Unmet needs and the effect of healthcare system generosity on prevention activity – A multilevel analysis

Introduction: Maintaining a healthy lifestyle and obtaining preventive care (hereafter, prevention-activity) usually have an inverse association with poverty status and unmet needs. We seek to estimate the extent to which the effect of individual unmet needs status on prevention-activity is moderated by the generosity of the healthcare system. Materials and methods: Two datasets were combined: Pre-Covid Wave-8 (2019–2020) of the Survey of Health, Ageing and Retirement in Europe (SHARE, Release 8.0.0), with 46,500 individuals aged 50+ from 27 countries (26 European countries and Israel) and 12 healthcare generosity variables obtained from the OECD Health Statistics Library. An econometric two-level model was used in three sequentially models. Outcome variables included five prevention-activities align over a continuum (sports, smoking, flu vaccinations, mammography, and colon cancer screening) and unmet needs status, defined as the lack of resources necessary to meet basic human and medical needs. Results: We found that unmet needs at the individual level had a significant negative fixed effect in all of the prevention-activity models including a healthy lifestyle, primary prevention and secondary prevention. Sources of intra-country variation were social/public insurance, health expenditure and number of nurses, which have had a significant and positive effect on an individual's prevention-activities (except years of smoking). Nonetheless, the gaps in generous countries between people reporting on unmet need and others were larger or similar to those in less generous countries, suggesting that disparities increase with the generosity of the health system. Conclusions: The study provides insight into the effect of health system generosity on socioeconomic inequalities in healthy lifestyle and prevention care. Our findings suggest that the state has an important and decisive role to play in ensuring that prevention services are accessible to the entire population, particularly those reporting unmet needs.