Summary with the article: The use of outpatient mental health care services of migrants vis-á-vis Dutch natives: Equal access? - Koopmans, Uiters, Deville, Foets - 2012

Although migrants have a higher risk and frequency of mental health problems, not much is known about the use of mental health care among European migrants. Ethnic minorities in North America are less likely to seek mental help than other groups, regardless of their health.

This research uses the definitions from Andersen's behavioural model to investigate the differences in health care usage between migrants and natives. This behavioural model is used in health care to demonstrate which factors lead to the use of health care services. These factors include risk factors, protection factors, and needs. The model is used for both perceived needs (how you see your own health and symptoms) and evaluated needs (a professional's medical judgment). Realized access to health care is its actual use, and fair access is when the need accounts for the majority of health care use.

The following factors (some have been extensively researched, others less so) can influence the use of formal health care:

• age

• gender

• marital status

• perceptions of mental disorders

• expectations about the role of formal health care

• ideas on ​​causes (some cultures see a disease as something supernatural and seek help from an informal resource)

• place of birth

• The amount of time spent in the new country,

• age when migrating

• SES

• proficiency of the country's language.

This study focuses on the largest non-Western migrant groups in the Netherlands: Moroccans, Turks, Surinamese and Antilleans. Nowadays these groups make a lot of use of outpatient care (care at your home) compared to natives (Dutch people with only a Dutch background). However, whether the needs also differ between these groups has not been investigated. One study found that usage doesn't differ significantly, when focussed on subjective psychological stress.

This article examines whether the degree of access of outpatient mental health care for Turkish, Moroccan, Surinamese and Antillean migrants is the same as for natives .

Which methods were used?

The data used for this research comes from an existing national survey of 104 GP practices, which together had 385,000 patients. All groups had approximately the same interviews. The interviews took place at the homes of the participants, and were conducted in the native language of the participants if necessary (which was often the case).

During this interview the following factors were measured:

• the use of mental health care: by asking whether there had been any contact with health authorities in the past year

• the need for health care: emotional problems, vitality and mental health were measured with questionnaires

• anxiety and depression: with two short questions

• perceived health: the participants had to rate their health from 'very poor ' to ' excellent'

• the common risk factors such as age, gender and marital status.

• belief in the healing effect of nature and of prayer and orientation towards modern Western values​.

• protection factors, such as SES: through education level

• command of the Dutch language: speaking & understanding

Six models were tested. These can be found below in the results.

What are the results?

There are some differences in demographic measurements between the groups. For example, the education level was higher among the natives. Health care use was lowest among the natives and highest among the Turkish migrants. All migrant groups had worse health than the natives - of which the Turkish migrants the worst - and reported more anxious and depressed feelings. The perceived health was best among the natives. The Moroccan group was least likely to see lifestyle and stress as the cause of illness. The Turkish and Moroccan groups had higher scores than the Antillean and Surinamese groups for believing in the role of nature and praying for disease. Western orientation was higher in the Antillean and Surinamese group than the Turkish and Moroccan group.

After a correlation analysis, it appears that variables related to need are highly correlated with health care use.

Models used

Model 1 focussed on the raw scores, and showed that the Turkish group had a higher chance of using health care than the natives .

Model 2 focussed on health care needs. This model showed that poorer health was associated with a greater likelihood of health care use, unless perceived health was different. All differences between all groups (including the natives) disappeared, except for the Moroccan group. They still used less health care after this check.

Model 3 added risk factors. In this model, older age was associated with less frequent health care use. All migrant groups were less likely to use health care than the natives. From the smallest to the greatest chance of using health care: the Moroccan group - the Turkish group - the Surinamese group - the Antillean group - the natives .

Model 4 also looked at the educational level of the participants. Higher educational attainment was found to be associated with higher health care utilization. There were still differences between natives and migrant groups, but they were smaller. Only the difference between the Antillean group and the natives was fully explained by education level (for the other groups only partially explained).

Model 5 showed that Dutch language proficiency contributed nothing to the use of health care.

Model 6 proved that Western orientation was an indicator of health care usage, but this did not explain the differences in health care use between the groups, except for the Turkish group. The other two health belief variables (influence of nature and prayer on illness) were no indicator of health care usage.

Discussion

At first, the use of health care seemed to be the same for all groups. However, if you focus on care needs and risk factors, health care utilization is lower among migrants than among natives. Education level explained the differences between the Antillean group and the natives, and for the other groups it explained part. Surprisingly, Dutch language proficiency was not associated with health care use. Other studies sometimes have different findings with regard to language proficiency. If you focus on Western orientation, the use of health care became even smaller for the Surinamese group. Older age was also associated with less use of health care. Monitoring this leads to differences between migrants and natives. The role of SES (the measurement was education level) was average.

Andersen's definition of fair access is: when the need accounts for the majority of health care use. This study therefore suggests unequal access to health care, because some differences in health care use are explained by differences other than just the need for care.

Limitations

This study relied on self-report. All findings are based on perceived situations, but those are not always the real situations. There may be a bias in the data. The measurement of Dutch language proficiency is quite rigorous: you had to speak and understand it fluently to be able to answer “yes”, otherwise the answer would be “no”. Also, the only measuring point for SES was the level of education, because it was too difficult to adjust an income to the size of the family living from it. The measurement of belief in the effect of nature or prayer on illness must also be more specific.

Future literature should also look to belief in spiritual healing or other alternative informal health care services. The measurement of health complaints may also be influenced by cultural differences, what is appropriate when reporting these types of complaints.

Conclusion

This study was the first to paint a national picture of health care use among migrant groups and natives in the Netherlands. If perceived need is included in the analysis, the study suggests that access to healthcare is unequal for the migrants.