Determinants influencing the use of non-reimbursed services among mothers of infants

INTRODUCTION

In recent years, the market for medical services in Poland has been undergoing a dynamic transformation, characterised by intensive commercialisation and a growing share of the private sector [1]. According to reports by the Centre for Public Opinion Research and the Central Statistical Office, in 2023, 35% of Poles had additional private health insurance and 40.4% reported using private medical services [2, 3].
According to the applicable law in Poland, every citizen has the right to healthcare and equal access to publicly funded health services, provided they have mandatory health insurance. These services are also available to certain uninsured persons, including all women during pregnancy, childbirth and postpartum, children under the age of 18, and individuals with refugee status [4].
Despite the widespread availability of reimbursed services, an increasing number of patients are opting for services offered by private facilities. This growth is particularly evident among young mothers who, driven by concern for their children’s health, seek alternative, often more individualised and accessible forms of medical care, sometimes prioritising their child’s healthcare needs over their own [5]. This trend is observed not only in Poland, but also globally. For example, in Finland approximately 40% of children have private health insurance, with children under the age of three constituting the largest group utilizing private medical services [6].
During early motherhood, women are particularly sensitive to their children’s healthcare needs. The first weeks and months of a child’s life are crucial for proper development, making the decisions during this period highly impactful on their child’s health and future growth [7]. Parents are aware of their responsibility for the child’s health and development, leading them to seek additional specialist consultations – not only medical, but also physiotherapy, neurologopedia and osteopathy. Some decisions regarding the use of non-reimbursed medical services are made even before birth. One such example is the banking of stem cells obtained from fetal umbilical cord blood, which can be used in the future to treat the child’s hematopoietic system diseases [8]. A particularly popular yet controversial service is the recommended vaccinations included in the National Immunization Programme [9].
Awareness of the risks associated with infectious diseases may encourage mothers to ensure the highest level of protection for their child [10].
The sense of responsibility leads parents to seek the best possible solutions, leading to an increased demand for services that are not public funding. It is worth noting that healthcare providers are aware of this trend and often offer a wide range of specialised services that appeal not only to rational healthcare needs, but also to the emotions and concerns related to childcare. Marketing strategies in this area frequently emphasise a higher level of comfort, a personalised approach to patients, and reduced waiting times for appointments, which contribute to a more favourable perception of the private sector and its advantage over the public sector [11, 12]. Modern medical equipment and the accessibility of facilities create a positive company image, which builds trust among patients and may encourage mothers to seek additional services for their children [12, 13].
The aim of this study is to identify the factors that determine mothers’ decisions to use non-reimbursed medical services for their infants. Specifically, this research will focus on analysing the sociodemographic and psychological determinants of these decisions, such as education level, income, access to information, prenatal education and health anxiety, which may also extend to concerns about the child’s health. Additionally, another objective is to understand how emotional factors and subjective perceptions influence the perceived quality of medical services and the willingness to incur additional costs to ensure optimal healthcare for their child.
In the context of the increasing commercialisation of medical services in Poland, this study holds significant value from a theoretical and practical perspective. Understanding the motivations behind mothers’ decisions can not only contribute to better adjustment of medical service offerings, but also to the optimisation of health policies aimed at this specific group of patients.

MATERIAL AND METHODS

STUDY DESIGN AND PARTICIPANTS

This study was a quantitative, cross-sectional observational study, conducted among 243 mothers of children aged 6 to 18 months via online platforms. The research was carried out in accordance with the principles of the World Medical Association’s Declaration of Helsinki and was approved by the Bioethics Committee of the Medical University of Gdansk (no. NKBBN/429/2024).

INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria included women aged 18-50 years, who had a child aged 6-18 months, had opted for additional non-reimbursed healthcare services for their child, and provided informed consent for participation in the study. Exclusion criteria included mothers under the age of 18 and woman who had not chosen to utilize paid healthcare services for their children.
The fathers of the children were not invited to participate in the study, due to the intention to analyse the results based on obstetric variables such as the number of pregnancies, deliveries, miscarriages and stillbirths.

SETTING

The research was conducted using the Computer Assisted Web Interview (CAWI) method, due to its extensive reach and ease of access to respondents. Through web portals dedicated to parents of young children, thematic discussion forums, support groups for mothers of infants and social media platforms, participants were provided with a unique web link containing an anonymous questionnaire. This approach enabled mothers from various regions of the country to participate, ensuring the collection of reliable and diverse data. Data collection took place from October to December 2024.

DATA COLLECTION TOOLS

Data from respondents were collected using a diagnostic survey, consisting of two parts:
I. Author’s survey questionnaire
The first part of the questionnaire contained 23 closed and open-ended questions addressing sociodemographic data, such as the woman’s age, education and economic status, obstetric history, prenatal education received, and information about the health services chosen for the child.
II. Health Anxiety Inventory (SHAI)
The second part of the questionnaire is a Polish adaptation of the SHAI questionnaire by Janusz Kocjan [14]. This tool is used to assess the patient’s level of health anxiety, based on their feelings over the past 6 months. This questionnaire contains 18 questions rated on a 4-point Likert scale and consists of two components.
The first component includes 14 questions evaluating the patient’s attitudes towards health, including fear of illness. These questions assess concerns about falling ill and a tendency to overreact to symptoms of illness.
The second component consists of 4 questions examining the patient’s attitudes in the event of a serious illness (e.g. heart disease or cancer). Respondents are asked to determine their likely reactions, based on their self-knowledge and understanding of severe diseases. Higher scores indicate greater health-related anxiety and stronger beliefs about the negative consequences of the disease [14, 15].
The reliability of the health anxiety assessment tool was evaluated using Cronbach’s alpha coefficient (α_C). The results demonstrated a satisfactory level of measurement accuracy for health anxiety in the present study (α_C = 0.85).

VARIABLES AND OUTCOME MEASURES

In this study, the independent variables included:
• sociodemographic factors – age, place of residence, level of education, economic situation,
• obstetric factors – the number of previous pregnancies, births, miscarriages and stillbirths,
• clinical condition – the woman’s current chronic diseases, genetic/congenital defects occurring in her children,
• participation in prenatal education,
• health anxiety, measured through the SHAI questionnaire.
In turn, the dependent variables included women’s responses regarding the choice of non-reimbursed medical services for their children.

STATISTICAL ANALYSIS

The results were processed using Statistica 13.3 software. An alpha level of 0.05 was selected for all analyses. To answer the research questions, it was decided to use linear regression models. In presenting the results, we provide de-tailed models that integrate partial models into a unified framework. In some of the analyses, response frequency analysis was also additionally used for qualitative questions.

RESULTS

The study sample consisted of 243 women aged between 18 to 50 years (M = 31.29, SD = 5.34). All variables used in the study and analysis were described in the sample assessment. The Table 1 summarises the sample description.
Assessing the results, it can be observed that women from rural areas constituted nearly 25%, indicating that the remaining participants identified various urban areas as their place of residence. The vast majority of women in the study had higher education. Over 76% of the women reported their financial situation as good or very good. Further-more, 51% and 64% of the women indicated that this was their first pregnancy and first birth. Additionally, 30% of participants reported previous problems issues related to miscarriage or stillbirth. In terms of clinical variables, it is noteworthy that 55% of the respondents reported chronic illnesses of various types. The study also included 7% of women who reported having given birth to a child with a congenital or genetic defect. A basic childbirth preparation course (group) was reported by 69% of the women, while only 36% of the women attended an individual course. The health anxiety variable was also an important factor in the study. The Figure 1 presents the distribution of the health anxiety score in the study sample.
Health anxiety scores ranged from 3 to 43 points (M = 14.79, SD = 6.43). Upon evaluating the distribution of health anxiety in the sample, asymmetry in the results can be observed (SKE = 0.88). The skewness score, as well as the figure itself, presents a right-skewed distribution indicating a higher number of low scores compared to high scores. In this study, high (maximum) scores were notably less frequent than low scores. The kurtosis score (K = 1.89) also suggests a high concentration of results around the mean, leading to the conclusion of lower variability in the scores. Health anxiety scores will also be used in further data analysis.
The first area of analysis was identifying the reasons for the decision to opt for non-reimbursed medical services after childbirth. The Figure 2 presents the responses of the participants for this area.
Over 40% of the surveyed women indicated the desire for additional diagnostics, despite the absence of medical indications, and long waiting times for reimbursed services as reasons for choosing non-reimbursed medical services for their child. The expansion of diagnostics due to the suspicion of a medical issue was the third most common reason. It is noteworthy that a significant number of responses also highlighted the lack of certain reimbursed services.
To answer the research questions regarded the relationship and the potential prediction of the level of usage of non-reimbursed services after childbirth, a series of linear regression analyses were prepared. The predictor variable was the level of usage of non-reimbursed services, with the predictors in the detailed models being the groups of variables highlighted in the study. A summary of the detailed regression analyses is presented in the Table 2. The results showed that the models with predictors from the groups of variables related to maternity, clinical varia-bles and health anxiety were not well fitted to the data. These models were unable to explain the variability in the level of non-reimbursed medical services after childbirth, and the identified predictor groups in these models were not sig-nificantly associated with the level of services.
The models using sociodemographic and prenatal education variables were well fitted to the data and explained 15% and 7% of the variability in the level of choice of non-reimbursed services after the childbirth, respectively. In the sociodemographic variable model, material status was found to be significantly correlated with the choice of services. The associations were moderate for education and weak for material status. As educational level and material status increased, the level of choice for non-reimbursed medical services after childbirth also increased. In the model with variables related to education, participation in prenatal group education was weakly correlated with the choice of non-reimbursed services.
The next step in predicting the selection of unreimbursed services was an attempt to build a general model. Multiple regressions were used with both entry and selection methods. The Table 3 summarises the multivariate analyses conducted.
The first model, which included all variables, was well fitted to the data and explained 17% of the variability in the choice of non-reimbursed services. In this model, education, economic status and participation in group prenatal education were identified as significant predictors. It is worth noting that these predictors were the only ones that were significant in their respective detailed models presented above. Higher levels of education and economic status were associated with a greater choice of unreimbursed services. Similarly, attendance at prenatal classes was also associated with a higher choice of such medical services. In the second model presented, variable selection was performed. This model was also well fitted to the data and explained 19% of the variability in the choice of non-reimbursed medical services after the childbirth. In this model, education, economic status and group prenatal education were significant predictors.
It can be observed that, both in the detailed and multiple models, the level of education, economic status, and participation in prenatal education were associated with the level of choice of non-reimbursed medical services after childbirth. The other variables were not significant in predicting the level of choice of these medical services.

DISCUSSION

The results obtained in the conducted study highlighted the complexity of the issue regarding the factors guiding mothers of children aged 6-18 months in their choice of non-reimbursed medical services. Based on the results, it is not possible to make statistical generalisations about what guides mothers in the process of selecting additional services for their children.
Our results indicate that the use of private healthcare services is significantly more common among women with higher economic status – as many as 76.54% of the respondents reported their material situation as good or very good. This may suggest the existence of significant inequalities in access to additional diagnostics, stemming from financial barriers [2, 16-18]. Women with lower economic status may forego additional testing, even if their children need it, which could lead to delays in diagnosis and implementation of appropriate interventions [5]. However, it is worth noting that Poland has various financial support programmes for families, such as the 800+ child benefit, newborn allowance and parental benefit, which theoretically could reduce economic barriers to accessing private healthcare services. The available data do not provide conclusive information regarding whether funds from social programmes are allocated for private healthcare services [19]. However, studies from 2018 show that 57% of Poles used private medical ser-vices, financing them either independently or through additional health insurance. This most often concerned dental services (43%) and visits to specialists (29%) [20]. Further analysis is necessary to access the impact of social benefits on decisions regarding the use of private medical services.
The analysis of the responses indicates a significant correlation between the level of education and the propensity to use additional medical services. The vast majority of respondents (80.2%) had higher education, which may suggest that women with higher education levels possess better health education and a greater awareness of the importance of health preventive. This could translate into a more proactive approach to protecting their children’s health, thereby leading to more frequent use of additional diagnostics and specialist consultations. Our results are consistent with previous studies indicating that people with higher socioeconomic status have higher expectations regarding the quality and accessibility of medical services [21]. Moreover, higher education is often associated with a better orientation in the healthcare system and an increased ability to make informed decisions regarding medical care. However, the effect of education on the use of private medical services may also be associated with other factors, such as income level or the availability of public healthcare services. Therefore, further research should focus on analysing these relationships within a broader socio-economic context.
Antenatal education also plays an important role in health awareness. Participation in group and individual classes preparing for motherhood was reported by 69.14% and 36.21% of women, respectively. The responses suggest that some of them participated in both forms of training. These results indicate that prenatal education is an important source of knowledge about available medical services, including recommended vaccinations, which may influence a greater willingness to utilize additional medical services. In Poland, prenatal education is largely provided by mid-wives, emphasizing their crucial role in shaping health-promoting attitudes among pregnant women. The high quality and comprehensiveness of the information provided can contribute to more informed decisions regarding the choice of medical services, both in the public and private sectors. The results of this study indicate the need to further strengthen educational programmes, which could increase women’s health awareness and thus influence their decisions regarding perinatal care [22].
A surprising finding was the lack of correlation between the choice to pursue additional tests and specialist consultations for children, and women with chronic illnesses, as well as mothers who had previously given birth to a child with a genetic or congenital defect or had experienced miscarriage or stillbirth. Research in this area suggests that this may be a significant predictor; e.g., parents who have experienced reproductive loss may develop a ‘protected child syndrome’, where they become overprotective of their child, justifying their behaviour with the desire to protect their child from potential diseases and risks [23, 24]. The results may be due to the fact that individuals who experienced abnormalities were fully cared for within the healthcare system, and therefore additional services were not necessary. Another reason may be that women with chronic diseases were under strict obstetric and paediatric supervision, which provided them with more comprehensive and frequent access to reliable information, allowing them to consult whether additional interventions were necessary.
One hypothesis proposed that women with higher levels of health anxiety are more likely to opt for additional ser-vices for their child. However, the hypothesis was not confirmed in the study, despite the fact that health anxiety is often associated with excessive concern about the health of the child as well [25]. This may suggest an attitude in which women prioritise their child’s health over their own. It is worth noting, however, that the study focused exclusively on mothers, suggesting the need for further research to include attitudes and levels of anxiety among fathers of children, which would make the study more objective.
The current healthcare system in Poland, funded through public resources, provides the same package of services for every child. However, in practice, children’s needs are diverse and sometimes require in-depth diagnostics in various areas, which is not necessarily reimbursed [26]. 35.54% of the respondents decided to pursue additional diagnostics, while 44.63% decided to undergo such procedures despite the lack of indications for them. This may reflect a desire to verify and confirm that the child’s development is going well. The level of expectations among mothers also varies, which can create additional pressure to seek private medical care.
A significant issue with the public healthcare system is its overall efficiency – nearly half of the respondents (42.98%) reported unacceptably long waiting times for specific services, which translates into a shift away from the public sector and a migration towards private healthcare providers. The length of waiting lists is influenced not only by increased demand for a particular service, but also by the insufficient number of specialists in certain fields, a challenge that the public sector has been facing for years [27]. Furthermore, the lack of availability of certain services within the services guaranteed by the National Health Fund, reported by 34.3% of mothers, undermines the quality and effective-ness of the system, ultimately forcing mothers to seek paid alternatives.
In conclusion, the results of the study highlight the multifactorial determinants of mothers’ decision to use non-reimbursed medical services for their young children. Further research in this area could have significant implications for health policy. By understanding the needs and expectations of mothers, it may contribute to optimising the quality of care for the Polish population. If no action is taken, the consequence could be a decline in public trust in institutions such as the National Health Fund, potentially intensifying the migration of patients to the private sector.

LIMITATIONS

One of the limitations of our study is the over-representation of women with higher education in our sample. In recent years, according to the Central Statistical Office, there has been a systematic increase in the level of education, particularly among women, making this group more representative in most studies. Furthermore, recent reports indicate a dynamic increase in the number of people with higher education in Poland, by more than 30%. In practice, this means that women with higher education are more likely to share their problems, which is a positive development. However, an additional challenge arises for health professionals from this: the need to establish deeper communication with women belonging to diverse demographic groups [28, 29].
Due to the small sample size of patients following a miscarriage or stillbirth, it was not possible to conduct an analysis confirming that women in this group are more likely to choose non-reimbursed medical services for their subsequent children. This points to the need for further research to confirm this hypothesis, focusing on women who have experienced reproductive loss.
Additionally, as discussed in the discussion, an important aspect in future studies is to include the perspectives of fathers, as they also play a role in making healthcare decisions for their children.

CONCLUSIONS

The survey highlighted the commercialisation and increased involvement of the private sector in healthcare ser-vices, particularly among mothers of young children. A possible reason for this phenomenon is the insufficient package of healthcare services provided to young children offered by the National Health Fund. This is evidenced by the fact that young mothers most frequently opt for additional testing and service packages to ensure that their child’s development is progressing correctly – deepening diagnostics even in the absence of indications. The decision to seek additional healthcare services is also strongly correlated with the level of education and participation in prenatal education pro-grammes by mothers. This phenomenon emphasizes the important role of education in people’s lives, which translates into an awareness of not only their own health needs but also those of their offspring, motivating mothers to pursue further diagnostics and ensure the proper development of their children in multiple areas. Health anxiety did not im-pact the frequency of choosing services outside the reimbursed benefit package, as shown by the SHAI tool – the results indicated that mothers exhibited low health anxiety, suggesting that they prioritize their child’s health over their own.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Medical University of Gdansk (Approval No. NKBBN/429/2024).
The authors declare no conflict of interest.

References