Update deliverables WP 8: Self-perceived health and Health care utilisation

Department of Health Services Research Update deliverables WP 8:Self-perceived health and Health care utilisation Signe Smith Nielsen & Allan Krasnik Department of Health Services Research Institute of Public Health University of Copenhagen "This project is funded under the framework of Public Health Programme 2003-2008 of the European Commission (contract number 2005122)"

Department of Health Services Research Disposition • Identification of data sources • Registration of data • Prelimanary findings • Problems • PhD-protocol

Department of Health Services Research Identification of databases/sources • In progress of making an inventory of available and appropriate databases and survey data on health care utilization and self-perceived health among immigrants in EU-countries • So far, we have included nine countries and will keep the focus on these • Using different sources – other databases, EUROStat, collaboration partners, newsletters, National Board of Health

Department of Health Services Research Registration of data • Name of source (eg. Survey) • Year • Frequency • Past year • Next year • Study design • Number of people included • Number of respondents • Response rate • Collection of information on non-respondents • Area of collection (local, national) • Groups (e.g. patients, general population)

Department of Health Services Research Registration of data • 13. Delimitation (e.g. sex, age) • 14. Oversampling • 15. Inclusion of indigenous population • 16. Kinds of immigrants • 17. Mode data collection • 18. Languages • 19. Place of interview

Department of Health Services Research Registration of data • Precise measures of: • (Inclusion of questions and answer categories) • Ethnicity • Health care use • Self-perceived health • Sociodemographic factors • Institution • Contact person • Accessibility • Reference

Department of Health Services Research Registration of data • For studies: Main results • Registers: Date of establishment • Surveys: Only from 1997-

Department of Health Services Research Preliminary findings • Blurred picture of how migrants are defined • The same questions measuring especially self-perceived health are employed • However, it varies how many aspects of self-perceived health that are included (e.g. global self-rated health, chronic conditions, physical limitations, mental limitations, and mental as well as physical wellbeing) • The picture of health care utilisation is more diverged (survey data vs. register data)

Department of Health Services Research Problems • Different or limited definition of migrants • (e.g. answer categories: three choices: Italian, other, stateless) • Language problems • Lack of data in some countries • How do we ensure that all data sources are identified, including not internationally publiced data? • - Networks, collaboration partners • - Update newsletters • - National Board of Health/Ministry of Health • - MEHO-partners

Department of Health Services Research Timeline • Continue to identify data sources in the nine countries • Ensure we have included all available data • Start to make an overview of the most frequently used questions in surveys/register data • Search literature for validation of indicators of self-perceived health and health care use • Start on the process of developing the relevant indicators

Department of Health Services Research PhD-protocol • Hopefully, I will start my PhD-project in which the overall idea is to combine the content of the work package: health care utilisation and self-perceived health among immigrants in different EU-countries

Department of Health Services Research PhD-protocol: Background • Differences in health care utilisation between immigrants and the indigenous European population have been documented • Additionally, studies have pointed at that immigrants have a worse self-perceived health as compared to the indigenous population • An adequate use of health care services is an important precondition for health

Department of Health Services Research PhD-protocol: Background • Central to investigate: • whether differences in utilisation among immigrants versus the indigenous population are an indication of inequality in terms of problems in access to the health care services, • or • whether they reflect differences in need

Department of Health Services Research PhD-protocol: Background • Equity with respect to health care use may be interpreted in a variety of ways • It can refer to the treatment provided by health care services, to access to these services, or to the outcome of the services • One of the principal interpretations of the term is equal use for equal need

Department of Health Services Research PhD-protocol: Background • By comparing migrant-related differences in the use of health care services controlling for potential differences in health status equity in health care utilisation can be assessed. • If the use of health care is in accordance with differences in health status, the principle of equal use for equal need can be said to be realised. • If the use of health care is showing an excessive consumption or an under consumption inequality can be said to be present.

Department of Health Services Research PhD-protocol: Background • Only scanty knowledge exists about equity in utilisation for equal need between different immigrant groups in Europe. • The few studies within this field have shown an inconsistent picture. • The diverging findings point to a need of further investigation of migrant-related inequality of health care utilization in Denmark as well as in different EU-countries.

Department of Health Services Research Background • In order to improve the contact between the immigrants and the health care system, it is significant to survey which factors in the health care systems which the immigrants themselves perceive as reinforcing or restraining for access and treatment. • Identification of problems and forces of the health care systems may lead to a strengthening of access to the health care services as well as to a better contact between the immigrants and health professionals.

Department of Health Services Research Objectives • In order to reveal national and international inequalities in health care utilisation in respect to health care need as well as factors determining such inequalities the study will investigate the following: • Whether migrant-related inequality in health care utilisation exists between the seven largest immigrant groups and the indigenous population in Denmark when self-perceived need is included in the perspective.

Department of Health Services Research Objectives • 2) Whether migrant-related inequality in health care utilisation in respect to health care need exists between different immigrant groups and the indigenous population across seven different EU-countries with different health care characteristics • 3) the reinforcing and restraining factors in connection to health care utilisation from the immigrants’ perspective in three different EU-countries

Department of Health Services Research Material and methods • Overall study population • Immigrants from Turkey, Ex-Yugoslavia, Iraq, Lebanon, Pakistan, Somalia, and Iran • Both 1st generation immigrants and descendants are included in the project • The reasons for this choice of immigrant groups are that they constitute the seven largest groups of immigrants in Denmark, and from a cross-country perspective these groups comprise a dominating part of immigrants in Europe

Department of Health Services Research Material and methods • Re 1) • Based on “Immigrants’ health”. Answers from 4,925 persons have been collected (51.8 %). • The persons constitute Danes, immigrants from Turkey, Ex-Yugoslavia, Iraq, Lebanon, Pakistan, Somalia, and Iran as well as descendants from Turkey and Pakistan. • Health care utilisation will be presented by visits to the hospital, GP, specialist doctor, dentist and doctor in a foreign country. • Self-reported need will be based on self-perceived health, chronic illnesses, physical and mental limitations as well as physical and mental well-being. • Multivariate analyses are conducted by logistic regression (SES will be controlled for)

Department of Health Services Research Material and methods • Re 2) • Starting from primarily existing literature, migrant-related (in)equality in health care utilisation in respect to self-reported need among the seven immigrant groups with the indigenous population as reference group will be recorded for the selected EU-countries • A comparison between the different countries and immigrant groups will be carried out along with a discussion of the methodological problems of this comparison

Department of Health Services Research Material and methods • Re 3) • Semi-structured qualitative interviews with the 15 patients suffering from diabetes type II from one immigrant group in three different EU-countries will be carried out. • By the use of grounded theory, reinforcing and restraining factors in connections with the contact to the health care system will be surveyed. • Differences and similarities between the health care systems will be elucidated.

Department of Health Services Research Research environment • The project is carried out at Department of Health Services Research, Institute of Public Health, University of Copenhagen under instruction of Allan Krasnik • We are hoping for a continuation of a collaboration with the other MEHO-partners in this! • THANK YOU! "Disclaimer: The study has received funding from the European Commission under the Public Health Programme 2003-2008. However, the sole responsibility for the study lies with the author and the European Commission is not responsible for any use that may be made of the information contained therein."

Update deliverables WP 8: Self-perceived health and Health care utilisation