Gender differences in cost-related unmet healthcare needs: a national study in Turkiye | BMC Public Health

This pioneering study is the first to analyze gender differences in cost-related unmet healthcare needs within a representative sample of the Turkish population. It reveals that socioeconomic determinants impact men and women differently, highlighting the need for an intersectional approach in public health.

Prevalence of cost-related unmet healthcare needs

We found that 15.4% of people aged 15 years or older reported unmet healthcare needs due to cost, exceeding the European Union’s average of 13.0% [29]. In comparison, earlier studies from 2016 using TURKSTAT data showed a prevalence of 13.6% [6, 16, 25]. The increase in unmet needs from 2016 to 2019 may be linked to Turkey’s economic instability, reflected in the decline of GDP per capita from $10,734.4 to $9,103 during this period [30]. Additionally, Turkey’s healthcare spending decreased from 6% of GDP in 2009 to 4.7% in 2019, according to the World Health Organization’s Global Health Expenditure database. This decline has intensified private healthcare expenses, particularly through out-of-pocket payments and private health insurance, increasing the financial burden on individuals [9]. The rise in unmet needs among women may be due to these heightened out-of-pocket healthcare expenses, with underprivileged groups disproportionately affected, perpetuating gender inequalities in Turkey and similar trends observed in Europe [24, 33].

Our findings revealed a greater prevalence of unmet needs among females (16.8%) than among males (13.5%), consistent with the findings of various reports and studies in this domain [1, 3, 4, 6, 25]. Notably, this finding aligns with Turkiye’s Global Gender Inequality Index, which, after increasing between 2000 and 2016, stagnated and declined in 2017 [25]. Gender inequality has been a substantial issue in Turkiye, especially in the labor market, where women face greater challenges than men in terms of informal work, unemployment, and lower wages [31]. Despite this disadvantage, universal health insurance covers both widowed and single women as beneficiaries of their husbands and fathers. An existing regulation allowing unmarried or widowed women lifelong utilization of their fathers’ health insurance still contributes to improved healthcare access in terms of financial support and necessary medical services [32]. However, it should be noted that this right applies only to women born before the law was accepted in 2008, meaning the number of female beneficiaries will steadily decrease over the years.

According to the study, accessing dental care services had the highest cost-related unmet needs for both genders. The significant unmet need for dental care could be attributed to the historically limited national health care system, the dominance of the private sector in Turkiye, regional disparities despite public sector growth, copayments for high-quality materials, and challenges in appointment scheduling. A higher cost of dental care exacerbates economic disparities between men and women [33,34,35].

Andersen and Newman’s model

In this study, we found that Andersen and Newman’s model [21] was an effective tool for understanding the socioeconomic determinants of unmet needs across all subgroups, consistent with previous findings [2, 26, 36, 37].

Predisposing factors

Predisposing factors such as younger age, lower education level, marital status, and difficulty with linguistic communication had differential impacts on access to healthcare between genders. Contrary to the findings of certain studies [16, 17], our findings align with those of other studies demonstrating a greater prevalence of unmet needs among younger age groups, with the highest occurrence occurring within the 35–44 age bracket [15,16,17,18,19]. This trend, where younger age serves as a risk factor for unmet needs across genders, except for men older than 55, can be attributed to multifaceted factors, including increased copayments and high youth unemployment rates in Turkiye, where the unemployment rate for those aged 15–24 was 22.5% for men and 30.6% for women [28,29,30,31,32,33,34,35,36,37,38,39,40].

The study revealed that lower education levels are a risk factor for unmet needs among both men and women when only predisposing factors are considered. This could be attributed to the fact that women with lower education levels may have greater perceived unmet needs due to a lack of health literacy. However, when enabling factors such as employment status and income are added to the model, the effect of lower education levels on perceived unmet needs for women disappears. This observation continues even after adding need factors such as chronic disease, health status, and limitations in daily activities. This finding suggests that education, therefore, may play a more determining role in employment, income, etc., among women in Turkiye. Similarly, a research study revealed that health insurance and income play crucial roles as primary mediators in connecting education levels with the utilization of healthcare services [12]. On the other hand, low education is related to unmet medical care and prescribed medicine needs among both men and women according to multivariate regression models. This finding aligns with previous research indicating that higher education levels are associated with better health literacy, leading to more effective utilization of healthcare services [14]. Unexpectedly, education is not related to the unmet need for dental or mental care among women. This could be due to various reasons, such as lower prioritization and postponement of dental and mental health due to mostly nonurgent conditions, a lack of awareness about the importance of these services, or other barriers to access.

Furthermore, while marriage elevated the risk of unmet medical, dental, and prescription drug needs for both genders, divorce or widowhood presented a heightened risk, specifically for women in terms of healthcare access. The literature encompasses studies reflecting diverse perspectives on the impact of marriage on healthcare utilization, suggesting either a positive, negative, or neutral influence [3, 40,41,42,43,44]. For women, especially housewives, divorce implies income loss, whereas for men, the risk is mitigated. Studies on low-income divorced women in Turkiye reveal that these women often struggle to improve their lives due to limited opportunities and legal challenges favoring men [45].

Consistent with the literature, having difficulty communicating with one’s mother tongue was one of the variables found to be a determinant of unmet needs in all three models for both genders [46,47,48]. Among the types of unmet needs, language barriers were important for unmet medical care among both men and women and unmet dental care for men only.

Enabling factors

In Andersen’s model of unmet needs, enabling factors are the conditions that make health service resources available to individuals and are grouped into family and community factors [21, 25]. In our study, enabling factors contributing to unmet healthcare demand for both genders included lower and middle household income, a lack of universal health insurance, and caregiving responsibility, while employment was statistically significant only for men. Lack of universal health insurance and low/lowest income are associated with all types of unmet needs. While unmet medical and dental care needs are significantly greater among employed and unemployed men, the unmet need for prescribed medicine is related only to unemployed men.

Family income directly influences the affordability of healthcare services, encompassing both the ability to purchase all services and covering copayments during healthcare utilization [7, 14, 49]. Emphasizing the significance of universal healthcare coverage as a strategy to foster health equity is noteworthy in this context [50, 51]. In addition, our analyses revealed a notable discrepancy in unmet needs, with men who are not covered by universal healthcare insurance experiencing higher rates of unmet needs than women. This divergence could be linked to the availability of facilities serving women’s health, such as nonprofit health centers operated by NGOs and local government initiatives.

However, a noticeable gender disparity is observed in the predictive role of employment, which is not statistically significant for women. A seemingly contradictory finding at first glance was that both employed and unemployed men reported greater unmet needs. Regular employment often correlates with having some form of health insurance, which facilitates access to healthcare [52, 53]. In this context, the association between unemployment and unmet healthcare needs is understandable, particularly in countries with limited social protection. On the other hand, a significant portion of employed men in Turkiye, estimated between 30.9% and 31.8% in 2019, are in unregistered employment, which typically does not offer health insurance through employers [54]. This lack of insurance could explain some of the unmet needs among employed men. Furthermore, within this age group, the higher prevalence of unmet needs among men may be attributed to the insufficient availability of occupational health services in workplaces, the limited scope of services, challenges in obtaining employer permission to seek healthcare, and wage deductions for obtaining health reports [55,56,57].

Many studies have shown that caregiving responsibilities may be related to postponing health care utilization, especially for women, due to gender differences [58,59,60,61]. Female caregivers, which are more prevalent in Turkiye, significantly impact women’s unmet needs and experience a greater burden [58, 62]. However, our study shows that caregiving also affects men, although differently. Male caregivers, despite being fewer in number, might experience significant stress balancing work and caregiving duties, compounded by societal perceptions of caregiving as a “feminine” role. This stigma can lead to a lack of support, social isolation, and increased stress for male caregivers [63,64,65]. Recognizing the diverse experiences of caregivers and providing adequate support for all, regardless of gender, is essential to mitigating the negative impacts of caregiving on healthcare access.

Needs factors

In our study, gender emerges as a statistically significant determinant in Models 1 and 2. However, its significance diminishes in Model 3 when we incorporate factors related to health needs. This shift in significance suggested that while gender might influence predisposition and access to resources (as seen in Models 1 and 2), it does not directly impact unmet healthcare needs when we account for actual health status and requirements (need factors) in the analysis (as in Model 3).

Consistent with the literature, women experience a greater frequency of poorer self-rated health status, chronic diseases, and limitations in daily activities due to health problems than men do [2, 42, 66,67,68,69]. In our study, both men and women who had any chronic illness reported a statistically significant influence on each type of unmet need. In contrast to the greater frequency among women, poor self-rated health had a more substantial impact on men’s cost-related unmet care needs. This could be due to differing perceptions of health severity and delayed healthcare-seeking behavior influenced by societal expectations of masculinity [70,71,72].

However, limitation in daily activities due to health problems primarily affected women’s access to medical care, highlighting a sex-specific factor. Cultural, social, and economic barriers, coupled with these health-related limitations, create additional challenges for women when seeking medical attention [3, 67]. Despite being proactive in seeking healthcare, women may prioritize their households’ needs over their own, leading to unmet medical care. Societal norms and expectations regarding gender roles may also cause women to downplay their health concerns or delay seeking care until their conditions worsen [73, 74]. These factors collectively pose significant barriers for women in accessing timely and adequate healthcare services.

In this study, need factors likely play a substantial role in mediating or explaining the relationship between gender and unmet healthcare needs. This change in the significance of sex from Models 1 and 2 to Model 3 underscores the importance of considering health status and requirements in understanding unmet healthcare needs.

Limitations

This study has several limitations. First, the cross-sectional nature of the study prevents us from exploring causal associations. The cross-sectional design may also cause selection bias because the temporal dynamics between predisposing, enabling, and need-related factors were not provided. Second, self-reported data are potentially based on perception and may also lead to recall bias. Additionally, the age grouping of < 35 years encompasses a wide and heterogeneous population, from adolescents to adults, which may influence the interpretation of age-related findings. The complexity of the determinants influencing unmet needs could extend beyond the variables analysed. Addressing these limitations through more comprehensive data collection, broader variables, and a deeper understanding of contextual influences would enhance the credibility and applicability of future studies.