The influence of social support on healthcare service use following transport-related musculoskeletal injury

Musculoskeletal injuries (MSI) are a major public health problem worldwide, contributing to a large burden of disability. According to the World Health Organisation’s Global Burden of Disease study, the majority of admissions for various non-fatal injuries as a result of a road traffic accident were MSI, with almost 50 % of these being fractures [1]. The burden of MSI is expected to become more significant in coming years with an ageing population and an increase in road traffic accidents in low and middle-income countries, largely due to the increased use of motorised transport and less developed trauma care systems [2]. Considering the probable increase in MSI, the provision of services by healthcare systems to improve health outcomes is crucial. Therefore, an understanding of what facilitates the use of healthcare services, and what influences individuals with MSI to behave differently in relation to their health is urgently needed.

Past studies have demonstrated that the decision to seek healthcare services is influenced by a number of factors including the individual’s health status, socio-demographic characteristics of the individual and their ability to access the type of resources they may need [3–5]. Social support has been identified as a potential factor that may either facilitate (i.e. increase uptake) or buffer (i.e. provide direct support) the uptake of healthcare services [6, 7]. Social support is defined as information leading individuals to believe they are cared for and loved, esteemed and valued, and belong to a network of communication and mutual obligation [8].

The evidence for the relationship between social support and healthcare service use among persons with MSI is limited. Much of what is currently known about social support and healthcare service use has been gathered from research conducted within the general population, older persons, and those with mental illness in which injury effects may be obscured [7, 9–15]. Among these populations, studies have shown mixed evidence for the role of social support on healthcare service use. A study suggests that social support is relatively unimportant when it comes to healthcare service use [9], whereas, other evidence suggests that social support can either enhance or reduce reliance on healthcare services [7, 10–15]. Several studies have also shown that the combination of stressful life events and social support has a modifying effect on healthcare service use [6, 16]; however, these results have not been replicated in all studies [12]. Variations in study populations, social support measures, availability of healthcare resources, and statistical analysis most likely account for these mixed results [7, 9–15]. Another possible reason is that the studies were not designed to explain how social support affects healthcare services utilisation. Thus, the mechanism through which social support influences healthcare service use remains unclear.

In this study, we adopt the Berecki-Gisolf et al. Healthcare Services Utilisation Framework [17] to explore the mechanisms through which social support influences healthcare service use in the MSI population. Berecki-Gisolf et al. proposed an adapted Andersen and Newman Framework of Healthcare Services Utilisation for a compensated population. In a compensated population, financial barriers to healthcare services are removed, under clauses set by the compensation system. In addition to the three factors proposed in the Andersen and Newman framework to explain healthcare service use: 1) predisposition factors (i.e. socio-cultural characteristics) 2) enabling factors (i.e. individual and community factors) and 3) need factors (i.e. health problems) [3], this extended framework proposes the additional following four factors to reflect the compensable context: 1) compensation system (i.e. scheme policies) 2) regulator (i.e. administrating body) 3) provider incentives and 4) individual incentives.

Figure 1 depicts the proposed conceptual framework. Based on this framework, the aims of the study are to investigate 1) the association between social support and healthcare service use (direct effect); 2) whether social support mediates the association between predisposing factors, need factors and healthcare service use (mediator); and 3) whether social support modifies the association between predisposing factors, need factors and healthcare service use (effect modifier).

The aim of this study was to address a gap in the literature through exploring the association between social support and healthcare services utilisation among people with compensable MSI. Understanding the mechanisms through which social support influences healthcare services utilisation can lead to the development of social support interventions and ultimately improve health outcomes. Using Berecki-Gisolf et al. adapted Andersen and Newman Framework of Healthcare Services Utilisation for a compensated population [17], the study explored whether social support (i) had a direct effect on healthcare service use, (ii) mediated the association between predisposing factors, need factors and healthcare service use, and (iii) interacted with various predisposing factors, need factors on healthcare service use. Finally, this paper examined whether these associations varied depended upon the source of support and the type of healthcare services involved. In support of the hypotheses, the findings indicated that social support was a direct factor related to healthcare services, and also an effect modifier, but contrary to the hypothesis, not a mediator. The findings suggest that the role of social support is complex and appears to vary depending on the source of support and the type of healthcare services accessed.

The results potentially suggested that individuals with greater social support make less use of healthcare services than to those with less support. This finding is inconsistent with past research conducted within the general population [7], older persons [13] and mental illness [14, 15] populations which found that individuals with greater social support were more likely to seek general medical services. We found that greater support from family and friends were associated with lower uptake of allied healthcare services. Greater support from friends was also associated with lower rate of allied healthcare services. Family relationships are the earliest and often the most enduring of social ties. Families also tend to provide a substantial amount of support in many areas of daily life following injury [28]. Similarly, friendships tend to grow stronger over long periods of time and are linked to positive physical and mental health outcomes [29]. Thereby, supportive relationships may reduce allied healthcare service use by providing direct support. Alternatively, the results may suggest that supportive relationships substitute for formal treatment or perhaps even delay help seeking behaviour.

Interestingly, we also found that no support from family and friends was associated with lower uptake of allied healthcare services. This is inconsistent with the literature which suggests that when support from family and friends are limited, people are more likely to access healthcare services provided by healthcare professionals [6, 11]. In our study, the absence of social support may have decreased access to healthcare services because there was a lack of health knowledge sharing among social network members and no provision of help from the social network to enable health care seeking behaviour. Alternatively, individuals with no support may have had difficulties in navigating the compensation system in order to access healthcare services. In a compensation system, requests for compensable treatment are mostly required to be approved by the insurer prior to commencement of the service. A qualitative study conducted by Murgatroyd et al. [30] showed that delayed treatment approvals and lack of consistent decision making between insurer and healthcare professionals resulted in dissatisfied participants. In our study, among those with no social support, 30 % had lower satisfaction with the TAC (data not shown). Those with no social support and lower satisfaction with the TAC were also more likely to have a high SEIFA. Given the timeliness of and access to healthcare services via the compensation system, it is possible that these results suggest that individuals with no support and high SEIFA sought healthcare services outside of the compensation system as there were reduced financial barriers. Further research is warranted to explain the relationship between lack of support and healthcare service use.

Furthermore, we found that greater support from friends, but not from family, were associated with lower uptake of mental healthcare services. The results suggest that support from friends reduces the need for mental healthcare services through providing another avenue for support. Research has shown that friends are associated with numerous mental health benefits [29]. For example, having a friend to confide in provides emotional support and contributes to a sense of belonging and overall well-being. This is consistent with past studies conducted in the general population which found that individuals with greater social support were less likely to seek mental healthcare services [7, 10, 12]. In contrast, we found no effect of family support on mental healthcare service use. A likely explanation for the differential effect is that individuals had a greater tendency to confide in friends than family. Past research suggests that family relationships tend to be more complex and viewed by individuals as ambivalent, that is, both closer and more troublesome than friendships [31].

We found that social support from family and friends did not mediate the relationship between predisposing factors, need factors and allied and mental healthcare services. This finding indicates that predisposing factors and need factors do not facilitate the use of healthcare services via social support. There is sparse research in this area, with the majority of research focusing on the role of social support in mediating stress and health outcomes [8, 32, 33]. Further research is needed to understand the precise nature of the relationship between predisposing factors, need factors, social support, and healthcare service use.

For mental healthcare service use, significant interaction effects emerged between family support and SEIFA. Individuals with no family support and a lower SEIFA were associated with a higher likelihood of consulting a mental health professional than those with a higher SEIFA. This finding suggests that in a no-fault compensable population, financial barriers to healthcare services are reduced, thereby allowing individuals with easy access to healthcare services regardless of socio-economic status and family support. This is inconsistent with past research examining solely SEIFA and healthcare service use. Some studies found that the uptake rates for psychological services decreased among people from more disadvantaged areas, compared to those from less disadvantaged areas [34, 35]. In contrast, a study conducted by Dal Grande et al. reported that the proportion of people who accessed psychiatry and psychological services did not vary by SEIFA [36]. However, these studies did not explicitly test for interaction effects of social support and SEIFA on the uptake of mental healthcare services. Further research is warranted to support the relationship between SEIFA, social support and mental healthcare service use.

Although this study provides greater insight into the role of social support and healthcare service use, several limitations of this study must be noted. By using an existing survey generated by the TAC, the study was restricted in its measures of social support. First, the social support measure was non-standardised and it is therefore not known if the items measured were what they were intended to measure. Second, the social support item was based on a single dimension of social support. There are several dimensions to social support including informational, tangible, appraisal and emotional support; thus, it is plausible that the type of support affects the use of healthcare services differently. Third, only the perception of social support was assessed. It is possible that the size of the participants’ social network, the pattern of interaction within the social networks, and the content of advice given by the social network members influences healthcare service use. Future research should investigate supportive exchanges between individuals and social network members in order to better understand how and when social network members either prevent or encourage the uptake of healthcare services. Fourth, we were unable to examine whether social support had an impact on healthcare service use outside of the compensation system, that is, services paid for by a private insurer, or services fully billed to Medicare, the Australian universal healthcare program [37]. Fifth, we recognised that the decision to engage with healthcare services is influenced by a variety of psychosocial and socio-economic factors including social support. Future research is required to determine which factors have the greatest impact on the use of healthcare services. Finally, the sample included in this study should not be considered to be representative of the population of individuals with MSI. All participants were injured in a transport accident within a jurisdiction that provides no-fault compensation for healthcare services. This relatively unique situation reduces financial barriers in accessing healthcare services. It also provides data that allows detailed examination of healthcare service use. The study is therefore unlikely to represent those cases of MSI without access to a similar compensation system (e.g. those incurring a MSI via sport, recreation or home). Furthermore, the extent to which these results are applicable to other jurisdictions will need to be considered given the various transport accident compensation schemes in Australia (i.e. hybrid, fault-based, no-fault). Future research is needed to determine the extent to which these findings can be generalised to other jurisdictions, non-compensable transport injury, and to injury that is not transport-related.

There are several implications arising from this study for the prevention, treatment and intervention of individuals with MSI. Regarding prevention, the findings suggest that individuals can cope better with MSI by drawing on the strength of their social support network and decreasing the need for healthcare services. Social support networks should therefore be protected, strengthened and mobilised as potential channels to provide health education and information to alleviate distress. Regarding treatment, these findings suggest that healthcare service providers could potentially engage appropriate individuals within one’s social network (e.g. spouse/friends) in the health treatment plan. Prior to the development of a health treatment plan, healthcare service providers could assess the abilities, assets and capacities of an individual’s social network including potential challenges in the required uptake of healthcare services. Regarding intervention, interventions could be developed and delivered to sustain support services, particularly for those with limited social support. In addition, healthcare service providers could direct intervention efforts toward helping individuals to develop skills that are needed to mobilise and maintain the individual’s existing social support network. They may also aid in the development of new networks such as patient support groups to promote optimal health service use for those without access to a social support network.

In summary, the findings of the current study highlight the importance of social support in accessing healthcare services following a MSI sustained in a transport accident. Although the results varied across sources of support and different types of services, the findings suggest that social support has a direct and modifying effect on healthcare service use. The findings do not suggest that social support mediates the association between predisposing factors, need factors and healthcare service use. This study contributes to the existing literature through clarifying the mechanisms of social support in healthcare service utilisation. The study findings have implications for the role of social support in the treatment and intervention of individuals with MSI.

ANZSCO, Australian and New Zealand Standard Classification of Occupations; CATI, computer automated telephone interview; COS, client outcomes survey; CRD, Compensation Research Database; IQR, interquartile ranges; IRR, incidence rate ratio; ISCRR, Institute for Safety, Compensation and Recovery Research; KHB, Karlson, Holme and Breen; MCS, mental component summary; MSI, musculoskeletal injuries; OR, odds ratio; PCS, physical component summary; SEIFA, socio-economic indexes for areas; SF-12V2, Short-Form-12 Health Survey Version 2; TAC, Transport Accident Commission; ZINB, zero-inflated negative binomial regression