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Equity in the health sector is one o the centralaims o public health policy. In literature thereis distinction between horizontal equity, which

is a measure o equal treatment or those withequal needs, and vertical equity, which is theextent to which individuals with unequal needsreceive different levels o care (1).

In most o the developed countries, the ac-cess to publicly provided health care is grant-ed on the basis o need, rather than on thebasis o the ability o the individual to a-ord it. Concordantly, the Croatian consti-tution defines Croatia as a social state, pro-claims social justice to be one o the highest

values o the countrys constitutional order,and that all Croatian citizens have the rightto health care (2). Te Croatian Health CareAct states that all citizens o the Republic oCroatia have the right to health care servicesthroughout their entire lives (3). Te Croa-tian state-administered mandatory health in-surance scheme has near universal coverage(4) and is provided ree o charge to unem-

ployed individuals by the Croatian Instituteor Health Insurance.

Use and access are closely related con-cepts, as access can be defined as the use ohealth care, conditional on the need or care(5). According to the definition, equality oaccess can be used as an operable definitiono equity, with access defined as the use ohealth care conditional on the need or care.Te effectiveness o and thus the need or

preventive programs have been long well es-tablished.

It has been well established that the un-employed suffer rom worse health than theemployed, both internationally (6-11) andin Croatia (12,13), and a number o studieshave shown that a positive association existsbetween unemployment and higher healthcare consumption (14-16). However, discus-sions about equity and health care consump-tion among the unemployed are ar rom be-

ing conclusive, as other studies argue thatthe unemployed and other groups associated

with extensive use o health care more ofen

have unmet care needs (17,18). Te effects ounemployment on the use o preventive ser-vices have so ar not adequately caught theattention o researchers, neither internation-ally, nor in Croatia. Our hypothesis was thatemployment status was associated with theconsumption o preventive health servicesamong Croatian citizens. As the unemployedin Croatia receive ree mandatory health in-surance and as they are relieved o all out-o-

pocket expenses related to publicly provided

health care services, our hypothesis reflectedthe influence o psychosocial mechanisms butalso the effects o the provision o preventiveservices in the private market, which the un-employed were less likely to use due to their

worse financial status.

Participants and methods

Data on the use o preventive health careservices and employment status were takenrom the 2003 Croatia Adult Health Sur-

vey (CAHS), which covered a wide range ohealth-related variables (19). A multistagestratified sample design was used to draw arepresentative sample o general adult popu-lation. Te survey targeted persons aged 18

years living in private households in the Re-public o Croatia. Persons living in non-conventional households and institutions,ull-time serving members o the Croatian

Armed Forces, and the residents o certainremote regions were excluded rom the sur-

vey. Te 2001 Croatian Census was used toselect a representative sample o households tobe included in this survey (20). Te CroatianBureau o Statistics provided the health surveyteam with 11 345 randomly selected house-hold addresses rom 6 officially defined regionso Croatia (ie, Northern, Eastern, Southern,

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Western, Central, and the City o Zagreb). Noother individual data were used or the sampledefinition. In total, 10 766 households were

selected to participate in the 2003 CAHS. Re-sponse was obtained rom 9070 individuals,which gave the overall response rate o 84.3%.Te questionnaire was administered by trained

public health nurses in ace-to-ace interviews(21). Data were collected over three months,rom April to June 2003.

Outcome measures

Utilization o preventive services was consid-ered in both healthy and unhealthy individu-

als in the period o 12 months beore the sur-vey. Te use o blood pressure control, bloodglucose control, general preventive examina-tion and doctors advice or ood habits chang-es, was considered in those individuals thatdid not report cardiovascular (hypertension,stroke, heart attack, varicose veins, renal dis-eases) or metabolic (hyperglycemia, hypercho-lesterolemia) diseases in their medical history.On the other hand, utilization o preventive

health services by individuals that reportedcardiovascular and/or metabolic diseases intheir medical history was considered or thesame activities as or primary prevention andadditionally or influenza immunizations. In-fluenza immunizations are recommended orall chronic patients in Croatia and adminis-tered ree o charge in order to prevent influ-enza complications that can sometimes be a-tal in that group.

Statistical analysis

Variables included in the analysis were: age(18-29, 30-64, and 65+), sex, region (South-ern, Eastern, Northern, Western, Central,and the City o Zagreb), marital status (mar-ried or living with a partner, single, separatedor divorced, widowed), education (unfinished

primary school, primary school, high school,college, university), sel perceived economic

status in comparison with average economicstatus (1 much worse, 2 somewhat worsethan average, 3 average, 4 much better, and

5 much better than average), aggravating e-ect o distance rom general practitioners(GP) acilities or the use o health services(answered as no, moderate, extreme), employ-ment (employed and unemployed among ca-

pable to work, except students and house-

Table 1.Distribution of employable individuals from the popu-

lation by self perceived economic status and need for second-

ary prevention and distance from general practitioners (GP)

ofce (n = 3290)

No. (%) of

Parameter men women

Age group :

18-29 163 (12.0) 327 (16.9)

30-64 1130 (83.3) 1565 (81.0)

65 and more 64 (4.7) 41 (2.1)

Region:

Zagreb City 187 (13.8) 379 (19.6)

East 261 (19.2) 295 (15.3)

South 197 (14.5) 337 (17.4)

West 205 (15.1) 298 (15.4)

Central 282 (20.8) 318 (16.5)

North 225 (16.6) 306 (15.8)

Marital status:

married or living with a partner 947 (69.8) 1427 (73.9)

single 311 (22.9) 270 (14.0)

separated or divorced 63 (4.6) 128 (6.6)

widowed 35 (2.6) 106 (5.5)

Education: unnished primary school 78 (5.7) 64 (3.3)

primary school 234 (17.2) 260 (13.5)

high school or similar school 811 (59.8) 1177 (60.9)

college 1 00 (7.4) 173 (9.0)

university 131 (9.7) 256 (13.3)

unknown 3 (0.2) 2 (0.1)

Economic status:

much worse than average 271 (20.0) 262 (13.6)

somewhat worse than average 250 (18.4) 333 (17.2)

average 649 (47.9) 1042 (53.9)

somewhat better than average 150 (11.1) 250 (12.9)

much better than average 36 (2.7) 46 (2.4)

Aggravating effect o f distance for use ofhealth services:

no 796 (59.2) 1321 (68.7)

moderate 1 19 (8.9) 191 (9.9)

great 26 (1.9) 32 (1.7)

not applicable 403 (30.0) 379 (19.7)BMI-group:

40 17 (1.3) 9 (0.5)

Need for secondary prevention:

no 833 (61.4) 1150 (59.5)

yes 524 (38.6) 783 (40.5)

Employment status:

employed 974 (71.8) 1460 (75.6)

unemployed 382 (28.2) 472 (24.4)

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wives). For analytical purposes we used binarylogistic regression. Adjusted odds ratios (OR)

were estimated or the presence o association

between employment status and preventivehealth services use, controlling or age, sex, re-gion, marital status, education, sel perceivedeconomic status, and distance rom GP acili-ties. All confidence intervals (CI) that were es-timated or adjusted odds ratios were calculat-ed with 95% probability levels. Sofware SASV8.02 (SAS Institute Inc., Cary, NC, USA)

was used or analysis.

Results

We started the statistical analysis by dividingthe population into subgroups o 974 (71.8%)and 1460 (75.6%) employed, and 382 (28.2%)and 472 (24.4%) unemployed men and wom-en, respectively (excluding 230 students, 3229retired, 1970 housewives, and 351 person withunspecified employment status) (able 1). Temajority o the employable population (83.3%men and 81.0% women) was in the 30-64 agegroup. Tey were evenly distributed over thecountry regions (rom 13% to 21% or eachregion). Most respondents (69.8% men and73.9% women) were married or living with a

partner. Te majority had high school or vo-cational school education (59.8% men and60.9% women). Most o them (47.9% men

and 53.9% women) were in the group that hadaverage sel-perceived economic status.Among the individuals who did not report

having cardiovascular or metabolic diseases(able 2), unemployed persons used signifi-cantly less primary prevention services thanthe employed, afer controlling or age, sex, re-gion, marital status, education, sel perceivedeconomic status, body mass index (BMI),and distance rom GP acilities. Te nega-tive association with the unemployment sta-

tus was strongest with general preventive ex-aminations attendance (OR, 0.563; 95%CI, 0.410-0.772; P=0 .001), blood pressurecontrol (OR, 0.738; 95% CI, 0.576-0.945;P= 0.016), and blood glucose control (OR,0.751; 95% CI, 0.565-0.999; P= 0.049). Teassociation with receiving doctors advice orood habits changes, was not statistically sig-nificant (P= 0.564).

Among individuals who reported havingcardiovascular and metabolic diseases (a-ble 3), unemployed persons used some o theanalyzed preventive services significantly lessthan employed individuals. Afer controlling

Table 2.Utilization of preventive servic es in healthy individuals in the 12 months preceding 20 03 Croatia Adult Health Sur vey*

No. (%) of

Parameter P Adjusted OR (unemployed ) 95% CI employed unemployed

Blood pressure control 0.016 0.738 0.576-0.945 481 (32.2) 117 (23.9)

Blood glucose control 0.049 0.751 0.565-0.999 336 (22.5) 80 (16.4)

General preventive examination

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or age, sex, region, marital status, education,sel perceived economic status, BMI, and dis-tance rom acilities the negative association

with the unemployment status was strongestor influenza immunization (OR, 0.627; 95%CI, 0.424-0.928; P=0 .020) and with gener-al preventive examinations attendance (OR,0.661;95% CI, 0.456-0.959; P=0.029). Teassociations with blood pressure control,blood glucose control, and doctors advice orood habits changes were not statistically sig-nificant (P= 0.268, P= 0.396, and P= 0.349,respectively).

Discussion

Our study ound that both the unemployedwith cardiovascular and metabolic diseases inCroatia and those without it used less preven-tive health services than the respective sub-groups o the employed. Most o the studiessuggest that the unemployed use health careservices more requently than the employed(13-16). Others ound that the number o

primary health care visits increased rom alow to a normal level when a person was re-employed afer a period o unemployment,and decreased during re-unemployment (22),and that a lack o employment may be relat-ed to unmet care needs, especially amongthe unemployed who are experiencing psy-chological symptoms (23). However, theissue o use o preventive health care pro-grams among the unemployed has so arbeen largely neglected. Similar to our study,

Australian authors reported that examineeso low socioeconomic status (including theunemployed) received less preventive care(6).

Due to the cross-sectional design o ourstudy, we cannot discuss causation betweenunemployment and lower preventive healthcare use in Croatia. However, inormation

provided by this research may provide useul

inormation that might shed additional lighton what is already known. Furthermore, ar-guments presented by other researchers may

be relevant to Croatian circumstances, par-ticularly in the light o the results obtainedby this study. While it might be argued thatthe unemployed are generally o lower so-cioeconomic status than the employed, sev-eral actors that explain the relationship be-tween socioeconomic status and abstainingrom care are usually discussed in literature.he association between economic costso care and under provision has been thor-oughly researched in lower socioeconom-

ic groups. It has been shown that even withinsurance coverage, cost sharing in terms oco-payments, co-insurance, and deductiblesin general exert a negative impact on receipto preventive services and counseling (24).However, socioeconomic disparities remainhigh even in countries such as Croatia thathave universal health insurance coverage(25), ie where the unemployed are entitledto ree health insurance. he strong eects

o poverty status and education remain evenater controlling or access to care; this mayrelect an inluence o unmeasured eects osocio-economic status on the receipt o pre-

ventive services and counseling (26).In our study, utilization o preventive

services was analyzed ater controlling oreconomic status, thus reinorcing the argu-ments that associate underutilization andunemployment itsel as a variable. hismight relect the results o current Croatian

practice, where companies oten organizepreventive examinations or their employ-ees and is in accord with our indings, as thegreatest difference in use was discovered in at-tending general preventive examinations.

Waters reports that most o the theoreti-cal and empirical discussions published so aranalyzed horizontal equity (27). Our studyalso analyzed horizontal equity and ound that

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equals (the employed and unemployed) donot use preventive services equally. However,

we would also like to pay attention to issues

pertaining to vertical equity as we argue thatthe unemployed should be positively discrimi-nated with regards to the provision o preven-tive health services. I we accept the proposi-tions that preventive health care services arebeneficial to health and that unemploymentnegatively aects utilization, it might be ar-gued that unemployment negatively inlu-ences health. While societies may produceinequalities and inequities by themselves orby the way in which they unction, health

care systems should not ollow the same pat-tern. On the contrary, health care systemso most developed countries are meant to

protect the vulnerable and provide servicesor all, irrespective o their socio-economicstatus. Data presented by this study suggestthat the Croatian health care system doesnot entirely succeed in accomplishing this,and that it may actually be contributing tothe growth o the health gap between theemployed and the unemployed. Negativediscrimination in the provision o preven-tive health care services based on the criteri-on o employment status is contradictory tothe health care systems core social concepts.On the contrary, due to their documented

worse health status (or higher chance o be-ing in ill health), it might be argued that theunemployed are in greater need o preven-tive health care services than the employed.

Furthermore, it has been suggested

that unemployed persons who have devel-oped health related diiculties and chronichealth problems have diiculties in return-ing to work (28,29). he possible inequityin health care utilization in the unemployedgroups may thereby inluence not onlyhealth, but also the ability o these groupsto return to employment. his argumentmight be o special relevance to transition

economies such as Croatia, suering romhigh unemployment rates.

he conclusions o our study need to be

considered in the light o a number o limi-tations to this research. First, the cross-sec-tional nature o CAHS does not allow us toconclude on causation. Second, results maybe subject to recall bias as CAHS recordedsel reported use and health status. hird,due to the wording o the questions, CAHSonly recorded events in the 12 months pre-

vious to its administration. Fourthly, al-though the interviewed individuals wereselected randomly among household mem-

bers and the overall response rate was quitehigh, it may be argued that the unemployed

were less likely to decline participation dueto working obligations as opposed the em-

ployed. Finally, CAHS was undertaken in2003 and, although we are not aware o anyorganized eorts targeted at the health othe unemployed in the meantime, 4 yearshave passed between the survey and the pub-lication o our result.

However, we believe that the policy im-plications o arguments presented by thispaper are clear. In order to achieve equalaccess or equal needs, health care systemsshould provide additional attention to vul-nerable groups such as the unemployed. Interms o practical steps, variables, such as eco-nomic costs, that have been ound to influ-ence under-utilization should be adequatelyaddressed. In times o, internationally om-nipresent, cost containment measures heav-

ily relying on interventions on demand sideie, patient cost sharing, this argument is o

particular importance. Furthermore, to bet-ter and more cost efficiently meet the needso the unemployed, it is essential to heightenawareness o psychological problems, such asdepression and anxiety, that are more com-mon in this group (30-32), and which pre-

vent the population rom seeking care and

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make them especially vulnerable to unmethealth care needs (23).

Finally, we argue that in order to achieve

equal access or equal needs or both the em-ployed and the unemployed, health care sys-tems might have to pay more attention onthe unemployed who are less likely to use thebenefits that they offer. Tus, in order to betruly equitable, in some aspects they mightreorient their development toward providingequal utilization or equal needs, rather than

just offering equal access to everybody as themore privileged take better use o it than theunderprivileged. Tis course o action would

be in line with the vertical equity criterion,as it would ensure that the unemployed, whoare in greater need o both curative and pre-

ventive health care, receive proportionallymore services. In the light o the finding othis study, this may imply organizing preven-tive examinations targeted specifically at theunemployed.

Acknowledgments

Displayed results were obtained rom data collected

through the project Regionalism o cardiovascularbehavioral risks model o intervention, (Project No108-1080135-0264) which was unded by the CroatianMinistry o Science, Education, and Sports.

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