This study estimated complex inequalities and horizontal inequities in primary and secondary health care utilization in Northern Sweden at the intersection of gender and education. The results illustrate the complexity and unique evidence arising from applying an intersectional perspective. First, we did not find robust evidence for any excess disparity of double (dis)advantage, but rather that the axes of gender and education were independently expressed in health care utilization disparities. Second, low-educated women utilized primary and secondary care considerably more frequently than men, but this inequality was largely (primary care) or completely (secondary care) explained by the greater health care needs of this doubly disadvantaged group. In contrast, high-educated women utilized primary – but not secondary - care to a greater degree than corresponding men, regardless of health care needs. Lastly, the moderately large utilization inequalities rooted in education were completely attributable to different health care needs, both for primary and secondary care. Taken together, the results paint a picture of primary and secondary care in Northern Sweden delivered according to needs when it comes to educational disparities, and with gender inequities disfavouring men remaining in primary care, but which appear equalized at entry to secondary health care.
One of the original tenets of intersectionality theory relates to the double jeopardy of multiple disadvantage - that “the intersectional experience is greater than the sum” (48). This notion has remained central in intersectionality-informed quantitative public health (31) and specifically operationalized in manners such as the excess intersectional disparity, originally defined by Jackson (38) as applied in this study. Whereas we found notable joint disparities observable throughout the analyses, they were not significantly different from the sum of the two referent disparities of gender and education, thereby not corroborating the double jeopardy hypothesis for these given outcomes and axes of inequality. It should be noted that the double jeopardy hypothesis indeed has been challenged as an oversimplified model, with conflicting empirical support (49) and critique for a simplified focus on “extreme groups” in any given intersectional space (35).
Nevertheless, our results unequivocally demonstrate that the doubly disadvantaged group of low educated women indeed report generally poor health and higher need of health care, and that this manifest disadvantage did not completely explain their high primary care usage (seen in the joint inequity). Despite their quite distinct structural position, health profile, and lower crude utilization of health care, even higher primary care utilization given equal needs was reported by high-educated women (as seen in the referent gender inequity). In our results gender thus had a profound effect in shaping health care utilization, particularly at the primary care level, which is consistent with other studies that reported higher utilization of health care amongst women as compared to men (50–54). The share of primary health care utilization not attributable to care needs among low- and high-educated women could possibly be explained by unobserved health care needs specifically relevant to women, such as maternity, gynaecological care and other aspects of women’s health. However, the inequalities could also be explained by the impact of lower health care seeking behavior amongst men as compared to women, e.g. comparable to the previously reported difficulties to reach and engage Northern Swedish men for health promotion (55). In this sense, despite their socially advantaged position, men are disadvantaged from seeking health care due to masculinity norms, which may portray them as weak if they seek health care even if they are in need (50). On the other hand, one can also construe this observation as women using health seeking behaviors to successfully leverage the structural disadvantages of gender and low education, and resultantly partly compensate for their poor health.
The absence of horizontal inequities in specialist visits across all the four intersectional categories is in stark contrast to the substantial joint and referent gender inequities in general practitioner utilization. The comparatively equitable use of specialist visits could be reflective of the underlying forces that determine usage at each level of the Swedish health care system. As access to specialist doctors is mostly based on referrals from the primary health care level, this pattern may be indicative of greater equity within the health care system itself. Specifically, the access to primary health care is contingent on women or men’s differential health seeking behaviour as discussed above, but when inside the system, both men and women end up accessing specialists more equally because the decision lies with the primary health care doctors responsible for referrals. In this sense, our results could reflect an equalizing effect of referral in the health care system in Northern Sweden that is linking those with greater health care needs at the primary level to specialist care. Another possible explanation could be that when faced with more serious health needs that require specialist care, men may not be negatively influenced by masculinity norms which otherwise may refrain them from seeking care.
The results showed no education-related intersectional inequities in accessing primary or secondary health care in Northern Sweden. This adds to previous studies on simple, non-intersectional, socioeconomic inequities in health care utilization from the same context, including small horizontal inequities in general practitioner visits, no inequities in specialist visit usage or hospitalizations (7), and among young adults, large income-related but no education-related inequities in youth clinics utilization (5,7). While we indeed found large educational inequalities in both health and health care usage, they were in proportion to each other; i.e. health care utilization was commensurate to need, as posited by the principle of horizontal equity. The Swedish health care system is considered progressive and traditionally framed around the Beveridge model of health care financing, where health care is financed by general taxation thus promoting universal health access. Even though there has been a successively increased market-orientation and privatization of Swedish primary health care that may impact negatively on health care equity (3), Northern Sweden has been a region less affected by these developments (56). We conclude that health care at the primary health care level was utilized according to needs amongst intersectional groups of different educational level in this study. This finding could reflect the inherent impact of universal health coverage mitigating classism in the health system.
Although this study proposes a refinement to existing quantitative methods in assessing intersectionality in health care, we have noted some limitations that should be considered. Firstly, our method proposes adjusting for health care needs to assess horizontal (in)equity, and consequently, there is a risk of underestimation of health care needs as it is theoretically impossible to capture all health care needs. For instance, and as noted above, we could not provide adjustments for women’s health needs such as maternal health care needs, gynaecological requirements or other women reproductive health needs, as this information was not available in the survey data. Nevertheless, we tried to capture several facets of health care needs that have also been applied in previous literature (5–7). Secondly, although the response rate was 49%, we could not establish the demographic and social characteristics of the non-respondents and this may introduce some selection bias into our study. The response rate nonetheless is comparable to most studies conducted in the same setting with reliable results. Finally, we cannot draw any causal inferences from our study as our data was collected from a cross-sectional survey