Stockdale Susan E, Tang Lingqi, Zhang Lily, Belin Thomas R, Wells Kenneth B
UCLA Semel Institute Health Services Research Center, 10920 Wilshire Blvd., Ste 300 Los Angeles, CA 90024, USA.
Health Serv Res. 2007 Jun;42(3 Pt 1):1020-41. doi: 10.1111/j.1475-6773.2006.00636.x.
This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.
Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.
The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.
Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.
Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.
本研究采用安德森行为模型，以确定卫生部门的市场状况对弱势群体使用酒精、药物和心理健康服务（ADM）的影响是否与普通人群不同，特别关注社区层面的诱发因素和促成因素。
来自社区卫生保健研究的第2波数据（2000 - 2001年），并补充了第1波（1997 - 1998年）的案例，与来自人口普查、区域资源文件（ARF）和其他数据源的区域特征进行了合并。
该研究使用四级分层逻辑回归来检验从任何提供者获得ADM护理的情况以及专科ADM服务的可及性。探讨了社区层面的诱发因素和促成脆弱性特征与个体种族/民族、年龄、收入类别和保险类型之间的相互作用。
非白人、贫困人口、未参保者和老年人使用服务的可能性较低，但种族/民族、收入、年龄和保险状况与社区层面脆弱性因素之间的相互作用对于任何服务使用情况而言在统计学上均不显著。对于ADM专科护理，拥有医疗保险、医疗补助、私人全额管理保险和私人部分管理保险的人群，在健康维护组织（HMO）渗透率较高的地区使用服务的可能性更高。然而，对于拥有其他保险或没有保险计划的人群，在HMO渗透率较高的地区使用服务的可能性较低。
社区层面的促成因素解释了部分不利地位的影响，但除了HMO渗透率对保险与专科护理使用之间关系的影响外，并未改变任何剩余的个体层面不利影响。针对结构层面和个体层面的干预措施可能对于解决健康差异问题是必要的。需要更多利用纵向数据的研究来理清社会背景与ADM服务可及性结果之间的因果方向，以及改变卫生部门市场状况的政策干预措施是否能够改变ADM治疗的利用率。
