1. EUPHA conference, Helsinki, October 10, 2007 Dias 1 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)"

2. EUPHA conference, Helsinki, October 10, 2007 Dias 2 Department of Health Services Research Disposition Identification of data sources Registration of data Prelimanary findings Problems PhD-protocol

3. EUPHA conference, Helsinki, October 10, 2007 Dias 3 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

4. EUPHA conference, Helsinki, October 10, 2007 Dias 4 Department of Health Services Research Registration of data 1.Name of source (eg. Survey) 2.Year 3.Frequency 4.Past year 5.Next year 6.Study design 7.Number of people included 8.Number of respondents 9.Response rate 10.Collection of information on non-respondents 11.Area of collection (local, national) 12.Groups (e.g. patients, general population)

5. EUPHA conference, Helsinki, October 10, 2007 Dias 5 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

6. EUPHA conference, Helsinki, October 10, 2007 Dias 6 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

7. EUPHA conference, Helsinki, October 10, 2007 Dias 7 Department of Health Services Research Registration of data For studies: Main results Registers: Date of establishment Surveys: Only from 1997-

8. EUPHA conference, Helsinki, October 10, 2007 Dias 8 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)

9. EUPHA conference, Helsinki, October 10, 2007 Dias 9 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

10. EUPHA conference, Helsinki, October 10, 2007 Dias 10 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

11. EUPHA conference, Helsinki, October 10, 2007 Dias 11 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

12. EUPHA conference, Helsinki, October 10, 2007 Dias 12 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

13. EUPHA conference, Helsinki, October 10, 2007 Dias 13 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

14. EUPHA conference, Helsinki, October 10, 2007 Dias 14 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

15. EUPHA conference, Helsinki, October 10, 2007 Dias 15 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.

16. EUPHA conference, Helsinki, October 10, 2007 Dias 16 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.

17. EUPHA conference, Helsinki, October 10, 2007 Dias 17 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.

18. EUPHA conference, Helsinki, October 10, 2007 Dias 18 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: 1) 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.

19. EUPHA conference, Helsinki, October 10, 2007 Dias 19 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

20. EUPHA conference, Helsinki, October 10, 2007 Dias 20 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

21. EUPHA conference, Helsinki, October 10, 2007 Dias 21 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)

22. EUPHA conference, Helsinki, October 10, 2007 Dias 22 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

23. EUPHA conference, Helsinki, October 10, 2007 Dias 23 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.

24. EUPHA conference, Helsinki, October 10, 2007 Dias 24 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."