Factors Associated with Healthcare Avoidance among US Adults: Analyses of the 2019 Healthy Information National Trends Survey

  

    
Characteristics
    

    
95% CI
  
  

    
Adjusted OR
    
LL
    
UL
  
  

    
Age    group (years; Referent. >=65)
    

    

    

  
  

    
18-34
    
3.611*
    
2.461
    
5.299
  
  

    
35-49
    
2.36*
    
1.748
    
3.186
  
  

    
50-64
    
1.808*
    
1.444
    
2.263
  
  

    
Sex    (Referent. Female)
    

    

    

  
  

    
Male
    
1.435*
    
1.105
    
1.864
  
  

    
Race/Ethnicity    (Referent. Non-Hispanic white)
    

    

    

  
  

    
Hispanic
    
1.035
    
0.735
    
1.457
  
  

    
Non-Hispanic Asian
    
1.154
    
0.691
    
1.926
  
  

    
Non-Hispanic Other
    
1.588
    
0.579
    
4.355
  
  

    
Non-Hispanic black
    
0.725
    
0.47
    
1.117
  
  

    
Residence    (Referent. Urban)
    

    

    

  
  

    
Rural
    
1.193
    
0.851
    
1.672
  
  

    
Education    (Referent. College graduate or postgraduate)
    

    

    

  
  

    
<=High school graduate
    
1.348
    
0.999
    
1.819
  
  

    
Post–high school or some    college
    
0.998
    
0.767
    
1.298
  
  

    
Income    (Referent. <$35,000)
    

    

    

  
  

    
$35,000-$49,999
    
1.361
    
0.853
    
2.172
  
  

    
$50,000-$74,999
    
1.282
    
0.909
    
1.806
  
  

    
>=$75,000
    
0.775
    
0.545
    
1.103
  
  

    
Smoking    (Referent. Never)
    

    

    

  
  

    
Current
    
1.474*
    
1.037
    
2.094
  
  

    
Former
    
1.195
    
0.882
    
1.619
  
  

    
How    much do you trust information about health or medical topics from doctor?    (Referent. A lot)
    

    

    

  
  

    
Some/A little/Not at all
    
1.831*
    
1.421
    
2.36
  
  

    
In    the past 12 months, how many times did you go to health professional to get    care for yourself? (Referent. None)
    

    

    

  
  

    
1 or 2 times
    
1.109
    
0.777
    
1.582
  
  

    
3 or 4 times
    
0.526
    
0.352
    
0.787
  
  

    
5 - 9 times
    
0.417
    
0.231
    
0.753
  
  

    
10 or more times
    
0.583
    
0.308
    
1.104
  
  

    
General    Health (Referent. Excellent)
    

    

    

  
  

    
Fair/Poor
    
2.73*
    
1.629
    
4.574
  
  

    
Good
    
1.971*
    
1.36
    
2.856
  
  

    
Very good
    
1.572*
    
1.067
    
2.315
  
  

    
Health    Insurance (Referent. Yes)
    

    

    

  
  

    
No
    
1.658
    
0.98
    
2.805
  
  

    
Note: *p <0.05. 
  

Table 2: Associations between those who responded to ‘‘some people avoid
visiting their doctor even when they suspect they should. Would you say this is
true for you, or not true for you?” And characteristics of US adults.

Discussion

Avoiding necessary healthcare is a significant concern [9] that bears heavy public health and economic consequences. The primary aim of the current study was to identify key risk factors for healthcare avoidance when needed using nationally representative data. Notably, we found that almost 1 in 3 American adults (30.3%) avoided healthcare even when they suspected they should. This highlighted a large group at-risk for worsening health.

A concerning finding from the study showed that 29% of the sample reported no/little/some trust in medical information from their doctor. While patients generally trust their doctor or healthcare provider as a critical source of health information compared to other communication channels [32,33], the high rates of medical mistrust point to a public health concern. Thus, the patient-doctor relationship and impressions of the doctor can have long lasting consequences. This is particularly important among higher risk groups given that those with poorer health and less education tend to initially seek medical advice from a doctor [32]. Individuals may also choose to avoid doctor visits to avoid seeking health related information [22]. There is empirical support for the inverse relationship between healthcare information seeking and avoidance [9,22,30]. Accordingly, trust in doctors as a viable source of medial information is an important determinant of whether one may choose to avoid healthcare when needed.

The result showing that medical mistrust was related to healthcare avoidance was consistent with previous research [34,23]. Specifically, we found that those who reported lower levels of trust in information about health or medical topics from a doctor were more likely to report avoiding visiting their doctor even when they suspect they should. Unsurprisingly, medical mistrust has been associated with increased avoidance and delayed care in studies of diverse groups in the United States [15,23]. Mollborn, Stepanova, and Cook (2005) found that most patients who have a trusting relationship with their regular care physician were less likely than those with less trust to report having unmet health care needs.

We found that specific health behaviors were related to healthcare avoidance. In particular, healthcare avoidance was higher among those who were current smokers and had poorer self-reported worse health status, and those who never visited a healthcare professional in the past 12 months. These findings are consistent with previous studies showing unhealthy behaviors (e.g., excessive alcohol consumption, smoking) are related to healthcare avoidance. This is concerning as this also places individuals at increased health risks [35,36]. Given that health behaviors cluster together (e.g., smokers are also more likely to report physically inactivity, poor sleep, and unhealthy diets [37], smoking may be indicative of poorer health and an array of health risk behaviors. For instance, one study that examined the association of smoking status with health-related quality of life showed that current smokers reported poorer health related quality of life than those who never smoked, and were more likely to drink heavily, to binge drink, and to report depressive and anxiety symptoms [37].

Prior studies have associated self-rated health with health service use [38,39]. In this study, respondents who rated their health status as poor/fair, compared to excellent, were almost 3 times more likely to report avoiding healthcare. This contrasts with previous research suggesting poorer physical and mental health status as a significant predictor of healthcare utilization [40], greater physician visits [39], and greater likelihood of receiving treatment [38].

Sex and age were the only sociodemographic characteristics that predicted healthcare avoidance. Specifically, males were more likely to report healthcare avoidance, which is consistent with findings that men tend to lead less healthy lifestyles and adopt fewer preventative and health-promoting beliefs and behaviors [41,42]. Men report fewer healthcare visits than women [42,43] and are less likely to seek professional mental health services [44,45]. These differences may help to shed light on why men suffer from more severe chronic conditions, such as greater rates of cancer, heart disease, shorter lifespans [41,42,44]. Given that many of the health conditions for which men are at greater risk are preventable [42], public health efforts should seek to identify and confront the health-related beliefs, attitudes and practices that impede healthcare use that serves to place men at greater risk for poorer health outcomes.

An additional finding that younger adults were more likely to report avoiding healthcare is consistent with previous research [15,22,40]. Although younger adults are at lower risk for health problems compared to older adults, structural barriers to healthcare such as lack of health insurance may be a strong determinant of healthcare avoidance and delay in this group [15,46]. Because employmentbased insurance is the predominant form of healthcare access among individuals <65y, healthcare use may be largely a function of occupation status and employment benefit [47]. Structurally, young adults are less likely to have health insurance coverage compared to older age groups given age cutoffs for subsidized health insurance [46,47].

Although older individuals were less likely to avoid healthcare when needed, healthcare avoidance has particularly adverse health consequences for older adults [48] given more frequent chronic health problems and disability [48, 49]. Unlike younger adults, healthcare cost and lack of health insurance coverage are not commonly identified reasons for healthcare avoidance [46]. Rather, healthcare avoidance among older adults is largely related to perceived health care quality and the relationship with healthcare providers (e.g., communication and rapport) [46]. This underscores the importance expanding our understanding of medical care avoidance to include psychosocial factors. For example, psychosocial factors may include emotional costs of healthcare (e.g. fear of cancer treatment, embarrassment disclosing symptoms to healthcare professionals, cultural taboo, and stigma), distrust of healthcare providers and/or medical science community, low self-efficacy and low perceived need to seek medical care [13,23,24,29,34].

Although the current study did not find significant difference in healthcare avoidance by insurance status, healthcare cost remains a strong driving force for healthcare decisions.). The healthcare policy in the US does not guarantee universal coverage. The long-term economic and health consequences of avoiding medical healthcare on society and individuals is an important line of work that needs further exploration [9].

The study findings must be considered in light of the following limitations. First, the data were cross-sectional and based on participant self-report. As such, we cannot infer causality and the study measures were vulnerable to recall bias. Second, a one-item measure was used to assess healthcare avoidance. Future research should consider multidimensional measures that capture greater nuance. For example, it is important to consider how avoidance of preventive services (e.g. cancer screening) are distinct from avoidance of curative services [12]. Individuals seeking curative services are likely aware of and present with a host of symptoms [8] whereas individuals seeking preventive services may be non-symptomatic and healthy.

Third, quantitative data cannot holistically capture experiences of those avoiding healthcare. Future research should consider qualitative interviews to unpack the complex treatment seeking process and shed light on the context within which individuals engage in care-seeking behaviors. Although sociodemographic factors are widely cited antecedents of healthcare avoidance [9], individual characteristics such as racial/ethnic minority status, low income, and low education were not significantly associated with healthcare avoidance among the general population. Studies with different settings and populations have found differences in treatment seeking behavior by race/ethnicity and education level. One study found that Medicare beneficiaries with type 2 diabetes that reported lower levels of education (i.e. less than a high school diploma and high school degree) and of “other” racial/ethnic minority status (versus non- Hispanic White) were more likely to avoid healthcare [50]. Continual investigation of avoidant behavior among those with specific health conditions and racial/ethnic will facilitate better understanding of those at risk for avoidance of needed medical care.

By elucidating factors associated with healthcare use avoidance we can promote healthcare usage among individuals more likely to avoid healthcare. To promote healthcare usage among those at-risk for missing or delaying doctor appointments, interventions should aim to increase knowledge and awareness of the benefits of timely health screenings and routine checkups. The Community Guide developed by the nonfederal Task Force on Community Preventive Services (Task Force) provides evidence-based recommendations to improve population health through the uptake of breast, cervical, and colorectal cancer screening [51]. For instance, the guide identified appointment reminders (e.g., in print, phone call) as an effective intervention to increase community awareness of cancer screening services, group or one-on-one community-based educational activities can effectively promote healthy lifestyle behaviors, and efforts to minimize economic and logistical barriers to cancer screening services such as lowering out of pocket costs or expansion of clinic visitation hours can promote screening behavior [52].

A promising intervention is to foster collaborative care between patient-provider dyads to encourage healthcare usage and increase patient engagement [13]. An important aspect of collaborative care is patient engagement and involvement in the management of their own health [53]. Interventions that adopt and implement a range of eHealth applications such as healthcare system web portals, mobile health communication, and telehealth medicine, that are interactive, user friendly and accessible to diverse consumers may enhance provider and patient access to critical health information, increase collaboration, and improve quality of care [54]. Moreover, the development of effective health communication interventions centered on patient involvement in their own health and safety can help foster trust and collaborative partnerships between patients and their providers [54].

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