09/10/2019 Healthcare utilisation in the country of origin among immigrants in Denmark: the role of trust in the Danish healthcare system Authors: María P Zapata, Allan Krasnik, Susanne Rosthøj, Kristine Sorgenfri Hansen, Signe Smith Jervelund Kristine Sorgenfri Hansen, MSc Centre Coordinator University of Copenhagen Danish Research Centre for Migration, Ethnicity and Health (MESU) krsh@sund.ku.dk

09/10/2019 Background Cross-border healthcare utilisation is frequent among immigrants living in high-income countries. Very few studies have investigated reasons behind this behaviour Objective Explore factors motivating healthcare utilisation in the country of origin among immigrants in Denmark, focusing on distrust and communication in the Danish healthcare system. Cross-border healthcare use is more frequent among immigrants living in high-income countries compared with the native-born residents. However, there have been few studies investigating the reasons behind this healthcare seeking behaviour, both qualitatively and quantitatively. Denmark has a universal tax-based healthcare system with very few user charges, however a national survey study revealed that 26.6% of Turkish immigrants used cross-border healthcare services within the last year. A Dutch study found that cultural distance to the healthcare system in the new country was associated with cross-border healthcare use, and a Finnish study found that using cross-border healthcare services was associated with lower social integration. It has also been found that distrust in national healthcare services trigger patients to consider going abroad for care. However, this has never been investigated among immigrants in a European context before. The aim of the study was therefore to elucidate risk factors for seeking healthcare in country of origin among immigrants in Denmark, and to explore whether healthcare use country of origin was associated with distrust in the Danish healthcare system and poor communication with Danish healthcare providers.

Data and Measurements Sample size: 09/10/2019 Data and Measurements Sample size: 1,578 immigrants at a Danish language school Survey Data: Use of healthcare in country of origin Trust in Danish healthcare system Communication between immigrant and Danish healthcare providers Registry Data: Socio-demographic information Survey data stemmed from an intervention study performed in 2012-2013 with the primary objective of assessing whether healthcare information would affect immigrants’ healthcare-seeking behaviour. This data stems from the baseline survey done before the intervention. The sample size consisted of adult immigrants attending a free Danish language school The survey data was linked to registry data of socio-demographic factors such as gender, age, educational level, employment, etc. Multivariable logistic regression analyses were carried out to examine the association between cross-border healthcare utilisation and distrust in the Danish healthcare system, adjusted by covariates added progressively with demographic factors, socio-economic factors and quality of communication. Analyses were performed using R version 3.0.2. P-values less than 0.05 were considered significant.

Prevalence of healthcare utilisation in country of origin 09/10/2019 Prevalence of healthcare utilisation in country of origin   Healthcare Utilization in country of origin N No (%) Yes (%) P-value Distrust No 730 463 (63) 267 (37) <0.001 Yes 784 329 (42) 455 (58) 48% had used healthcare services in their country of origin, either when on vacation and/or when they were really sick. 58% of the respondents reported distrust in the Danish healthcare system In total, 48% of the respondents reported to use healthcare in their country of origin, either on vacation and/or when they were very ill. 58% of the respondents distrusting the Danish healthcare system and 37% of respondents trusting the Danish system travelled to their country of origin to utilize healthcare services.

Association between healthcare use and distrust 09/10/2019 Association between healthcare use and distrust Odds ratios describing the association between healthcare utilization in country of origin and distrust in Danish healthcare services   Model I* ( n= 1,514) Model II** (n=1,346) OR (95% CI) p Distrust <0.001  <0.001 No Ref. Yes 2.40 (1.95-2.96) 2.36 (1.87-2.98) This table illustrates the unadjusted and adjusted odds ratio for the association between distrust in the Danish healthcare system and healthcare utilization in country of origin. The association between distrust and healthcare utilization in country of origin persisted in the adjusted analysis (Odds Ratio of 2.36). This model has been adjusted for gender, age, grounds for residence permit, country of origin, country of origin of spouse, length of residence in Denmark, educational level, employment status, household income level, and quality of communication between immigrants and Danish healthcare providers. *Model I: Unadjusted **Model II: Adjusted for gender, age, grounds for residence permit, origin, origin of spouse, length of residence in Denmark, education, employment status, and household income and quality of communication.

Other main findings Sex OR (95% CI) P-Value <0.001 Male Ref. Female 09/10/2019 Other main findings Sex  OR (95% CI)  P-Value   <0.001 Male Ref. Female 1.70 (1.31-2.20) Origin 0.03 Westernb South & East Asia 1.04 (0.75-2.84) Sub-Saharan Africa 0.56 (0.35-0.90) Middle East/ North Africa 0.87 (0.58-1.30) Otherc 1.46 (0.75-2.84) Spouse origin 0.08 Danish Western 1.40 (0.79-2.49) Non-Western 1.58 (1.06-2.36) No Spouse 1.90 (1.17-3.09) Not associated factors: Age, grounds for residence permit, length of residence in Denmark, employment status, household income and quality of communication. The following factors were associated with healthcare use in countries of origin: Being a female, having a non-western spouse or no spouse, and educational level - as education level increased, the use of healthcare services in country of origin decreased. Immigrants married to an ethnic Dane or originating from Sub-Saharan Africa were least likely to use healthcare services in country of origin. Interestingly, age, grounds for residence permit, length of residence in Denmark, employment status, household income and quality of communication between immigrants and Danish healthcare providers did not seem to be associated with utilization of healthcare services in their country of origin.

09/10/2019 Conclusion High frequency of healthcare utilization in country of origin Distrust in the Danish healthcare system may be a motivating factor Need for building trust in the Danish healthcare system, especially among female immigrants, immigrants with a non-western spouse or no spouse, and a low to medium educational level. Further research is needed to understand the root causes of distrust in the Danish healthcare system. In this combined survey and registry study, we observed a very high frequency (48%) of healthcare utilization in the country of origin and distrust in the Danish healthcare system by the responding immigrants. Although, this study did not investigate reasons for distrusting the Danish healthcare system, it did provide further evidence that immigrants’ relative high distrust in the new country’s healthcare system may affect their healthcare-seeking behaviors, such as seeking care abroad. This knowledge can serve as a platform for development of policies and services in the Danish healthcare system to increase the level of trust, such as interpretation assistance, cultural competence training for healthcare professionals, improved provision and access to information about the Danish healthcare system to help immigrants navigate the system. Further research is needed to understand the root causes of immigrants’ distrust in the Danish healthcare system, how it potentially affects their use of healthcare services in Denmark, and ultimately how it may affect the immigrants’ own health.

Acknowledgements and further info 09/10/2019 Acknowledgements and further info A special thank you to the management, teachers and students at the language school and Camilla Lawaetz Wimmelmann For mere information: www.sulim.ku.dk or contact Signe Smith Jervelund (ssj@sund.ku.dk)