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Factores asociados a la búsqueda y uso de servicios de salud: del modelo psicosocial al socio-económico / Associated factors to the search and use of health services: from the psychosocial to the socio-economic model
Arredondo, Armando.
  • Arredondo, Armando; Instituto Nacional de Salud Pública. MX
Salud ment ; 33(5): 397-408, sept.-oct. 2010. ilus, tab
Article in Spanish | LILACS-Express | LILACS | ID: lil-632825
ABSTRACT
This article includes the results of a multi-level conceptual approach review, considering four models of analysis, delving into the determinants and the explanatory factors in the process of search and use of health services. Such models are psychosocial, epidemiological, sociological, and socio-economic. The implications, determinants, and characteristics of utilization of health care services have been subject to scrutiny since the eighties. Research on this matter has not been independent of the process of reform, which has been carried out simultaneously in virtually every country in the world. In fact, establishing adequate health services for patients who need them most has become a generally accepted priority. For the purpose of this study, and as a preamble to understanding the process of search and use of health services, the concept of need, along with its applications in the different models of service use, must be defined. In the literature, there are four types of need a) normative need, that which is expert-defined as such in a given situation, b) felt need, which corresponds to a perceived lack of something beneficial to the individual, c) expressed need, one not only experienced, but also articulated by the individual, and d) comparative need, i.e. a standard that meets the same characteristics of another receiving certain coverage or service. This paper will refer to the expressed need, which may or may not correspond exactly to the use of health care services. Along the same lines, the concept of demand, applied from an economic perspective, will be utilized as a synonym for use. The implementation of reform processes and the evaluation of the possible implications of such reforms require extensive knowledge regarding the determinants of use of health care services. A main determinant can be identified, for example, when an individual uses such services, sometimes repeatedly, because he is in a situation of need (experienced), understood as the perception of discomfort or illness. There are certain biological differences (i.e. sex and age) that might explain some of the variations observed in the relationship between situations of need and use. However, could there be other reasons that would lead to use? If so, this situation might create unnecessary extra work for professional health care providers preventing them from engaging the real needs of the population served; on the other hand, if there are any other motives (besides the absence of necessity) causing an individual, or group of individuals, not to meet his care needs, he may be at risk. It is widely known that not all health problems are reported to physicians by patients at the time of consultation. Also, there are great numbers of single users who are responsible for the utilization of a large portion of consultations intended for that population, taking advantage and, occasionally, using health services without having, from a medical standpoint, a clear justification to do so. These examples are extremes that can be observed as patterns of use that are determined by the perceived need for health and a long list of factors described from different disciplinary perspectives. Analyzing the search and use of health services implies studying availability and accessibility to them. Although the measurement of these variables is not exact, it is used in most studies. When considering use by socio-economic group accessibility, the fairness of the system in question is also evaluated. This is highly relevant because problems of use of services are related to health equity and accessibility, two challenges currently being addressed by a substantive reform of the health systems in most countries of the world; particularly in Latin America, and more so in Mexico. Thus, this paper intends to address, through a review of different theoretical models, factors affecting the search and use of health services. It assumes that the central premise in the context of health sector reforms in Latin America, especially in Mexico, is that the health service users have come to occupy a leading role in establishing the health needs addressed by care systems. Indeed, the main issues of structural adjustment in health systems are related to setting health needs according to epidemiological changes, changes in perception of diseases, and changes in the variables of equity, efficiency, coverage, and accessibility to health systems for different population groups. From this new perspective, the health systems, in turn, propose relevant changes in the interaction between the two main social actors within this reform process first, the behavior of suppliers (any institution that provides health services to the population), and second, the behavior and perceptions of consumers (population using health services demanded from a particular institution). The path converges when both social actors represent the process of seeking and obtaining medical care, as determined by a number of variables and constraints addressed in this article through different conceptual approaches, i.e. whenever the explanatory conceptual model is used, the process of medical care is primarily conceived as two chains of activities and events where participants are parallel -the care- giver on the one hand, and the client or user of health services on the other. In an extended approach, use and its determinants have much to do with the study of accessibility, coverage, and equity in health. Some authors claim that, under this approach, the study of accessibility and coverage in health are made identical to the determinants of service utilization. This wider vision includes various aspects, considering use as a schematic sequence of events from the time the need for medical attention arises until it initiates/is followed by the use of medical services. Throughout this process, psychosocial and epidemiological determinants of care are identified, including seeking process aspects such as health-related beliefs, confidence in the health care system, disease frequency, pain tolerance, and presence of disability. This schematic succession of events is precisely what has allowed the study of health service use to exhibit different approaches, which in turn has led to the creation of various psychosocial and epidemiological models that have attempted to explain why the population does not use health services. From an economic perspective, the literature on health service utilization mainly considers two approaches the traditional approach and the managerial approach. These provide different but complementary explanations regarding demand and investment in health services. The traditional approach to demand for health services is based on consumer theory, where demand for medical services is mainly determined by the patient but conditioned by the health system. Within this emerging model, demand for health services is the result of a problem of inter-temporal utility maximization of the patient, and considered a function in the production of health. The managerial approach, related to human capital theory, considers information asymmetries between doctor and patient regarding the type and quantity of necessary medical treatment. In this context, the decision making process can be divided into two parts first, patients initially choose whether or not to seek treatment, and then, once the patient begins treatment, the physician determines the number of visits and use of services for tracking, monitoring, and controlling the damage that initially triggered the stages.
RESUMEN
El presente artículo incluye los resultados de una revisión y reflexión sobre diferentes niveles de aproximación conceptual que plantean cuatro modelos de análisis para el estudio de los condicionantes, determinantes y factores explicativos del proceso de búsqueda y utilización de servicios de salud. Dichos modelos son el psicosocial, el epidemiológico, el sociológico y el socioeconómico. Se parte de la premisa central de que en el contexto de reformas del sector salud en países de América Latina, y particularmente en México, los usuarios de servicios de salud pasan a ocupar un rol preponderante en el establecimiento de las necesidades de salud que deberán responder los sistemas de atención médica. En efecto, los principales hilos conductores y de ajuste estructural de los sistemas de salud lo constituyen los cambios en el establecimiento de necesidades de salud de acuerdo con cambios epidemiológicos, cambios en la percepción de daños a la salud, así como cambios en las variables de equidad, eficiencia, cobertura y accesibilidad de los sistemas de salud para diferentes grupos poblacionales. Desde esta nueva perspectiva, los cambios del sistema de salud proponen a su vez cambios relevantes en la interacción entre los dos principales actores sociales de este proceso de reforma por un lado, el comportamiento de los proveedores (toda institución que provee servicios de salud a la población) y, por otro, el comportamiento y percepción de los usuarios (población que busca y solicita servicios de salud a determinada institución). El camino de ambos actores sociales converge en lo que representa el proceso de búsqueda y obtención de la atención médica, determinado por una serie de variables y condicionantes que se abordan en este artículo, desde diferentes enfoques conceptuales. En un enfoque ampliado, la utilización y sus determinantes tienen mucho que ver con el estudio de la accesibilidad, la cobertura y la equidad en salud; es más, algunos autores afirman que bajo este enfoque, el estudio de la accesibilidad y cobertura en salud se hace idéntico al de los determinantes de la utilización de los servicios. Este enfoque ampliado comprende diversos aspectos, considerando la utilización como una sucesión esquemática de acontecimientos desde el momento en que surge la necesidad de atención médica hasta el momento en que se inicia o se continúa la utilización de servicios médicos. A lo largo de este proceso se identifican como determinantes psicosociales, sociales y epidemiológicos del proceso de búsqueda de atención aspectos que incluyen creencias relativas a la salud, la confianza en el sistema de atención médica, la frecuencia de la enfermedad, la tolerancia al dolor y la presencia de discapacidad. Esta sucesión de acontecimientos es precisamente lo que ha permitido el estudio del uso de servicios de salud desde diferentes enfoques, dando lugar al diseño de diversos modelos psicosociales, sociales y epidemiológicos, que han intentado explicar el motivo por el cual la población hace uso o no de los servicios de salud. Por otra parte, desde una perspectiva económica, la literatura sobre utilización de servicios de salud considera principalmente dos enfoques el enfoque tradicional y el enfoque gerencial. Estos enfoques proveen explicaciones diferentes pero complementarias sobre la demanda y la inversión en servicios de salud. El enfoque tradicional de la demanda por servicios de salud se basa en la teoría del consumidor. Bajo este enfoque, la demanda de servicios médicos está determinada principalmente por el paciente pero condicionada por el sistema de salud. El enfoque gerencial, relacionado con la teoría de capital humano, considera las asimetrías de información entre el médico y el paciente en relación con el tipo y cantidad de tratamiento médico necesario. En este contexto, el proceso de toma de decisiones puede dividirse en dos partes. En la primera, el paciente elige inicialmente si busca tratamiento o no y en la segunda, una vez que el paciente empezó el tratamiento, el médico determina el número de visitas y uso de servicios para seguimiento, monitoreo y control del daño que inicialmente desencadenó las fases del proceso. Todas y cada una de las fases descritas son abordadas desde diferentes perspectivas en este artículo, donde se describen los condicionantes y/o determinantes del proceso de búsqueda y utilización de los servicios de salud y se hace un análisis cruzado con cada modelo revisado mediante una matriz de contingencia. Finalmente, el análisis integral de los modelos estudiados se propone como punto de partida para avanzar en un modelo que permita, de manera transdisciplinaria, encontrar la explicación más acertada de los determinantes y condicionantes del proceso de búsqueda y uso de servicios de salud.

Full text: Available Index: LILACS (Americas) Type of study: Health economic evaluation / Prognostic study / Risk factors Language: Spanish Journal: Salud ment Journal subject: Psychiatry Year: 2010 Type: Article Affiliation country: Mexico Institution/Affiliation country: Instituto Nacional de Salud Pública/MX

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Full text: Available Index: LILACS (Americas) Type of study: Health economic evaluation / Prognostic study / Risk factors Language: Spanish Journal: Salud ment Journal subject: Psychiatry Year: 2010 Type: Article Affiliation country: Mexico Institution/Affiliation country: Instituto Nacional de Salud Pública/MX