title: Is the association between physical activity and healthcare utilization affected by self-rated health and socio-economic factors?
abstract: BACKGROUND
  Physical activity and healthcare utilization has negative association. However, there appears to be limited knowledge of how this association is affected by self-rated health (SRH) and socio-economic status (SES). Therefore, the aim of this study was to examine the association between leisure-time physical activity (LTPA) and healthcare utilization, and investigate how SRH, gender, age and SES affected this association.
  
  
  METHODS
  A cross-sectional public health survey was conducted in Skåne, Sweden 2012, based on a random sample with 55,000 participants (response rate 51 %; 28,028 individuals included in the study) aged 18-80 years. The data was linked to individual healthcare utilization data and socio-economic data. Logistic regression analyses were conducted to study the association between LTPA and healthcare utilization. Path analysis was used to investigate the possible mediation effect of SRH to the association between LTPA and healthcare utilization.
  
  
  RESULTS
  Compared to sedentary leisure time the odds ratio for health care utilization decreased with increasing level of LPTA; physically active 0.89 (95 % CI: 0.81-0.96), for average exercise 0.74 (0.67-0.81) and for vigorous exercise 0.65 (0.60-0.72). The socio-economic variables attenuated this association to a small degree, but SRH had a strong impact. While the mediation analysis illustrated that the indirect effects were strong (and in the expected order so that higher levels of LTPA were more negatively associated with poor health) and highly significant, the direct effects suggested that higher levels of physical activity were more positively associated with healthcare utilization than lower levels. The indirect effects were substantially stronger than the direct effects.
  
  
  CONCLUSIONS
  There was a significant negative association between decreased healthcare utilization and increased LPTA, and the association remained after adjustment for socio-economic variables. The mediation analysis (with SRH as the mediator between LTPA and healthcare utilization) showed that the indirect effects were strong and in the expected order, but the direct effects of LTPA on healthcare utilization was positive so that higher levels of LTPA had higher healthcare utilization. These results suggest that even though higher physical activity in total decreases the healthcare utilization, parts of the association that is not mediated through SRH actually increase healthcare utilization.
authors.affiliation: Department of Clinical Sciences in Malmö/General Practice, Lund University,, CRC, Jan Waldenströms gata 35:28:11, SE 205 02, Malmö, Sweden. patriciarocca75@gmail.com.
authors.forename: Patricia
authors.initials: P
authors.lastname: Rocca
authors.affiliation: Department of Clinical Sciences in Malmö/General Practice, Lund University,, CRC, Jan Waldenströms gata 35:28:11, SE 205 02, Malmö, Sweden. anders.beckman@med.lu.se.
authors.forename: Anders
authors.initials: A
authors.lastname: Beckman
authors.affiliation: Department of Clinical Sciences in Malmö/General Practice, Lund University,, CRC, Jan Waldenströms gata 35:28:11, SE 205 02, Malmö, Sweden. eva.ekvall-hansson@med.lu.se.
authors.forename: Eva
authors.initials: E
authors.lastname: Ekvall Hansson
authors.affiliation: Department of Clinical Sciences in Malmö/General Practice, Lund University,, CRC, Jan Waldenströms gata 35:28:11, SE 205 02, Malmö, Sweden. henrik.ohlsson@med.lu.se.|Lund University Center for Primary Health Care Research, Malmö, Sweden. henrik.ohlsson@med.lu.se.
authors.forename: Henrik
authors.initials: H
authors.lastname: Ohlsson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D015444:Exercise; D005260:Female; D015438:Health Behavior; D006304:Health Status; D006801:Humans; D007899:Leisure Activities; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D057566:Self Report; D012959:Socioeconomic Factors; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult