title: Unconnected and out-of-sight: identifying health care non-users with unmet needs.
abstract: While current debates on how to deliver sustainable health care recognise socio-economic dimensions to health service use, attention has focussed on how to reduce demand for services. However, the measures of demand may not account for a subgroup of the population who to date have remained out of sight because they do not access health services. This study aimed to describe the characteristics of individuals who self-reported having fair or poor health but did not use health services.
  
  
  
  Data from the 2010 LINKIN health census survey (n = 7895) and the 2013 HILDA National Panel Survey (n = 13,609) were analysed focussing on the population who self-reported their overall health status as fair or poor. Simple and multivariable logistic regression modelling examined characteristics associated with a lack of health services use. The outcome measure of interest was no health service use in the previous 12 months and co-variables included demographic and socioeconomic indicators, health-related quality of life, having no health condition and health risk factors.
  
  
  
  Overall 21% of LINKIN respondents reported their overall health as fair or poor compared to 18% in the HILDA dataset. In LINKIN, 4.4% of those reporting fair or poor health, reported not using any health service provider in the past 12 months. Similarly, 4.5% of HILDA respondents were non-users. When adjusted for multiple co-variables, unemployment (aOR 3.24, 95% CI 1.28-8.17), educational level at Year 10 or below (aOR 1.94, 95% CI 1.02-3.70) and smoking (aOR 2.67, 95% CI 1.38-5.17) were significantly associated with non-use for the LINKIN data, as did lack of health conditions (aOR 0.18, 95% CI 0.08-0.41). The HILDA regression analyses indicated the same directions of association between equivalent variables and lack of health service use, with the exception of educational level.
  
  
  
  In line with recent assertions on real denominators in health need, this study describes those people rarely included in the population at risk and the potential for systematic bias towards the overestimation of the effectiveness of interventions. This study informs current policy debates and planning, including how we connect with hard-to-reach populations and how this sub-group might be more appropriately included when measuring effectiveness of health policies and programs.
authors.affiliation: School of Public Health, Mail Drop DX 650 171, The University of Adelaide, Adelaide, SA, 5005, Australia. Elizabeth.Hoon@adelaide.edu.au.
authors.forename: Elizabeth
authors.identifier: 0000-0002-7077-7902
authors.initials: E
authors.lastname: Hoon
authors.affiliation: School of Public Health, Mail Drop DX 650 171, The University of Adelaide, Adelaide, SA, 5005, Australia.
authors.forename: Clarabelle
authors.initials: C
authors.lastname: Pham
authors.affiliation: School of Public Health, Mail Drop DX 650 171, The University of Adelaide, Adelaide, SA, 5005, Australia.|Torrens University, GPO Box 2025, Adelaide, SA, 5001, Australia.
authors.forename: Justin
authors.initials: J
authors.lastname: Beilby
authors.affiliation: School of Public Health, Mail Drop DX 650 171, The University of Adelaide, Adelaide, SA, 5005, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Karnon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001315:Australia; D003695:Delivery of Health Care; D005260:Female; D006291:Health Policy; D006296:Health Services / Q000706:statistics & numerical data*; D006304:Health Status; D006306:Health Surveys; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: Health service use; Measurement of omission; Non-users