# Health Care Utilisation and Attitudes towards Health Care in Subjects Reporting Environmental Annoyance from Electricity and Chemicals

Authors: Frida Eek; Juan Merlo; Ulf Gerdtham; Thor Lithman
Journal: Journal of Environmental and Public Health
 (2009)

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## Abstract

Environmentally intolerant persons report decreased self-rated health and daily functioning. However, it remains unclear whether this condition also results in increased health care costs. The aim of this study was to describe the health care consumption and attitudes towards health care in subjects presenting subjective environmental annoyance in relation to the general population, as well as to a group with a well-known disorder as treated hypertension (HT).Methods. Postal questionnaire
(n = 13 604) and record linkage with population-based register on health care costs. Results. Despite significantly lower subjective well being and health than both the general population and HT group, the environmentally annoyed subjects had lower health care costs than the hypertension group. In contrast to the hypertension group, the environmentally annoyed subjects expressed more negative attitudes toward the health care than the general population. Conclusions. Despite their impaired subjective health and functional capacity, health care utilisation costs were not much increased for the environmentally annoyed group. This may partly depend on negative attitudes towards the health care in this group.


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## Body

## 1. Introduction

Through the years several so-called “modern diagnoses”
have succeeded each other. Subjective health complaints attributed to the
pressure of “modern life” have been described in the medical literature since
the 19th century [1]. The similarities between
these different syndromes have often been larger than the differences. The most
obvious difference between the syndromes has been the attribution of the
symptoms.Even
though some of the diagnoses have some specific components, most of the
symptoms are shared among almost all of these conditions [2]. Another similarity is that
there are no objective medical tests to confirm these diagnoses; instead, the
diagnoses are based on reporting of symptoms [3–6]. There have been many suggestions for a common term
for these syndromes, but as yet no agreement has been reached regarding a
suitable term. “Medically unexplained symptoms (MUSs),” “unexplained clinical
conditions,” “functional somatic syndromes,” “somatisation” and “subjective
health complaints,” “somatoform disorders,” “fashionable diagnoses,”
“functional symptoms,” and “chronic multisymptom illness” are some of the terms
that have been used to describe the condition of somatic complaints not
explained by any known somatic disease. The present study focuses on one form of
the so-called medically unexplained symptoms (MUSs), namely symptoms or
annoyance related to electricity and/or chemicals and smells—environmental
illness or intolerance. When the concern about illness attributed to
electricity was first raised, the terms “electric allergy” and
“hypersensitivity to electricity” were commonly used. Use of these terms is not
recommended; however, since they imply an established aversive physiological
effect of EMFs. No such effects have yet been proven [7], which is why the terms
should preferably not be used. “Sensitivity to electricity” is another
frequently used term. Since it does not directly imply allergic or
“hypersensitivity” reactions, it is at least a little more appropriate. This
term could be viewed as a correlate to the more established term “multiple
chemical sensitivity (MCS)”. However, during the years other terms that
probably better describe the phenomenon in question have been suggested. In
1996, the term “idiopathic environmental intolerance (IEI)” was suggested to
replace “MCS” [8]. “Idiopathic environmental
intolerance” covers subjective illness attributed to a variety of environmental
factors normally tolerated by the majority of people. Moreover, the symptoms
should not be explained by any known medical or psychiatric disorder [8–11]. This term is preferable, since it does not make any
unsupported judgement about the cause of the symptoms or illness [10]. In 2004, it was added that
the term IEI
should not be used as a medical diagnosis, because of the lack of scientific
basis to link the IEI symptoms to EMF exposure [12]. The term “IEI” includes both
MCS and sensitivity to electricity [11].The present paper examines a
somewhat less pronounced form of IEI, which we call “environmental annoyance”.  Such annoyance from environmental factors
(i.e., “visual display units,” “fluorescent tube light,” “other electrical
equipment,” “chemicals” and “other smells”) has been found to be rather common
in the population. A previous study showed that 28% of a Swedish population
reported that they had been a little annoyed, and 6% much annoyed, by at least
one of these environmental factors during the past two weeks [13]. Subjects reporting annoyance from environmental factors were found
among most groups in society, but it was more common among women, immigrants,
unemployed, disability pensioners, and students. Environmentally annoyed
subjects presented low self rated health, and difficulties to perform every-day
duties. Subjects experiencing annoyance from both electrical and chemical factors (2–4%) was found to be the most
affected  regarding subjective health and
functioning, and also experienced higher degree of every day stress and subjective
health complaints [13–15]. Apart from these studies,
“environmentally annoyed”   populations
(by this definition) have not been studied much so far. In contrast,
symptomatic IEI patients have been found to be more anxious, stressed, and
depressed than people without IEI [16].Health care utilisation in subjects suffering from
environmental intolerance related to electrical factors has scarcely been
examined [17, 18]. However, military
personnel reporting ideopatic environmental intolerance (IEI)/multiple chemical
intolerance (MCS) had higher out-patient rates of physician visits, emergency
ward visits, and in-patient hospital stays than did military personnel without
IEI/MCS [19]. One study showed an average of 23 health care visits per year for
IEI subjects [20]. McGlone et al. [21] found increased health care utilisation in 24 persons reporting
environmental illness, compared with 48 controls. In another study, among
subjects reporting hypersensitivity to common chemicals 45% reported that they
had received medical treatment [22]. However, the study revealed neither what kind of medical treatment
was used, nor the extent of the treatments. A study of 917 MCS subjects
revealed that the participants had consulted a mean of twelve health care
providers [23]. By contrast, only a few of subjects experiencing symptoms in
connection with mobile telephone use reported that they had consulted a
physician or been on sick leave because of the symptoms [18]. These two studies were based on self-reports on health care and
treatments. A study examining psychiatric symptoms and medical utilisation in
primary care patients revealed that patients identified as depressed and/or
anxious, that is,  presenting symptoms that have been associated also with
IEI-patients, reported significantly increased medical utilisation compared
with patients without depression or anxiety. However, this was not confirmed by
the hospital’s computerised record system, which revealed no significant
differences between the groups with and without depression or anxiety [24]. These results indicate that self-reports of health care
utilisation may not always be reliable, especially when examining subjects who
may be depressed or anxious.MUS and somatisation have been associated with increased
health care utilisation [25–32]. MUS
have also been associated with frequent primary care seeking [27, 33]. “Modern health worries”
have been found to be associated with medical care utilisation, mainly with
alternative health practitioners [34].Patients with MUS have been
experienced as difficult to manage by general practitioners [35], which may impair the relation between doctor and patient, and
originate feelings of frustration for the general practitioner [36]. Patients with medically unexplained symptoms have also reported
frustrating experiences of their contact with doctors [37, 38]. The
question as to what causes environmental annoyance is quite controversial, and
the opinion of patients and doctors may be divergent, which may contribute to the reluctance to seek and give medical care.
There may be reasons to believe that meeting patients expressing annoyance from
electricity and smells may give rise to negative experiences not only for the
doctor but also for the patient. These aspects might condition a reduced access
to health care resources for these patients. The question that rises is how subjects annoyed by
electricity and chemicals utilize the medical care system. Do they get medical
care or treatment for their problems? Since these subjects present decreased
self-rated health, in combination with the facts that MUS in general have been
associated with increased health care utilisation, it might exist a  preconception that these subjects also
originate high health care costs.


### 1.1. Aims

The aim of this study was on the one
hand to describe health, health care consumption, and
subjective experience of health care in subjects annoyed by both electricity
and smells and, on the other,  to rank
this group in relation to the general population, and a group with a well-known
disorder as treated hypertension.


## 1.1. Aims

The aim of this study was on the one
hand to describe health, health care consumption, and
subjective experience of health care in subjects annoyed by both electricity
and smells and, on the other,  to rank
this group in relation to the general population, and a group with a well-known
disorder as treated hypertension.


## 2. Methods

### 2.1. Participants

The Health Survey Scania 2000
(HSS-2000) was a postal self-administered questionnaire sent out between
November 1999 and April 2000 to a random sample of 23 437 individuals born from
1919 to 1981 living in Scania. In total, 13 604 subjects (58%) participated.
The 13 604 respondents have been compared with the entire population in
same ages in Scania (n = 850 476) and found to be fairly representative regarding
age, gender, and health care utilisation [39].The Ethical Committee at the
Medical Faculty of Lund University approved (LU 179-99) the study proposal of
The HSS-2000, and all of the participants received written information about
the survey.


### 2.2. Subject Grouping

Five
questions regarding environmental annoyance were included in the survey, to
assess the prevalence of annoyance related to electrical and chemical factors
in the population. These questions read: “Did you during the past 14 days
experience annoyance that you associate with (1)
fluorescent tube lighting/(2) visual display units/(3) other electrical
equipment/(4) breathing air that smells of chemicals/(5) other smells and
if so, how much annoyance did that cause you?”  with possible responses “No,”
“Yes, some” or “Yes, very much”. In this study, we
chose to focus on the subjects who reported annoyance from both any electrical
factor and chemicals or smells, at least one of the factors as being much
annoying (n = 315).Treated hypertension (n =  1373) was
defined as use of antihypertensive medication, based on an affirmative answer
to the question “Have you during the last year used medicine, which was bought
at the pharmacy…?”… “For the treatment of high blood pressure”.Subjects in the electrical and
chemical annoyed group who were also treated for hypertension (n = 20), were
excluded from the analyses, as well as subjects who did not leave information
on neither HT medication nor environmental annoyance (n = 29). The final number
of subjects in each group is presented in Table 1.Table 1
Characteristics of the population in relation to
environmental annoyance and treatment of hypertension.
Electrical and
chemical annoyanceTreated
hypertensionRef.Number of
subjects295135311907Mean age436447Women (%)665354Cost  > 0 SEK
(%)849677Having been in
need of, but not491720having sought, medical care (%)Medical staff
neglected2547my wishes/needs (%)Not treated with
respect613from doctor on last visit (%)Mostly negative
experience (%)1946Use of
alternative medication (%)493328General Health
Questionnaire2.26 (2.22–2.31)2.01 (1.98–2.03)1.95 (1.94–1.95)mean(a) score  (95% CI)Self-rated
health score,4.13 (3.98–4.29)4.83 (4.76–4.91)5.16 (5.13–5.18)mean(a) (95% CI) SEKMean total cost
(95%6 658 (3 182–10
134)14 424
(12 807–16 040)7 890 (7 346–8 435)Confidence Interval) SEKMean(a) total cost7 888 (4 417–11 358)11 698 (10 024–13 372)8 216 (7 664–8 767)(95% Confidence Interval) SEKMedian total
cost SEK251943291628Mean(a) GP cost1371 (1195–1546)1594 (1510–1679)963 (935–991)(95% Confidence Interval)Median GP cost
SEK7901 185395Mean(a) (95% CI)1.9 (1.6–2.1)2.4 (2.3–2.5)1.4 (1.4–1.5)number of visits to GP(a)Age and gender adjusted.


### 2.3. Outcome Measures

#### 2.3.1. Health Care Utilisation

Health
care utilisation was the main outcome measure in our study, and it was approximated
by information on number of visits to general practitioners and direct health
care costs in SEK. This information was provided to us by the
health authorities in the county which calculated it following the same
standard procedures all over the county [40].A ten-digit civic
registration, assigned to each individual in Sweden for their lifetime, is recorded at the county of Scania
in the Patient Administrative System (PASIS) for public care and PRIVA for
private care, and also in the Health Survey 2000, and was used for record
linkage. The Regional Office at the Scania County Council did the tabulation
preserving the anonymity of the subjects. Health care costs were related to
health care visits for the year 1999. The total cost for each nursing ward,
clinic, and hospital was broken down into individual in-patient nursing contact.
The Diagnosis-Related Groups (DRG) system is currently used in many countries
as a proxy for the cost of in-patient care [41].
When the actual cost for each visit was unknown, DRG codes were used to
calculate costs for each visit. Visits that had no DRG code were given the mean
amount of DRG points for the clinic. If the clinic did not use DRG codes, the
cost was divided among days when medical care was provided.  Out-patient
costs were calculated directly through a Patient Cost System, where every
contact received a specific cost for the actual use of resources. The costs
included correspond to what in health economics is referred to as direct costs
(i.e., out-patient and in-patient care including surgery, intensive care,
diagnostic services,  and drugs). Cost of drugs included concerned only what was
consumed by the patients during in-patient care. Costs of drugs in out-patient
care are not available on the specific patient level.


#### 2.3.2. Additional Variables and Outcome Measures

The survey also included among other
items, information on self-reported health (SRH-7) [42], mental well-being (General Health Questionnaire [GHQ-12], [43]), medication use including alternative medication, and
experiences  of the health care system,
later dichotomized with the negative response as outcome; such as “do you
consider yourself having been in need of, but not sought, medical care” (i.e.,
“unsatisfied health care needs”),  “Was
the medical staff open to your wishes/needs” (i.e., “neglected health care
needs”),  “Did the doctor treat you with
kindness and respect on your latest visit” (i.e., “nonrespected health care
needs”), and “What is your experience of the health care in your local
authority” (i.e., “mostly negative experience of health care”).


### 2.4. Statistical Analysis

For statistical analysis, the SPSS
computer software version 11.0 was used. Odds ratios (ORs) and 95% confidence
intervals (95% CI) were estimated by use of conditional logistic regression
adjusting for age and gender. Means of health care utilisation costs, number of
visits, and subjective well-being, were calculated through univariate analysis
of variance (ANOVA). Since the cost data was not normally distributed, the
Kruskal WallisH-test was used to test the null hypothesis of nondifferences
in health-care consumption costs between groups. Pairwise comparisons between
groups were performed through the Mann-Whitney U-test.  A P-value below  .05 was
considered statistically significant. Mean costs and 95% confidence intervals
are also presented.


## 2.1. Participants

The Health Survey Scania 2000
(HSS-2000) was a postal self-administered questionnaire sent out between
November 1999 and April 2000 to a random sample of 23 437 individuals born from
1919 to 1981 living in Scania. In total, 13 604 subjects (58%) participated.
The 13 604 respondents have been compared with the entire population in
same ages in Scania (n = 850 476) and found to be fairly representative regarding
age, gender, and health care utilisation [39].The Ethical Committee at the
Medical Faculty of Lund University approved (LU 179-99) the study proposal of
The HSS-2000, and all of the participants received written information about
the survey.


## 2.2. Subject Grouping

Five
questions regarding environmental annoyance were included in the survey, to
assess the prevalence of annoyance related to electrical and chemical factors
in the population. These questions read: “Did you during the past 14 days
experience annoyance that you associate with (1)
fluorescent tube lighting/(2) visual display units/(3) other electrical
equipment/(4) breathing air that smells of chemicals/(5) other smells and
if so, how much annoyance did that cause you?”  with possible responses “No,”
“Yes, some” or “Yes, very much”. In this study, we
chose to focus on the subjects who reported annoyance from both any electrical
factor and chemicals or smells, at least one of the factors as being much
annoying (n = 315).Treated hypertension (n =  1373) was
defined as use of antihypertensive medication, based on an affirmative answer
to the question “Have you during the last year used medicine, which was bought
at the pharmacy…?”… “For the treatment of high blood pressure”.Subjects in the electrical and
chemical annoyed group who were also treated for hypertension (n = 20), were
excluded from the analyses, as well as subjects who did not leave information
on neither HT medication nor environmental annoyance (n = 29). The final number
of subjects in each group is presented in Table 1.Table 1
Characteristics of the population in relation to
environmental annoyance and treatment of hypertension.
Electrical and
chemical annoyanceTreated
hypertensionRef.Number of
subjects295135311907Mean age436447Women (%)665354Cost  > 0 SEK
(%)849677Having been in
need of, but not491720having sought, medical care (%)Medical staff
neglected2547my wishes/needs (%)Not treated with
respect613from doctor on last visit (%)Mostly negative
experience (%)1946Use of
alternative medication (%)493328General Health
Questionnaire2.26 (2.22–2.31)2.01 (1.98–2.03)1.95 (1.94–1.95)mean(a) score  (95% CI)Self-rated
health score,4.13 (3.98–4.29)4.83 (4.76–4.91)5.16 (5.13–5.18)mean(a) (95% CI) SEKMean total cost
(95%6 658 (3 182–10
134)14 424
(12 807–16 040)7 890 (7 346–8 435)Confidence Interval) SEKMean(a) total cost7 888 (4 417–11 358)11 698 (10 024–13 372)8 216 (7 664–8 767)(95% Confidence Interval) SEKMedian total
cost SEK251943291628Mean(a) GP cost1371 (1195–1546)1594 (1510–1679)963 (935–991)(95% Confidence Interval)Median GP cost
SEK7901 185395Mean(a) (95% CI)1.9 (1.6–2.1)2.4 (2.3–2.5)1.4 (1.4–1.5)number of visits to GP(a)Age and gender adjusted.


## 2.3. Outcome Measures

### 2.3.1. Health Care Utilisation

Health
care utilisation was the main outcome measure in our study, and it was approximated
by information on number of visits to general practitioners and direct health
care costs in SEK. This information was provided to us by the
health authorities in the county which calculated it following the same
standard procedures all over the county [40].A ten-digit civic
registration, assigned to each individual in Sweden for their lifetime, is recorded at the county of Scania
in the Patient Administrative System (PASIS) for public care and PRIVA for
private care, and also in the Health Survey 2000, and was used for record
linkage. The Regional Office at the Scania County Council did the tabulation
preserving the anonymity of the subjects. Health care costs were related to
health care visits for the year 1999. The total cost for each nursing ward,
clinic, and hospital was broken down into individual in-patient nursing contact.
The Diagnosis-Related Groups (DRG) system is currently used in many countries
as a proxy for the cost of in-patient care [41].
When the actual cost for each visit was unknown, DRG codes were used to
calculate costs for each visit. Visits that had no DRG code were given the mean
amount of DRG points for the clinic. If the clinic did not use DRG codes, the
cost was divided among days when medical care was provided.  Out-patient
costs were calculated directly through a Patient Cost System, where every
contact received a specific cost for the actual use of resources. The costs
included correspond to what in health economics is referred to as direct costs
(i.e., out-patient and in-patient care including surgery, intensive care,
diagnostic services,  and drugs). Cost of drugs included concerned only what was
consumed by the patients during in-patient care. Costs of drugs in out-patient
care are not available on the specific patient level.


### 2.3.2. Additional Variables and Outcome Measures

The survey also included among other
items, information on self-reported health (SRH-7) [42], mental well-being (General Health Questionnaire [GHQ-12], [43]), medication use including alternative medication, and
experiences  of the health care system,
later dichotomized with the negative response as outcome; such as “do you
consider yourself having been in need of, but not sought, medical care” (i.e.,
“unsatisfied health care needs”),  “Was
the medical staff open to your wishes/needs” (i.e., “neglected health care
needs”),  “Did the doctor treat you with
kindness and respect on your latest visit” (i.e., “nonrespected health care
needs”), and “What is your experience of the health care in your local
authority” (i.e., “mostly negative experience of health care”).


## 2.3.1. Health Care Utilisation

Health
care utilisation was the main outcome measure in our study, and it was approximated
by information on number of visits to general practitioners and direct health
care costs in SEK. This information was provided to us by the
health authorities in the county which calculated it following the same
standard procedures all over the county [40].A ten-digit civic
registration, assigned to each individual in Sweden for their lifetime, is recorded at the county of Scania
in the Patient Administrative System (PASIS) for public care and PRIVA for
private care, and also in the Health Survey 2000, and was used for record
linkage. The Regional Office at the Scania County Council did the tabulation
preserving the anonymity of the subjects. Health care costs were related to
health care visits for the year 1999. The total cost for each nursing ward,
clinic, and hospital was broken down into individual in-patient nursing contact.
The Diagnosis-Related Groups (DRG) system is currently used in many countries
as a proxy for the cost of in-patient care [41].
When the actual cost for each visit was unknown, DRG codes were used to
calculate costs for each visit. Visits that had no DRG code were given the mean
amount of DRG points for the clinic. If the clinic did not use DRG codes, the
cost was divided among days when medical care was provided.  Out-patient
costs were calculated directly through a Patient Cost System, where every
contact received a specific cost for the actual use of resources. The costs
included correspond to what in health economics is referred to as direct costs
(i.e., out-patient and in-patient care including surgery, intensive care,
diagnostic services,  and drugs). Cost of drugs included concerned only what was
consumed by the patients during in-patient care. Costs of drugs in out-patient
care are not available on the specific patient level.


## 2.3.2. Additional Variables and Outcome Measures

The survey also included among other
items, information on self-reported health (SRH-7) [42], mental well-being (General Health Questionnaire [GHQ-12], [43]), medication use including alternative medication, and
experiences  of the health care system,
later dichotomized with the negative response as outcome; such as “do you
consider yourself having been in need of, but not sought, medical care” (i.e.,
“unsatisfied health care needs”),  “Was
the medical staff open to your wishes/needs” (i.e., “neglected health care
needs”),  “Did the doctor treat you with
kindness and respect on your latest visit” (i.e., “nonrespected health care
needs”), and “What is your experience of the health care in your local
authority” (i.e., “mostly negative experience of health care”).


## 2.4. Statistical Analysis

For statistical analysis, the SPSS
computer software version 11.0 was used. Odds ratios (ORs) and 95% confidence
intervals (95% CI) were estimated by use of conditional logistic regression
adjusting for age and gender. Means of health care utilisation costs, number of
visits, and subjective well-being, were calculated through univariate analysis
of variance (ANOVA). Since the cost data was not normally distributed, the
Kruskal WallisH-test was used to test the null hypothesis of nondifferences
in health-care consumption costs between groups. Pairwise comparisons between
groups were performed through the Mann-Whitney U-test.  A P-value below  .05 was
considered statistically significant. Mean costs and 95% confidence intervals
are also presented.


## 3. Results

### 3.1. Subjective Health Status

The groups differed in their ratings
of subjective physical and mental well-being (P’s < .001). The
chemical-electrical annoyed group reported lower SRH-7 scores than the hypertension
(HT) group (post hoc:  −0.70  [−0.87; −0.53]) and the general population (post
hoc: −1.02  [−1.18; −0.87]). The HT group also differed from the general
population (post hoc:  −0.33 [−0.40;  −0.24]). The chemical-electrical annoyed
group also presented higher GHQ-scores compared to the HT group (post hoc: 0.26
[0.21; 0.31]) and the referents (post hoc: 0.32 [0.27; 0.36]). The HT-group also
differed from general population (post hoc: 0.06  [0.04; 0.08]) (see Table 1).


### 3.2. Health-Care Costs

Regarding mean health care costs,
the electrical-chemical annoyed groups presented similar mean total health care
costs as the general population, with overlapping the 95% confidence intervals.
The HT group showed significantly higher mean costs than the general
population. The nonparametric tests showed significantly higher median costs
for both the HT and the chemical-electrical annoyed group, compared to general
population (P’s  <   .001). The HT group also had significantly higher median
cost than the electrical-chemical annoyed group (P <  .001) (see Table 1).
Regarding the primary health care cost, both the environmentally annoyed group
and the HT group had significantly increased mean and median costs compared to
general population (P’s <  .001). The HT group also had significantly higher
median cost than the electrical-chemical group (P <    .001).The electrical-chemical annoyed group and the HT group
had significantly more visits to general practitioners than referents, both
regarding mean and median number of visits (P’s <  .003) (see Table 1.) The HT
group also had significantly higher median number of visits than the
electrical-chemical annoyed group (P <  .001). Mean and median costs and
number of visits are presented in Table 1.Compared with the reference group,
the odds ratio of having had some health care cost preceding year was 1.6
(1.2; 2.2) in subjects with electrical and chemical annoyance (adjusted for age
and gender). This odds ratio was 5.9 (4.4; 7.8) in patients treated for
hypertension compared with the general population (not shown in tables).


#### 3.2.1. Experiences of Health Care

The odds ratios of reporting unfulfilled health care
needs, of considering that the medical system neglected one’s needs and of not
being treated with respect,  were  increased in those reporting both electrical and
chemical annoyance compared to referents (P’s <   .004). The
environmentally annoyed group had also increased probability of having “mostly
negative experience” of the health care in their municipality (P <   .001). The
HT group did not differ from the general population on any of these variables. The electrical and chemical annoyed group, but not the
HT group, had significantly increased OR to have used alternative medication
(P <  .001) (see Table 2).Table 2
Odds ratio (95% CI)
of experiencing unsatisfied,  neglected,  and
nonrespected health care needs, having mostly negative experience of health
care, and of having used alternative medication.
Electrical and chemical annoyanceTreated hypertensionOR
(95% CI)OR
(95% CI)“Unsatisfied health care needs”3.5 (2.8–4.5)1.0 (0.8–1.2)“Neglected health care needs”3.8 (2.9–5.0)1.1 (0.8–1.5)“Nonrespected health care needs”2.1 (1.3–3.4)0.7 (0.4–1.3)“Mostly negative experience of health
care”3.3 (2.5–4.5)1.3 (0.9–1.7)Having used alternative medication2.4 (1.8–3.0)1.1 (1.0–1.3)Age and gender adjusted.


## 3.1. Subjective Health Status

The groups differed in their ratings
of subjective physical and mental well-being (P’s < .001). The
chemical-electrical annoyed group reported lower SRH-7 scores than the hypertension
(HT) group (post hoc:  −0.70  [−0.87; −0.53]) and the general population (post
hoc: −1.02  [−1.18; −0.87]). The HT group also differed from the general
population (post hoc:  −0.33 [−0.40;  −0.24]). The chemical-electrical annoyed
group also presented higher GHQ-scores compared to the HT group (post hoc: 0.26
[0.21; 0.31]) and the referents (post hoc: 0.32 [0.27; 0.36]). The HT-group also
differed from general population (post hoc: 0.06  [0.04; 0.08]) (see Table 1).


## 3.2. Health-Care Costs

Regarding mean health care costs,
the electrical-chemical annoyed groups presented similar mean total health care
costs as the general population, with overlapping the 95% confidence intervals.
The HT group showed significantly higher mean costs than the general
population. The nonparametric tests showed significantly higher median costs
for both the HT and the chemical-electrical annoyed group, compared to general
population (P’s  <   .001). The HT group also had significantly higher median
cost than the electrical-chemical annoyed group (P <  .001) (see Table 1).
Regarding the primary health care cost, both the environmentally annoyed group
and the HT group had significantly increased mean and median costs compared to
general population (P’s <  .001). The HT group also had significantly higher
median cost than the electrical-chemical group (P <    .001).The electrical-chemical annoyed group and the HT group
had significantly more visits to general practitioners than referents, both
regarding mean and median number of visits (P’s <  .003) (see Table 1.) The HT
group also had significantly higher median number of visits than the
electrical-chemical annoyed group (P <  .001). Mean and median costs and
number of visits are presented in Table 1.Compared with the reference group,
the odds ratio of having had some health care cost preceding year was 1.6
(1.2; 2.2) in subjects with electrical and chemical annoyance (adjusted for age
and gender). This odds ratio was 5.9 (4.4; 7.8) in patients treated for
hypertension compared with the general population (not shown in tables).


### 3.2.1. Experiences of Health Care

The odds ratios of reporting unfulfilled health care
needs, of considering that the medical system neglected one’s needs and of not
being treated with respect,  were  increased in those reporting both electrical and
chemical annoyance compared to referents (P’s <   .004). The
environmentally annoyed group had also increased probability of having “mostly
negative experience” of the health care in their municipality (P <   .001). The
HT group did not differ from the general population on any of these variables. The electrical and chemical annoyed group, but not the
HT group, had significantly increased OR to have used alternative medication
(P <  .001) (see Table 2).Table 2
Odds ratio (95% CI)
of experiencing unsatisfied,  neglected,  and
nonrespected health care needs, having mostly negative experience of health
care, and of having used alternative medication.
Electrical and chemical annoyanceTreated hypertensionOR
(95% CI)OR
(95% CI)“Unsatisfied health care needs”3.5 (2.8–4.5)1.0 (0.8–1.2)“Neglected health care needs”3.8 (2.9–5.0)1.1 (0.8–1.5)“Nonrespected health care needs”2.1 (1.3–3.4)0.7 (0.4–1.3)“Mostly negative experience of health
care”3.3 (2.5–4.5)1.3 (0.9–1.7)Having used alternative medication2.4 (1.8–3.0)1.1 (1.0–1.3)Age and gender adjusted.


## 3.2.1. Experiences of Health Care

The odds ratios of reporting unfulfilled health care
needs, of considering that the medical system neglected one’s needs and of not
being treated with respect,  were  increased in those reporting both electrical and
chemical annoyance compared to referents (P’s <   .004). The
environmentally annoyed group had also increased probability of having “mostly
negative experience” of the health care in their municipality (P <   .001). The
HT group did not differ from the general population on any of these variables. The electrical and chemical annoyed group, but not the
HT group, had significantly increased OR to have used alternative medication
(P <  .001) (see Table 2).Table 2
Odds ratio (95% CI)
of experiencing unsatisfied,  neglected,  and
nonrespected health care needs, having mostly negative experience of health
care, and of having used alternative medication.
Electrical and chemical annoyanceTreated hypertensionOR
(95% CI)OR
(95% CI)“Unsatisfied health care needs”3.5 (2.8–4.5)1.0 (0.8–1.2)“Neglected health care needs”3.8 (2.9–5.0)1.1 (0.8–1.5)“Nonrespected health care needs”2.1 (1.3–3.4)0.7 (0.4–1.3)“Mostly negative experience of health
care”3.3 (2.5–4.5)1.3 (0.9–1.7)Having used alternative medication2.4 (1.8–3.0)1.1 (1.0–1.3)Age and gender adjusted.


## 4. Discussion

Even though the electrical-chemical
annoyed group was the group with the lowest subjective health and the least
well-being, health care utilisation costs were not remarkably high as compared
with the general population or with a patient group with a relatively common
medical condition as treated hypertension. Rather, results suggest that
electrical-chemical annoyed subjects do not get, or seek, the health care that
could be expected according to their reduced subjective health. This last
aspect could presumably be linked to their reported negative experiences with
the health care system. These negative attitudes and experiences may probably
origin in the fact that there is a great discrepancy in what treatment that is
being offered in traditional medicine regarding problems associated with
environmental intolerance, and what is usually preferred by the persons
experiencing these problems.Since the distribution of costs is
extremely skewed, mean costs and ANOVAs are not the most appropriate way for
analysing differences between groups. When looking at median costs, even though
the difference between the electrical-chemical annoyed group and the general
population is statistically significant, it is not great in absolute terms.
Moreover, the HT group presented significantly higher median costs than the
electrical-chemical annoyed group, despite significantly better subjective well-being.A direct comparison between the HT
group and the electrical-chemical annoyed group might appear inappropriate due
to the different nature of these two medical conditions. The HT group is also
much older than the other groups. But, although adjustment for age decreases
the difference between the HT group and the other groups in mean health care
costs, the HT group still cost significantly more than both the other groups
after adjustment for age and gender. This adjustment was not possible to
perform regarding median cost, but theoretically, an adjustment for age
difference would possibly have a quite similar effect, that is,  reduce the present differences,
but not abolish it. This effect was seen in analyses of ranked or
log-transformed cost data. The differences remained even after age and gender
adjustments; hence, the HT group still cost significantly more than the other
groups.  However, we  want to stress that the aims of our
comparisons were strictly to describe and relate the heath and health care
utilisation of the electrical-chemical annoyed group to the general population
and to the HT patients. We did not investigate any causal hypothesis since
those groups are not comparable in this perspective.The nature of environmental sensitivity
gives rise to expectations of increased cost
[19, 25–31, 34].
Medically unexplained symptoms have been associated with “frequent attenders”
in primary care [27, 33]. “Frequent attenders”
were defined as the top 5% of the out-patient attenders, by the number of
appointments [33], which in our material would be >5 visits. So, despite a
slightly higher number of visits to GP’s compared with the reference group, the
environmentally annoyed subjects are far from being frequent attenders.
Nonetheless, subjects in this group did not feel well, and they often reported
to have been in need of, but not having sought, medical care.So, why did the
environmentally annoyed subjects not seek medical care? One explanation may be
their negative experiences of health care. These experiences may be a result of
various factors, and negative or frustrating experiences of health care
providers have also previously been reported in other studies on MUS patients [37, 38].
Today, there is no generally accepted treatment for environmental intolerance.
This could be one explanation why the environmentally annoyed subjects did not
seek medical care to a greater extent. Even if they did seek care, this contact
would probably not have resulted in continuous care because of the lack of
treatment options for environmental intolerance.
The results also contradict that the reduced health status in the
environmentally annoyed groups would be explained by other sicknesses. If the
reduction in health would depend on other sicknesses, more familiar to
physicians than environmental illness, one would expect them to have been
treated for these conditions, which would have led to evidently increased
costs.In a previous follow-up study, 50
subjects with perceived hypersensitivity to electricity revealed that 38% had
used “complementary therapies” [44]. In
the present study, almost half of the subjects in the environmentally annoyed
group had used alternative medication. Even though alternative medication was
commonly used also among the referent population and the HT group, it was even
more common in the environmentally annoyed group. This could indicate a
tendency to seek alternative ways to handle with experienced symptoms or health
related problems. This tendency could be a result of dissatisfying experiences
with the traditional health care. We did not have information on alternative
care except from medication; hence,  we do not know whether they also seek
alternative care to a higher extent. In a previous study, only a few of  subjects experiencing symptoms in connection
with mobile phone use reported that they had consulted a physician or been on
sick leave because of the symptoms [18]. In one study on subjects suffering from “hypersensitivity” to
electricity, fewer of the afflicted subjects used conventional medication than
the nonafflicted [17]. However, in our present study we have no results supporting that
the increased use of alternative medication excluded use of more traditional
medication.A model for health
care utilisation and somatisation was presented by Ciechanowski et al. [45]. This model was based on the attachment theory, showing that the attachment
style was associated not only with symptom reporting but also with  health care
utilisation. Data from that study showed that subjects with a “fearful”
attachment style had the lowest primary care cost, despite having just as many
symptoms as subjects with “preoccupied” attachment style, which had the highest
costs. Our study does not examine attachment style, but this is one factor that
may influence health care utilisation, irrespective of the number of symptoms
reported. The experience of, or attitudes towards, health care may also be
linked to attachment style.  According to
Bowlby, who first developed attachment theory, individuals internalise earlier
experiences of caregivers, forming cognitive schemas of relationships that may
influence not only whether they perceive themselves as worthy of care, but also
whether others can be trusted to provide care [45]. These “models of other”
may influence the interactions the individual has with others, and also form
the interpretations of these interactions throughout life. What cognitive
schemas that are formed, is suggested to be depending
on the individuals’ attachment style. A “secure” or “preoccupied” attachment
style is associated with larger trust or dependence on others, while a “dismissing”
or “fearful” attachment style is associated with “compulsory self-reliance” or
approach avoidance behaviour. Hence, also the attitudes of health care found
among the environmentally annoyed persons in the present study may be related
to these attachment styles, which are also associated with decreased health
care utilisation regardless of symptom severity. Both
the negative experiences and attitudes, and the not much increased health care
utilisation hence indicate the presence of a fearful (or perhaps dismissing)
attachment style among the environmentally annoyed subjects.


### 4.1. Study Limitations

In the present study, we analysed
direct health care cost only, as information on costs for sick-leave,
unemployment, and so forth were not available. These indirectly associated costs
may be increased and deserve further studies. Also costs for alternative
treatments would be highly relevant to examine in the environmentally annoyed
group, as there are reasons to expect these costs to be increased which is also
supported by the findings of  increased OR
of use of alternative medication as measured by the direct question in the
survey. However, the aim with this study was to analyse utilisation of and
attitudes towards “traditional” medicine, which was what we did.Outpatient medication costs are not included in the
health care costs which leads to an underestimation of health care cost among
patients treated for hypertension, and support our conclusions regarding the
electrical-chemical annoyed group. A strength of the study is the access to
record based data on health care utilisation, which reduces the reliability
problems associated with self-reported health care [24].Although the response rate was no
higher than 59%, the analysis of representativity indicates that selection bias
should not be a substantial problem, at least not in relation to information on
health care consumption [39].We performed extra calculations
using only subjects reportingno annoyance to any of the five factors as control group but the results were
similar. These extra analyses suggest that our main results regarding health
care utilisation should not depend on misclassification bias caused by a lack
of clear cut off regarding environmental annoyance between the annoyed group
and the population.In the present study, we analysed
direct health care cost only as information on costs for sick-leave,
unemployment, and so forth were not available. These indirectly associated costs
may be increased and deserve further studies.


## 4.1. Study Limitations

In the present study, we analysed
direct health care cost only, as information on costs for sick-leave,
unemployment, and so forth were not available. These indirectly associated costs
may be increased and deserve further studies. Also costs for alternative
treatments would be highly relevant to examine in the environmentally annoyed
group, as there are reasons to expect these costs to be increased which is also
supported by the findings of  increased OR
of use of alternative medication as measured by the direct question in the
survey. However, the aim with this study was to analyse utilisation of and
attitudes towards “traditional” medicine, which was what we did.Outpatient medication costs are not included in the
health care costs which leads to an underestimation of health care cost among
patients treated for hypertension, and support our conclusions regarding the
electrical-chemical annoyed group. A strength of the study is the access to
record based data on health care utilisation, which reduces the reliability
problems associated with self-reported health care [24].Although the response rate was no
higher than 59%, the analysis of representativity indicates that selection bias
should not be a substantial problem, at least not in relation to information on
health care consumption [39].We performed extra calculations
using only subjects reportingno annoyance to any of the five factors as control group but the results were
similar. These extra analyses suggest that our main results regarding health
care utilisation should not depend on misclassification bias caused by a lack
of clear cut off regarding environmental annoyance between the annoyed group
and the population.In the present study, we analysed
direct health care cost only as information on costs for sick-leave,
unemployment, and so forth were not available. These indirectly associated costs
may be increased and deserve further studies.


## 5. Conclusions

In conclusion, despite their
impaired subjective health and functional capacity, health care utilisation
costs were not much increased for the environmentally annoyed group. Negative
experiences in their contact with the health care system and perhaps other
factors not investigated in the present study may contribute to the possibility
that these patients do not get, or seek, the health care expected according to
their reduced subjective health.



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*Source: 106389-2009-04-14.xml*