Primary Health Care Use among Ethnic Minorities in the Netherlands A comparative study EllenUiters ISBN 978!90!6905!868!9 http://www.nivel.nl [email protected] Telephone +31 30 2729 700 Fax +31 30 2729 729 ©2007 NIVEL, P.O.Box 1568, 3500 BN Utrecht, the Netherlands Cover design: Bart Schure Painting: Frans Geenen Frans Geenen kindly gave permission to use his painting “Blindfolded faces: the society is multicultural, but to what degree do we see what’s intrinsic moving us” Word processing/layout: Ria Karamat Ali and Christel van Well Printing: Twin Design Language consultant: Vertaalkantoor drs. H. Kerkhoven All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of Ellen Uiters. Exceptions are allowed in respect of any fair dealing for the purpose of research, private study or review. Primary Health Care Use among Ethnic Minorities in the Netherlands A Comparative Study Zorggebruik onder etnische minderheden in Nederland Een vergelijkende studie PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof.dr. S.W.J. Lamberts en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op vrijdag 9 november 2007 om 11.00 uur door Anna Helena Uiters Geboren te Veendam Promotiecommissie Promotoren: Prof.dr. M. Berg Prof.dr. P.P. Groenewegen Overige leden: Prof.dr. B.W. Koes Prof.dr.med. O. Razum Prof.dr. J. Veenman Copromotoren: Dr. M.M.E. Foets Dr. W.L.J.M. Devillé The research in this book was financed by a grant from the Netherlands Organisation for Scientific Research, Social Cohesion Programme; sub programme, the Dutch Multicultural and Pluriform Society (MPS) (grant 261!98!618). Contents 1 Introduction and research questions 7 2 The use of primary medical care by migrant groups: a systematic review 29 3 Perceived health and consultation of GPs among ethnic minorities compared to the general population in the Netherlands 57 4 Is there a correlation between urbanisation level and ethnic differences in health care utilisation? 71 5 Use of health care services by ethnic minorities in the Netherlands: do patterns differ? 89 6 Quality of GP care, perceptions of ethnic minorities 103 7 Ethnic minorities and prescription medication: concordance between self!reports and medical records 119 8 Health care utilisation and acculturation 131 9 Summary and general discussion 153 Samenvatting (Summary in Dutch) 169 Literature 179 About the author 199 Primary health care use among ethnic minorities in the Netherlands 5 6 Primary health care use among ethnic minorities in the Netherlands 1 Introduction and research questions Chapter 1 7 1.1 Introduction In recent decades the Netherlands has increasingly been host to a large number of different ethnic groups. As a consequence of decolonisation, active labour recruitment and better labour circumstances, many immigrants came to live and work in the Netherlands. Subsequently, their number increased strongly because of family reunion and family formation (Penninx et al., 1993). These immigrants often end up in a minority position, charac! terised by various kinds of social disadvantage. As in other areas, also with respect to health, ethnic minorities are frequently disadvantaged: their health status is often poorer than that of the indigenous population (Van Wersch et al., 1997; Uniken Vernema et al., 1995; Uitenbroek and Verhoeff, 2002; Razum and Twardella, 2002). Nevertheless, this general picture is not straightforward with respect to all minority groups and diseases. Moroccan men, for instance, are found to have a higher life expectancy and are less likely to suffer from cardio!vascular diseases as compared to the indigenous Dutch males (RIVM, 2006). Ethnic background is therefore suggested to relate in many (complex) ways to differences in health status between various ethnic groups. Mechanisms possibly operating are linked to genetic factors, experiences before and after migration, culture and acculturation, socio!economic factors and societal context (Uniken Venema et al., 1995; Stronks et al., 1999; Dijkshoorn et al., 2000). Varying importance is attached to each of these factors. Most research attention is paid to the influence of individual factors on health status such as socio!economic position and demographic characteristics. In addition to the above, adequate use of health services is also perceived to be an important determinant of health (Andersen, 1995). Adequate use of health care is facilitated by accessibility and quality of the health care services. Reduced access and poorer quality of care can lead to delays in diagnosis and treatment and contribute to well!documented disparities in minority health (Amaddeo et al., 1995; Shin et al., 2005). For this reason one of the major themes in modern health policy is equity in health care services. Many definitions and criteria with respect to equity have been formulated (Andersen, 1995; Doorslear et al., 2000; Whitehead, 1990). In 1990, the World Health Organisation identified three goals in relation to equity: 8 Primary health care use among ethnic minorities in the Netherlands a) equity in access when equal needs b) equity in utilisation when equal needs c) equity in quality of treatment when equal needs (Whitehead, 1990) The principal interpretation of equity that underpinned much of the recent empirical work in this area focuses on equal use for equal need (Smaje and Grand, 1997). Need is most often measured by self!reported morbidity or perceived health. Since there are inequalities in need, use of care is expected to be distributed unequally. In this context horizontal equity (the equal treatment of equals) and vertical equity (the unequal treatment of unequals according to their inequality) can be distinguished (Alberts, 1998). When differences in health care use are explained predominantly by differences in need and demographic characteristics, one can speak of equity in health care use (Andersen, 1995). Utilisation is more unequal when variables such as social structure (e.g. ethnicity), health beliefs and income determine who gets care, rather than health care needs. Central to our study is equity in health care between ethnic groups in terms of the actual use of services (Smits et al., 2002). The objective is to provide insight into differences in the actual use of health care services by ethnic minorities as compared to the indigenous Dutch population. Furthermore, the role of different determinants of health care utilisation will be studied in order to establish to what degree ethnic differences in utilisation are explained by these determinants. In addition to the use of health care our study also pays attention to the quality of care by comparing differences between ethnic groups concerning the perceived quality of general practitioner care. Patients" perceptions about aspects such as personal treat! ment, communication and information and continuity will be studied in the context of the multidimensional concept of quality of care (Harteloh and Verheggen, 1994). Health care that takes into account the needs and expecta! tions of minority groups can contribute to a reduction in possible health disadvantage, which is the ultimate aim of equity in health care. 1.2 Theoretical background For our study the widely used theoretical framework developed and elaborated by R.A. Andersen served as the reference point. This model was Chapter 1 9