Essays in ‘global’ health utilization: How distance, gender, and stigma condition whether and when we seek care

The landscape of health service use varies across, and even within, countries and health sectors irrespective of payment model or health system, yet the fundamental purpose motivating its study is aimed at overcoming the challenges that prevent better and equitable uptake of effective interventions. This dissertation is fuelled by such purpose. Although each chapter poses a specific utilization question relevant to a unique target population, in its entirety, this work seeks to answer the following cross-cutting questions: (i) what are the factors that encourage and challenge utilization of health services, (ii) under which moderating conditions and through which channels is improved utilization supported, and (iii) how can a better understanding of the antecedents of improved utilization contribute to the design of well-targeted health interventions. In Chapter 1, we show that participation in health insurance increases the probability of meeting medical needs while decreasing the probability of incurring catastrophic out-of-pocket health payments in Ghana. Drawing on nationally representative survey data from India, Chapter 2 offers causal insight into the effect of female empowerment, in the form of marital age, on women’s utilization of cervical and breast screening. Our findings suggest that losses in female empowerment attributed to early marriage partly explain Indian women’s low cervical and breast screening participation. Aiming to contribute a better understanding of health utilization among hard-to-reach groups, Chapter 3 investigates the factors that determine the extent of thought given to screening in a sample of high-risk heavy smokers who attended the first free lung cancer screening program in Italy. We show that individuals with greater life-time smoking exposure, and therefore at higher risk of developing lung cancer, tend to contemplate screening less. Finally, Chapter 4 evaluates the cost-effectiveness of a population-based lung cancer screening program targeting high-risk prior and current heavy smokers (≥20 pack-years) aged between 55 and 74 years, in Italy. In doing so, we explore the economic relevance of programs designed with a view towards improving screening participation within hard-to-reach target populations. We offer evidence that rendering an annual LDCT-based screening – with three varying screening invitation strategies – available to the Italian heavy smoker population is more effective, yet more costly, than current clinical practice from the perspective of the national budget holder. Thus, in seeking to offer insight into the factors that encourage and challenge utilization, the conditions and channels that sustain it, and the design of programs that may, in turn, be sustained by it, this dissertation positions health utilization at centre stage.