. This in turn will limit very simple medical conditions from worsening and becoming a larger burden on the medical system later on (14)(15)(16). Many of these earlier studies formed foundations for the universal access movement.
The 1990s and 2000s brought what proponents of universal coverage had originally ignored: examination of health outcomes. Many studies began studying the effects of insurance and universal coverage on health outcomes in poor populations. The same model above was used: health coverage and access will lead to better outcomes among the insured and those with access. A study performed by Nelson Et. Al. concluded
...that providing improved access to high-quality care for uninsured adults with diabetes may increase use of important preventive care services that have been shown to improve care and prevent avoidable, serious, and costly complications (17).
Health insurance coverage and increased access have led to better outcomes in many cancer related outcomes, such as breast cancer and colon cancer, where each group of uninsured faced much more negative outcomes than their insured counterparts (18)(19). Overall this focus to outcomes brought to light what was known already to the medical community about universal access. It created and brought upon a dogma to the public health community: that access would lead to more positive health outcomes, lower costs, and increase the value of health care across all medical specialties as found by Kasper Et. Al. and Anderson in their respective studies (20)(21).
Problems With Dogma – The Age Old Models
As stated above, a silver lining connects each of the studies cited and the proponents of universal access to health care: they all use the same model. The model used by each, that access will lead to improved societal health, resonates very similarly to a hybrid of the health belief model and the theory of reasoned action/planned behavior. First developed by Rosenstock in 1966, the health belief model is the foundation for most public health interventions. The model takes into account four perceived factors that effect a person’s decision to perform and adopt a behavior: 1) perceived susceptibility/risk of becoming ill 2) perceived severity of the condition 3) perceived barriers between the individual and the desired action 4) perceived benefits of an individual adopting a certain action. These four perceived factors then lead to an individual’s intention to perform an action. The key assumption in this model is that intention will lead to action by the individual. Later, perceived self-efficacy and cues to action were added as factors also influencing intention (22)(23).
The theory of reasoned action/planned behavior was developed first by Martin Fishbein and Icek Ajzen between 1975 and 1980. Initially, two factors influenced individuals: 1) an individual’s attitude towards an action or behavior 2) the subjective norms in society. These both influenced a third factor: behavioral intention (strong individual actions and social norms will push an individual towards the action). The theory was later amended and labeled as the theory of planned behavior, when Ajzen added characteristics of an individual’s beliefs towards the actions, norms, and barriers to achieve the action. Here, as in the health belief model, intention is an ascendant to behavior, and it is assumed that strong intention will lead a likely lead to an action.
In terms of universal access solving the health disparities seen in the United States, the hybrid between the two models discussed above lacks the essential tools to understand and efficiently attack the problem. Here, the perceived barrier is the lack of access to proper health services among minorities and poorer populations. It is assumed and agreed upon by most in academia that universal access will lead to strong intention to seek the proper medical care. However, the failure in the models above and a failure in the universal access argument, is that it cannot link that strong intention to action (because of many socioeconomic barriers which arise).
Thus, by simply providing full access, we still cannot fully understand the factors that cause the underlying health disparities between various minorities and even between income levels. It is almost eccentric to say that universal access would eliminate these barriers in health. We must “dig deeper” to better understand what causes the underlying disparities in health, and why these models have failed to address these social issues
Challenging Dogma – What Will Bridge The Disparities Between Socioeconomic Groups?
As stated above, the implementation alone of a universal access program will not solve the problems which account for the various racial and economic disparities in health care across the United States. It is an underlying failure of the public models used to support the policy. It is important to identify socioeconomic factors that arise between intention and action, better bridging these gaps. Extending private insurance to all in the country will not solve many of the disparities in health: “private medical insurance is not associated with good health outcomes...” (7). Thus there must be many underlying social, psychological, and economic factors that lead to the widening of these disparities. Issues ranging from mistrust, to racism, to poverty all affect an individual’s decision to utilize healthcare when available (not only the individual’s intention to utilize that same care, as previously thought by many social science models). Thus it is important to highlight some important social aspects that cause and widen these disparities in an effort to eliminate health disparities among socioeconomic classes.
Often, mistrust grows among a certain groups towards the healthcare community. This can be through substandard care or even racism in the health care setting. One example of this was the Tuskegee experiments between 1932 and 1972 led to generations of African-Americans mistrusting their physician and other medical services across the country. The lack of utilization of health services, lack of participation in medical research, and even lack of proper health education highlights some features of this mistrust among African-American even today(24)(25). These mistrusts often have led to many not (or under) utilizing the health insurance or access they have to health care. These events have placed great social and psychological barriers between intention and action. While most agree that individual experience and other historical factors also play a large role in shaping and causing mistrust of the medical community (26), the Tuskegee Experiments of the mid-twentieth century only widened the racial gap in healthcare across the country.
Racism in the health care setting also plays a large role among African-Americans mistrusting the health care community. Racism and other factors associated with a rough childhood, living in a violent neighborhood, and/or family conflicts can cause detrimental effects on an individual’s health. Behind stress, these factors listed above are cited as the second most important factors leading to decreased health among African-American males. They are disproportionately affected by these conditions yet they underutilize the health care system (27). The model fails to understand when equal types of treatment are given to whites and African-Americans, why non-whites experience lower outcomes and lower utilization (28)(29). Thus this must be considered when discussing why access to care will not bridge these gaps, when clearly the models used to support the idea of universal access fail to take into account these factors.
The models also do not properly explain why with equal coverage, minorities utilize healthcare less than most white individuals, and why they also mistrust the medical community. That is an individual’s intention to seek proper medical care does not always translate into utilization of the proper health services. For example the majority of poorer populations who were insured were the least likely to seek preventative care to thwart diabetes among all other socioeconomic groups (30). Most minorities, even with access to health insurance, were more likely to report that they had poor or problems with accessing the proper medical services (31). In other studies, more whites with health insurance were reported to have had routine check-ups with physicians to monitor diabetes than other minority groups (32). Even among children, minority groups faced deficits in care and were more likely to be dissatisfied by the care provided to them (33)(34). This opens a large gap of mistrust between the medical community and minorities who reside in society. The healthcare models mentioned above do not touch upon this subject of mistrust. Thus, even when the barrier of access is alleviated, there are new social barriers that arise even after universal coverage is given. Here, since minorities are generally are more dissatisfied by their quality of care or mistrust the medical professional providing the care, there are less likely to seek care even with access to the full health care system (even though they have the intention to be well).
Educational level and income level also play a large role in thwarting people away from using their access to a form of health care. Patients, with medical insurance, who are illiterate or have a low level of education are “...1.5 to 3 times more likely to experience a given poor outcome” (35). With these poor outcomes, the low-level of literacy also leads to lower utilization, lack of check-ups, and the under utilization of preventative care (36). This could be attributed to the lack of understanding of health related information, or even attributed to the lack of literacy among this population.
The lack of literacy mentioned above and/or new immigration into the US can affect an individual’s understanding of the English language. These language barriers can cause large amounts of miscommunication between patients and the healthcare providers causing disparities. This might be one of the most over looked social factors that have widened the disparities in health care delivery across the country. Thus, “Implementing policies to improve communication…may be necessary to reduce health disparities relative to higher income children across a variety of health domains including utilization, satisfaction, and outcomes” (37). Many individuals cannot understand the medical and health information given to them, and thus cannot properly take care of themselves as well as those who understand the language well. These barriers provide another obstacle between intention and action among individuals and families, presenting the great failures of the health belief and theory of reasoned action models.
The less-fortunate poorer populations, even with coverage, have difficulties accessing their care. Much of this large barrier centers on the individual’s ability to pay deductibles and copayments as part of their plans. Even with their strong intention to make themselves well (by having the intention to utilize healthcare through their insurance), its is almost impossible for some to follow through with action because of financial hardships. Even children of low-income parents (who have insurance and access to healthcare) are more likely to have chronic illnesses and other acute illnesses (38)(39). These children:
…despite higher levels of insurance coverage and greater access to regular providers of medical and routine care compared with healthy peers…are reported by their parents to be less likely than other children to receive the full range of needed health services(39).
The public health models supporting universal access do not take such factors into account, presenting their underlying failures and the subsequent failures of the universal access movement.
Thus, even individuals and families with strong intention to perform an action (under the two social science plans discussed above), cannot fulfill their intention due to barriers outside the realm of current social science models. The ultimate flaw in the models discussed above is that they do not account of these social barriers that arise between intention and action. Proponents over look these factors that can cause under utilization of services (even when they are freely and fully available), eventually leading to the failure of their theories and widening of the disparities in health. These barriers can thwart even the most intentioned individual and not allow the individual to carry through with actions.
The Future
The examples above represent the large amount of social underlying factors that play a role in causing and even widening health disparities. As mentioned in the introduction, the benefits of universal care are not argued in this paper. It is the sweeping assumption that universal care can easily overcome and fix all health disparities that exist. This faulty assumption based upon two social science models has led to a failed dogma in public health. In the future for any key universal access legislation to be fully successful, it must incorporate and understand socioeconomic factors that also widen health disparities. As shown through the literature, access alone cannot force people to utilize the health system. Universal access cannot alone understand why minorities feel more dissatisfied by their health services than are most whites. There are large socioeconomic and racial gaps that are only widening daily in the United States, and in the future researchers much challenge dogma if they wish to understand and solve these ever growing social and behavioral conundrums.
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