J Immigrant Minority Health (2007) 9:349–357 DOI 10.1007/s10903-007-9043-0
ORIGINAL PAPER
Health Service Utilization by Ethiopian Immigrants and Refugees in Toronto Haile Fenta Æ Ilene Hyman Æ Samuel Noh
Published online: 23 March 2007 Springer Science+Business Media, LLC 2007
Abstract The purpose of this study was to examine the health service utilization patterns of Ethiopian immigrants and refugees in a random sample of 342 adults residing in Toronto. The results suggested that 85% of the study participants used one or more type of health services, most often from a family physician. However, only 12.5% of them with a mental disorder received services from formal healthcare providers, mainly family physicians. While the presence of somatic symptoms was significantly associated with increased use of healthcare (p < 0.05), having a mental disorder was associated with lower rate of health service use (p < 0.05). These findings suggest that family physicians could play important role in identifying and treating Ethiopian clients who present with somatic symptoms, as these symptoms may reflect mental health problems. Further research is necessary to determine the reasons for the low rates of mental health services use in this population.
H. Fenta (&) S. Noh Social Equity and Health Research, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, Canada M5T1R8 e-mail:
[email protected] H. Fenta S. Noh Department of Psychiatry, University of Toronto, Toronto, ON, Canada I. Hyman Joint Centre of Excellence for Research on Immigration and Settlement, Toronto, ON, Canada I. Hyman Department of Public Health Sciences, University of Toronto, Toronto, ON, Canada
Keywords Health services utilization Mental health Family physician visits Ethiopian immigrants
Introduction Immigrants represent a large and increasing segment of the Canadian population. In 2001, over five million Canadians (18.4%) were born outside the country, and over 200,000 new immigrants are received each year (1, 2). A large majority of these new immigrants are from non-European countries (2). Compared to European immigrants, those from non-European countries experience more cultural (3–5) and linguistic barriers to accessing the healthcare services of their host country (4, 6–8). Studies in general show that immigrants’ utilization of healthcare services is related to their length of residence in their host country (9–12), their level of education (11, 13–15), and discrimination against immigrants and racial minorities (16). However, empirical research that specifically describes the rates and patterns of healthcare service use by immigrants is limited. To our knowledge, no studies have examined the healthcare utilization patterns of Ethiopian immigrants in North America. The current, preliminary study aims to fill this gap through an analysis of the healthcare utilization by Ethiopian immigrants and refugees residing in Greater Toronto Area (GTA). Ethiopia is one of the main sources of African immigrants for both Canada and the United States (17). Over 21,000 Ethiopian immigrants arrived in Canada between 1974 and 1996, with the large majority settling in the GTA (18, 19). Currently, an estimated 30,000 Ethiopians reside in the GTA (oral communication with the Ethiopian Association in Toronto).
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Reports on healthcare service utilization by immigrants are inconsistent. On the one hand are studies suggesting that immigrants as a whole under-utilize healthcare services compared to native-born residents (20–28), while on the other are studies reporting that immigrants use healthcare services as much as, or even more than, native-born populations (29–35). Nevertheless, most Canadian studies report lower utilization, particularly among non-European immigrants who are under-represented in all forms of healthcare service use including hospital services, (13) emergency room visits (29), dental care services (12), mental healthcare services (21, 28, 36–38), and preventive health services, such as mammography and cervical cancer screening (29, 39, 40). Various hypotheses have been put forward to explain immigrants’ under-utilization of healthcare services, with differences between immigrant groups and the host culture (41–44), and language barriers (45, 46) being the most cited explanations. Immigrants of non-European origin may hold different views of health and appropriate care than those prevalent in North American society (47–50), which may point to cultural distance between care providers and recipients as an important barrier. Chugh and colleagues (46) found that while both patients and healthcare providers identified language as a critical barrier to healthcare access, healthcare providers focused more on cultural barriers, while patients identified racism as a greater concern. The negative impact of racism upon entry into the healthcare system, and during the subsequent treatment process, has been documented elsewhere (51–53). Many US studies have reported that economic status is a major barrier to healthcare (26, 54–58). Except few services such as eye care and dentistry, this seems less an issue in Canada where universal medical coverage is provided to all Canadian citizens under the terms of the Canadian Health Act (59). Nevertheless, some studies suggest that many immigrants to Canada may experience difficulty understanding how the healthcare system works (60, 61). For many immigrants, this knowledge gap can be exacerbated by lack of fluency in English or French (60). Although there are a number of initiatives in Canada to assist the orientation of newcomers, they are often provided by agencies or family members instead of the healthcare system itself, and so the quality and accuracy of such orientation may vary (62). Considering the extent of ethnic diversity in the Canadian population, especially in Toronto, there are surprisingly few empirical investigations of service use among new immigrant populations (63, 64). We know little about the extent to which the Canadian healthcare system addresses the healthcare needs of new minority immigrants. Seeking to fill this gap, therefore, this study reports
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the patterns of healthcare service use, considering both physical and mental health needs, among Ethiopians in Toronto.
Methods The study was a cross-sectional epidemiological survey based on a conceptual model of healthcare utilization suggested by Anderson and Newman (65) and Anderson (66), that has been used in other, similar studies (67–70). The model suggests three domains of factors contributing to health service utilization: predisposing, enabling, and need-related factors. Predisposing factors include sociodemographic characteristics (71). Enabling factors reflect the individual’s means of obtaining needed healthcare and information through personal and community resources, and include such factors as availability of services, and financial and social resources (social networks). Some studies suggest that enabling factors, such as social networks and social support, present opportunities to access healthcare services (9, 30, 58, 66, 72–74); however, others show that an individual’s social relationships can both facilitate or impede utilization of healthcare services (75–77). Finally, need-related factors include self-perceptions and objective evaluations of health conditions. Sampling Data was collected using face-to-face interviews from a sample of 432 adult (18 years or older) selected from the Ethiopian community in Toronto. A variety of strategies were used to select the study population. The sample selection procedure has been described in detail in our previous report (78). The data collection took place between May 1999 and May 2000 and the overall response rate was 85%. Measurement Healthcare utilization was operationalized as visits to healthcare facilities or health professionals for consultation, diagnosis, or treatments. Respondents were asked whether they ever sought healthcare services during the past 12 months from a hospital, family physician, or any other health professional. If they sought care, they were asked the number and reasons of visits that had occurred in the study period. The independent variables included predisposing factors, enabling factors, and healthcare need. Measures of predisposing factors included socio-demographic characteristics at the time of the interview. Enabling factors
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included the respondent’s English language proficiency, social support, number of friends, and length of stay in Canada. English language proficiency was measured using subjective self-reported ratings of respondents’ ability to speak, read, and write English, rated as poor ( = 1), fair (=2), good (=3), or excellent (=4) and has an overall score of 12. The social support measure was adapted from Wolchik and colleagues (79). Three dimensions of social support were assessed: advice and information, instrumental support, and emotional support. For each dimension of support, as well as overall support, respondents’ ratings of satisfaction were measured on a scale of 1 to 10, where 1 was least satisfied and 10 was most satisfied. Healthcare needs included the presence of mental disorder, chronic physical illness and the number of somatic symptoms experienced in the past 12 months. Somatic symptoms were assessed by the Diagnostic Interview Schedule Somatization Disorder Module, (DISSDM) (80), supplemented with items found in previous studies of immigrant groups (81). The DISSDM has been recommended for clinical and community studies of somatization disorder (82, 83). Individuals were classified as having a mental disorder if diagnosed with at least one of three disorders — depression, anxiety, and/or post-traumatic stress disorder (PTSD). To measure depression and anxiety disorders, we used the Composite International Diagnostic Interview or CIDI (84), which was designed for use in a variety of cultures and settings and has previously been used in Ethiopia (85). PTSD was measured using a 19–item scale suggested by Boehnlein and Kinzie (86). We included measures of post-migration stress, recent life events and perceived discrimination, which are relevant to immigrants. Recent life events were measured using a 14-item scale developed by Pykel and colleagues (87, 88). Perceived discrimination was assessed using a series of questions developed by Noh and colleagues (89), and used previously in a similar study (90). Refugee camps internment (yes/no) was also included in the study as it can instigate persistent and serious health problems and lead to elevated healthcare utilization (91–93). The interview questionnaire was translated in to Amharic (Ethiopian national language) and study participants were offered a choice of languages (Amharic and English) for their interviews. All of them were interviewed with their preferred language, Amharic. Data Analysis Data analysis consisted of descriptive data from the study population. The relationships of study variables, and healthcare utilization were first examined using bivariate analyses. Then, variables identified as critical factors in the bivariate analyses were re-examined using multivariate
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analysis. Multiple logistic regression analysis was used to examine factors associated with health service utilization (94).
Results Table 1 summarizes the study variables and examines differences by gender. The respondents were predominantly young, with ages ranging from 18 to 59 years and a mean age of 35.3 years. Approximately 60% of the study sample was male, and female respondents were significantly younger than males (p < 0.001). More males had a university education than females (10.1% versus 32.8%). A significantly higher proportion of males were employed than females at the time of the survey (p < 0.001). Compared to females, men were also more likely to have experienced pre-migration trauma (p < 0.01) and discrimination (p < 0.001). Table 2 summarizes healthcare utilization patterns of the study sample in 12 months preceding the interview. Approximately 85% of the respondents reported receiving healthcare services from a formal healthcare provider, most often (85%) from a family physician. Roughly 17% had visited hospital emergency rooms, 5% had been hospitalized, and 0.6% had consulted other healthcare providers at least once in the study period. Compared with males, significantly higher proportions of females sought health services from mainstream healthcare providers (p < 0.05), family physicians (p < 0.01), or from hospital inpatient services for physical problems (p < 0.01). Table 3 presents the results of bivariate analyses describing the relationship of the study variables with health service utilization. Health service utilization rate was associated with gender, levels of symptomatology, and English language proficiency. Females and individuals with higher somatic symptom scores were more likely than their counterparts to have used healthcare services. Individuals with higher English proficiency scores were less likely to have used healthcare services than those with lower scores. However, when the data was further examined, it was found that most of the individuals with higher proficiency scores were males, who also had lower somatic symptom scores, indicating that the association between language proficiency and service utilization may be spurious. A number of multivariate logistic models were examined using the predictors shown in Table 3. Once the gender difference was taken into account, only two predictors entered the equation with statistical significance (p < .05). Immigrants with at least one form of mental disorder were less likely to use health services compared to those free of mental disorders (OR =0.784, p < .05), whereas increased number of somatic symptoms was
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Table 1 Demographic and other characteristics of the study sample Variable
Total (N = 342)
Male (n = 203)
Female (n =139)
Mean age in years (SD)***
35.3 (7.2)
36.7 (7.5)
33.3 (6.3)
Marital status (currently married)
55.3%
56.2%
54.0%
High school or less
32.1%
26.4%
40.3%
College education
44.4%
40.8%
49.6%
University degree
23.5%
32.8%
10.1%
Level of education***
English language proficiency (Mean ± SD)**
9.8 ± 2.2
10.1 ± 1.9
9.4 ± 2.3
Employment status (Currently employed)***
78.1%
87.7%
64.0%
Mean age at emigration (SD)
22.9 (6.4)
23.6 (6.6)
22.1 (6.0)
9.2 ± 4.5
9.5 ± 4.7
Years in Canada (Mean ± SD) Experience of pre-migration trauma**
21.2%
27.1%
Experience of refugee camp internment
10.5%
12.6%
Discrimination score (Mean ± SD)***
2.5 ± 2.5
3.0 ± 2.4
8.7 ± 4.2 12.4% 7.1% 1.6 ± 2.2
Number of life events No Stressful life events 1–2 Stressful life events
49.9% 36.1%
47.8% 36.5%
52.9% 35.5%
‡ Stressful life events
14.1%
15.8%
11.6%
36.8%
39.4%
33.1%
Number of somatic symptoms: No somatic symptoms 1–3 somatic symptoms
42.2%
42.9%
41.7%
‡ 4 somatic symptoms
20.8%
17.7%
25.2%
Mental disorder (depression, anxiety or PTSD)
14.0%
15.8%
11.5%
Chronic illness
19.0%
18.2%
20.1%
Number of Ethiopian friends
2.72 ± 0.76
2.72 ± 0.76
2.71 ± 0.76
Number of non-Ethiopian friends
2.05 ± 0.71
2.05 ± 0.70
2.04 ± 0.71
Satisfaction with social support (Mean ± SD)
8.36 ± 1.71
8.23 ± 1.84
8.57 ± 1.46
** p < 0.01; *** p < 0.001; SD = Standard deviation Table 2 Healthcare utilization patterns of Ethiopian immigrants and refugees in Toronto Variable
Total (N = 342)
Male (n = 203)
Female (n = 139)
Sought any health services*
85.1%
81.8%
89.9%
Family physician’s services**
85.0%
80.8%
91.2%
Emergency room services
16.5%
14.8%
19.1%
Hospitalization for physical problems**
5.0%
2.0%
9.6%
Other formal healthcare providers’ services
0.6%
0.5%
0.8%
* p < 0.05; ** p < 0.01
associated with increase in the frequency of healthcare service use (OR = 1.515, p < .05). With these predictors in the equation, females used healthcare services more often than did males (OR=1.874), although the difference was not statistically significant.
Discussion
The main objective of this study was to assess the level and pattern of health service utilization by Ethiopian
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immigrants in Toronto and to identify factors associated with healthcare use. We found that during the past 12 months most of study participants (85%) sought healthcare services and, of those, all sought care from family physicians. This rate of family physician service use was slightly higher than that of the Ontario population as a whole (80%) (95) and consistent with other reports. Another study assessing the healthcare services use by immigrants and other ethnic/cultural groups in Ontario (37) found that the percentage of study participants who had ever visited family physician’s office in the 12 months
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Table 3 Bi-variate logistic regression analyses of healthcare utilization Variable
B
SE
OR
95% C.I. of OR
Age (years)
-0.001
0.021
0.999
(0.96, 1.04)
Gender (female)
0.688*
0.335
1.990
(1.03, 3.84)
Marital status (currently married)
0.299
0.327
1.348
0.74, 2.45
£ High school
0.285
0.405
1.329
(0.60, 2.94)
College education
0.218
0.374
1.244
(0.60, 2.59)
Level of education:
University degree (reference)
1.000 –0.178*
0.080
0.837
(0.72, 0.98)
Employment status (currently employed)
0.651
0.430
0.522
(0.22, 1.21)
Mean age at emigration
0.003
0.024
1.003
(0.96, 1.05)
Years stayed in Canada
0.022
0.036
1.022
(0.95, 1.10)
Pre-migration trauma
0.368
0.412
1.445
(0.65, 3.24)
Refugee camp internment
0.491
0.636
1.633
0.47, 5.80)
Discrimination score
0.038
0.067
1.038
(0.91, 1.18)
Number of post-migration stressful life events Number of somatic symptoms
0.019 0.373**
0.106 0.109
1.019 1.451
(0.82, 1.25) (1.17, 1.79)
English language proficiency score
Mental disorder
–0.121
0.098
0.886
(0.73, 1.1)
Chronic illness
–0.448
0.433
0.639
(0.27, 1.49)
Number of Ethiopian friends
–0.108
0.204
0.897
(0.60, 1.34)
Number of non-Ethiopian friends
–0.317
0.216
0.728
(0.47, 1.11)
0.022
0.094
1.022
(0.85, 1.23)
Satisfaction with social support
* p < 0.05; ** p < 0.01; b = Beta coefficient; SE = Standard error; C.I. = Confidence interval; OR = Odds ratio
preceding the interview was slightly higher among immigrants than non-immigrants. Similar findings were reported in a study of healthcare utilization by immigrants and nonimmigrant populations in a multicultural neighborhood in Montreal (30). Our findings differed, however, from a study (32) that found similar rates of medical service use by immigrants and non-immigrants but members of ethnic groups made more visits to specialists. Notably, males and females in our sample did not utilize healthcare services at the same rate. Compared to males, a higher proportion of females had utilized healthcare services in the past 12 months. This finding is similar to patterns observed in other studies (9, 10, 13, 21, 95) that found females to be more likely than males to report frequent contact with the healthcare system. Controlling for gender, only two variables were associated with healthcare use, number of somatic symptoms and mental disorder. Many other studies conducted in immigrant populations have found somatic symptoms to be strongly associated with healthcare utilization (92, 96, 97). Somatic symptoms are often considered to be an expression of psychological distress (97–99), and individuals who report more somatic symptoms are more likely to have contacts with the healthcare system (92, 97, 98). It is difficult to determine the extent to which somatic symptoms do represent emotional disorders in our sample. However, it suggests that
family physicians ought to pay careful attention to the possibility of finding emotional problems in patients with somatic symptoms. Our finding that study participants with a mental disorder were less likely to use healthcare services than participants without a mental disorder was somewhat surprising and deserves further discussion. It is possible that study participants did not recognize mental disorders as such and thus healthcare was not sought. In the area of physical and mental health, a vast literature attests to cultural variations in perceptions of health and help-seeking behaviour (16, 47, 100). Alternatively since the presence of a mental disorder was defined in terms of lifetime prevalence, it is possible that participants with mental disorders had sought healthcare in the past, and as a result of negative experiences did not seek healthcare again in the 12 months preceding the survey. There is ample evidence that immigrants often receive culturally inappropriate care or experience multiple barriers to care (36, 39, 47, 101). Another possible explanation is that Ethiopian immigrants with mental health problems prefer to use non-health professionals for mental health care. For example, in the Ethiopian Orthodox Church, a mental disorder is thought to result from possession by evil spirits. Patients are treated by priests using prayer, holy water, and even exorcism. These traditional conceptions and treatments of mental health problems are
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well documented (102–108). Thus, as most Ethiopians in Canada are relatively recent immigrants, (78, 109) they could carry over their traditional conceptions and treatments of mental health to the host country. Not surprisingly, we found that Ethiopian were more likely to consult religious leaders and traditional healers than medical professionals for emotional problems (data not reported). To our knowledge, the present study is the first community health survey of Ethiopians in North America. Among its strengths are its sampling procedure and the excellent response rate. However, the study has certain limitations and the results should be interpreted accordingly. For example, potential candidates may have been excluded if they had no telephone or membership status in Ethiopian organizations. Identifying Ethiopian Muslim names from non-Ethiopian Muslim names in the telephone directory was difficult and as a result we may have excluded Ethiopian Muslims who were not members of Ethiopian Muslim organizations in Toronto. It is difficult to estimate the number of potential study participants we did not reach, or how they might differ from those who participated in the study. Our outcome measure of healthcare utilization did not specify the main purpose of the healthcare visit or whether visits were for prevention. This is another study limitation since the literature suggests that immigrants experience the greatest barriers in accessing preventive services. Similarly, lack of data on perceived health status; a strong predictor of healthcare utilization (66) is another limitation. In addition, the use of subjective selfreported rating of English proficiency may underestimate or overestimate respondents’ English language ability. Nevertheless, our findings have important implications for healthcare service delivery. Given the high utilization rate of family physicians by Ethiopian immigrants, it would seem that family physicians could play an important role in identifying and treating Ethiopian clients who come to them with somatic symptoms, as these symptoms may reflect mental health problems. Since emotional symptoms seem less likely to be presented by patients in primary care (99), family physician should ask their Ethiopian clients, with somatic symptoms, specific questions about their emotional problems. Further research is necessary to determine the reasons for the low rate of mental healthcare services use. Acknowledgment This research project was supported by research grant from Heritage Canada to Dr. Ilene Hyman (1998) and from the Centre of Excellence for Research in Immigration and Settlement to Dr. Samuel Noh and Dr. Ilene Hyman. We also acknowledge Li Clark whose editorial work has improved significantly the quality of this manuscript. We want to thank all the participants of the study and the Ethiopian Community leaders without whose honest contributions to the present study would have not been possible.
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