Queensland University of Technology School of Public ... · Use of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland i Abstract Background

Queensland University of Technology

School of Public Health & Social Work, Faculty of Health

USE OF HOSPITAL EMERGENCY DEPARTMENTS BY

IMMIGRANTS FROM NON-ENGLISH SPEAKING

BACKGROUNDS IN QUEENSLAND

Ibrahim Mahmoud

MBBS, MSc., MPH

A Thesis by Publications

This thesis is submitted to fulfill the requirements for the degree of

Doctor of Philosophy at Queensland University of Technology

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Use of hospital emergency departments by immigrants from non-English speaking backgrounds in

Queensland i

Abstract

Background

Several international studies have revealed differences in the use of emergency

department (ED) services between immigrants and local populations, caused by

language and cultural barriers. Despite the increasing numbers of immigrants, only a

limited body of literature describes immigrants’ use of hospital ED services in

Australia.

Aim

The aim of this research was to examine the patterns of ED service use among

patients from a non-English-speaking background (NESB) compared to those of

patients from an English-speaking background (ESB), focusing on public hospitals in

Queensland (QLD), Australia. It was also sought to analyse the primary reasons for

ED service use and to investigate the extent of the NESB patients’ satisfaction with

the ED service.

Methods

To address the above aims, a secondary data analysis of Emergency Department

Information System (EDIS) data in Queensland public hospitals for the 3 calendar

years, from 1 January 2008 to 31 December 2010 was undertaken. Patients were

divided into groups based on language spoken at home. Differences in ambulance

utilisation as a mode of arrival, length of stay in ED, and admission to the hospital as

a departure status were tested. Furthermore, primary source data were collected at the

ED of an adult tertiary-referral hospital in Queensland to analyse the subjective

iiUse of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

reasons for ED service use and investigate the level of satisfaction with the service

provided among NESB patients compare to that of ESB patients.

Results

The ED utilization rate was highest among the English-only speakers (290 per 1,000

people), followed by Arabic speakers (105), and was lowest among German speakers

(30). Compared with English speakers, ambulance use rates by Chinese (odds ratio

0.50, 95% confidence interval, 0.47–0.54), Vietnamese (0.87, 0.79–0.95), and Arabs

(0.87, 0.78–0.97) were lower. NESB patients from refugee source countries (IRSC)

had longer lengths of stay (LOS) in the ED, that is, 33.0 (95% CI 28.8–37.2)

minutes, patients from main English speaking countries (MESC) had 6.6 (95% CI

5.8-7.4) minutes, and patients from other countries (IOC) had 9.4 (95% CI 8.5-10.4)

minutes, compared to Australian-born patients. The NESB patients were less

satisfied with the ED service than the ESB patients (OR 0.4, 95% CI 0.3–0.6, p <

0.05). Furthermore, the NESB patients were far more likely than the ESB patients to

report the absence of a GP (OR 4.0, 95% CI 2.1–7.4, p = 0.001) or experience of

long delays when seeking a GP consult (OR 7.1, 95% CI 3.4–13.3, p = 0.001) as

their reason for coming to the ED.

Conclusion

NESB patients use the ED service differently from ESB patients. The former had

lower utilisation, longer LOS, least likely to consider contacting a GP before

attending ED, and are less satisfied with the service than the latter. Future studies on

specific minority groups and employing representative samples might provide further

information relevant to addressing the unique health needs of such groups, and would

provide insight into the barriers that prevent these patients from being satisfied with

their ED service. Such studies could help in the development of educational


Queensland iii

programs for such populations and in the framing of policies for facilitating access to

health care services, including the ED service.

Key words: barriers, emergency department, immigrant, language, satisfaction

ivUse of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

Table of Contents

Abstract ..................................................................................................................................... i

Table of Contents .................................................................................................................... iv

List of Figures ......................................................................................................................... vi

List of Publications and Conference Presentations Related to the Research.......................... vii

List of Abbreviations ............................................................................................................... ix

Statement of Original Authorship ............................................................................................ x

Acknowledgements ................................................................................................................. xi

Chapter 1: Introduction............................................................................................. 1

Background .............................................................................................................................. 1

Context ..................................................................................................................................... 4

Purposes ................................................................................................................................... 4

Significance of the study .......................................................................................................... 5

Terminology and definitions .................................................................................................... 7

Chapter 2: Literature Review ................................................................................. 11

Background ............................................................................................................................ 11

Article 1: Immigrants and the utilization of hospital emergency departments (literature

review) .................................................................................................................................... 14

Chapter 3: Research Design and Methodology ..................................................... 31

Framework and Research Questions ...................................................................................... 31

Hypothesis…………………………………………………………………………...33

Methodology .......................................................................................................................... 33

Participants ............................................................................................................................. 34

Instruments ............................................................................................................................. 34

Analysis .................................................................................................................................. 36

Ethics ...................................................................................................................................... 37

Chapter 4: Results (Articles) ................................................................................... 39

Study I: Pilot Study ................................................................................................................ 39

Article 2: Is language a barrier for quality care in hospitals? ................................................. 40

Study II: A Population-Based Study ...................................................................................... 52

Article 3: Language and utilisation of emergency care in Queensland .................................. 52

Article 4: Language affects the length of stay in emergency departments in Queensland

public hospitals ....................................................................................................................... 70

Article 5: Utilisation of hospital emergency departments among immigrants from refugee

source-countries in Queensland .............................................................................................. 83

Study III: A Cross-sectional Survey ....................................................................................... 97


Queensland v

Article 6: Satisfaction with emergency department service among non-English speaking

background patients ................................................................................................................97

Article 7: Why patients from non-English speaking backgrounds visit the emergency

department.............................................................................................................................115

Chapter 5: General Discussion ............................................................................. 129

Utilization Rates....................................................................................................................129

Modes of Arrival at the ED ...................................................................................................130

ED Length of Stay ................................................................................................................131

Departure Status ....................................................................................................................133

Reasons for Attending the ED ..............................................................................................133

Satisfaction with ED Service ................................................................................................134

Limitations ............................................................................................................................136

Chapter 6: Conclusions & Recommendations ..................................................... 139

Conclusion ............................................................................................................................139

Recommendations Based on the Research Findings .............................................................139

Bibliography ........................................................................................................... 141

Appendices ............................................................................................................ 151

Appendix A Questionnaire & information sheet ..................................................................151 Questionnaire ........................................................................................................................... 151 Information Sheet..................................................................................................................... 155

Appendix B Ethics approvals ................................................................................................156 Study I .............................................................................................................................. 156 Study II .............................................................................................................................. 158 Study III .............................................................................................................................. 160

Appendix C Conference participation certificate ..................................................................161

viUse of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

List of Figures

Fig. 1. Anderson’s model of access to medical care (Andersen, R. M. (1995).

Revisiting the behavioral model and access to medical care: Does it matter? Journal

of Health and Social Behavior, 36(1), 1–10.)……………………………………..33

Fig.2 Distribution of the language groups that visited hospital EDs per 1000

population, QLD 2008–2010 (Mahmoud, I., Hou, X., Kevin, C., & Clark, M. (2013).

Language and utilisation of emergency care in Queensland. Emerg Med Australas,

25(1), 40-45.)………………………………………………………………………..61


Queensland vii

List of Publications and Conference Presentations Related to the

Research

Journal articles published/submitted

Mahmoud, I., & Hou, X-Y. (2012). Immigrants and the utilization of hospital

emergency departments. World Journal of Emergency Medicine, 3(4), 245–

250.

Mahmoud, I., Hou, X-Y., Kevin, C., & Clark, M. (2011). Is language a barrier for

quality care in hospitals? Australasian Epidemiologist, 18(1), 6–9.

Mahmoud, I., Hou, X-Y., Kevin, C., & Clark, M. (2013). Language and utilisation

of emergency care in Queensland. Emergency Medicine Australasia, 25(1),

40–45.

Mahmoud, I., Hou, X-Y., Kevin, C., & Clark, M. (2013). Language affects the

length of stay in emergency departments in Queensland public hospitals.

World Journal of Emergency Medicine, 4(1), 5–9.

Mahmoud, I., Hou, X-Y. (2013). Utilisation of hospital emergency departments

among immigrants from refugee source-countries in Queensland. Clinical

Medicine and Diagnostics, 3(4), 88–91.

Mahmoud, I., Hou, X-Y., Chu, K., Clark, M., & Eley, R. (in press). Satisfaction

with emergency department service among non-English speaking background

patients. Emergency Medicine Australasia.

Mahmoud, I., Hou, X-Y., & Eley, R. (in preparation). Why patients from non-

English speaking backgrounds attend the emergency department.

viiiUse of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

Presentations

Presentation to the Princess Alexandra Hospital (PAH) Multicultural Steering

Committee (2012)

Presentation to the research group of the PAH (2012)

Mahmoud, I. (2013). Use of emergency department in Queensland public hospitals

by immigrants. Paper presented at 18th

World Congress on Disaster &

Emergency Medicine, Manchester, UK.


Queensland ix

List of Abbreviations

ABS: Australian Bureau of Statistics

ATS: Australasian Triage Scale

ED: Emergency department

EDIS: Emergency Department Information System

ESB: English speaking background

GP: General practice/General practitioner

LOS: Length of stay

NESB: Non-English speaking background

IOC: Immigrants from other countries

IRSC: Immigrants from refugee source countries

MESC: Immigrants from main English speaking countries

PAH: Princess Alexandra Hospital

RBWH: Royal Brisbane Women’s Hospital

SEO: Patients who speak English only at home

NSEO: Patients who do not speak only English or who speak another language at

home

QLD: Queensland

UNHCR: United Nations High Commissioner for Refugees

WHO: World Health Organization

xUse of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet the

requirements for an award at this or any other higher education institution. To the

best of my knowledge and belief, the thesis contains no material previously

published or written by another person except where due reference is made.

Signature: _

Date: _________________________ 25/03/2014

QUT Verified Signature


Queensland xi

Acknowledgements

I would like to acknowledge my principal supervisor Associate Professor Xiang-Yu

(Janet) Hou for her great encouragement, support, inspiration and guidance during

the completion of this research. My deep gratitude also goes to my associate

supervisors Professor Michele Clark and Dr Kevin Chu for their invaluable

comments, feedback and guidance throughout my PhD journey.

I am also grateful to the Hospital Access Analysis Team (HAAT) of Queensland

Health, the data custodians of the EDIS data, and particularly Jean Sloan, who

extracted and provided the data.

I also would like to extend my thanks to the staff at the emergency department of

Princess Alexandra Hospital (PAH) for welcoming me during my primary data

collection. Many thanks to Diana Nocente, the Manager, Multicultural & Interpreter

Services, and Dr Rob Eley, the Academic Research Manager at PAH, who assisted

me with obtaining the ethics approval and took care of me during the data collection.

I am also grateful to all the study participants.

My heartfelt thanks to my wife Sahar, my children Aya and Ahmed, and my parents,

for their constant love, support and encouragement during my studies and in life.

Chapter 1: Introduction 1

Chapter 1: Introduction

Background

Migration has occurred throughout human history as a way for people to develop and

improve their lives. Historically, people have moved periodically following hunting

or gathering cycles (Jupp, 2001). Additionally, wars and the fear of genocide and

political or religious persecution have been contributing factors leading to migration

(DIAC, 2006). Human migration to the Australian continent is estimated to have

begun around 50,000 years ago, when the ancestors of the Australian Aborigines

arrived on the continent (Jupp, 2001). The first recorded European contact with

Australia was in the seventeenth century; however, colonisation only started in 1788

(Jupp, 2001). Australia entered a boom era after World War II and launched a

massive migration program dominated by the “White Australia policy” (Jupp, 2002).

Thousands of refugees and immigrants from Europe arrived in Australia during the

immediate post-war period (Jupp, 2002), and more than two million Europeans

migrated to Australia during the twenty years following the end of World War II

(Smolicz, 1997). Although the majority of these immigrants came from Britain and

Ireland, other European countries, such as Greece, Italy, Germany, Yugoslavia and

the Netherlands, also became predominant sources of immigrants (Smolicz, 1997).

Political refugees fleeing dictatorships in Spain and Portugal, and Communism in

Hungary, Czechoslovakia, Poland and the former Soviet Union (Russia) also

contributed to the migration during that period (DIAC, 2001). In 1972, the Labour

government announced a completely non-discriminatory migration policy which led

to a significant increase in immigration from Asian and other non-European

countries (Jupp, 2002). Since the end of Vietnam War, Australia has experienced a

2 Chapter 1: Introduction

large intake of Asian immigrants with a notable increased intake of Vietnamese

refugees (DIAC, 2001). In 1983, the level of British immigration was below the level

of Asian immigration for the first time in Australian history; thus began a new era of

multicultural migration to Australia (DIAC, 2001).

Australia’s immigration program has increased dramatically over the past decade,

from 70,200 immigrants in 1999–2000 to 168,685 in 2010–2011 (DIAC, 2011). The

major contributors to Australia’s immigration, permanent and temporary, include

skilled migrants, international students, family migrants, visitors and working

holiday-makers (DIAC, 2011).

In addition, Australia is among the countries that agreed to accept refugees under the

United Nations High Commissioner for Refugees (UNHCR) (UNHCR, 2005). After

the United States, Australia has the second highest refugee resettlement in the world,

in proportion to its population (UNHCR, 2005). The UNHCR has described

Australia as “one of the leading countries in the resettlement of this high-needs

group” (UNHCR, 2005). In 2010–2011 Australia allocated over 13,000 places under

its Humanitarian Program (Parliament of Australia, 2011). Since 2001, the largest

numbers of refugees have come from sub-Saharan African, the Middle East and Asia

(Jeanine, 2005; Thomas, Beckmann, & Gibbons, 2010).

Queensland (QLD) is the second largest in land mass and third most populous state

of Australia, located in the northeast of the country. QLD represents an attractive

destination for immigrants coming to Australia. The state’s population was estimated

at over 4 million in 2009, representing 20.2% of the Australian population (OESR,

2009). Overseas immigration made the largest contribution to QLD’s population

growth in 2009 (50.0%), followed by natural population increase (37.3%) and net

interstate migration (12.7%) (OESR, 2009).


The significant increase in immigration to Australia, including QLD, from all around

the world was accompanied by increased cultural and linguistic diversity. The 2011

Census revealed that almost one quarter (24.6%) of Australia’s 21 million inhabitants

were born overseas (ABS, 2013). Accordingly, the number of people whose primary

language is not English has increased dramatically. In total, over 260 different

languages are spoken in homes across Australia (DIAC, 2001). This increase in

language and cultural diversity poses new social, health, economic and political

challenges to Australia’s local governments in providing equitable services to people

who communicate ineffectively in English or who integrate poorly into the

Australian culture.

Immigrants’ right to access health care services was stated by the Universal

Declaration of Human Rights (UDHR): “Everyone has the right to a standard of

living adequate for health and well-being of himself and her/his family, including

food, clothing, housing, medical care…” (UN, 1948). Further, the World Health

Organization (WHO) has outlined policy and legal frameworks for immigrants

health: “adopt relevant international standards on the protection of migrants and

respect for rights to health in national law and practice; implement national health

policies that promote equal access to health services for migrants; extend social

protections in health and improve social security for all migrants” (Vertovec, 2006).

However, differences in language and cultural backgrounds between the health care

providers and recipients may create barriers to accessing health care services, which

may contribute to health disparities within the population (Hornberger et al., 1996).

Therefore, ensuring that health services are delivered to immigrants in a culturally

and linguistically appropriate way may reduce disparities in health (Brach &

Fraserirector, 2000).


Context

Studies on immigrant issues such as health, education, and rights are essential to

improve policies and programs to address the multiple needs and consequences of

these movements of people. In Australia, particularly in QLD, there is a lack of

studies on immigrants’ health issues, such as access to health care services, including

emergency department (ED) service.

This study aimed to examine the patterns of ED service use among the general

population of non-English speaking background (NESB) patients. In addition, it

aimed to analyse the primary reasons for ED service use and investigate the level of

satisfaction with ED service among NESB patients compared to that of English

speaking background (ESB) patients attending QLD public hospitals.

To accomplish the above aims, the study undertook a secondary data analysis of

Emergency Department Information System (EDIS) data in QLD. Furthermore,

primary source data were collected on the patients’ subjective reasons for using the

ED service as well as their level of satisfaction with the services provided.

Purposes

The main purpose of the research was to study how immigrants from NESBs use the

ED service compared to English speaking background (ESB) patients in QLD, in

terms of utilization rate, mode of arrival, departure status and length of stay (LOS) in

the ED. Another purpose was to investigate the primary reasons for ED service use

and satisfaction among NESB patients compared to ESB patients in QLD. The study

endeavoured to answer the following questions: Are the patterns of ED utilization

and outcomes similar or different for NESB patients compared to ESB patients?

What are the primary reasons for ED use among the two groups? Finally, are NESB

patients less satisfied with the ED service than the ESB patients?


Significance of the study

As migration increases, especially that of vulnerable populations, the health of

immigrants and their access to health care services become increasingly important

issues. One of the great challenges for policymakers is to address immigrants’ health

needs, some of which may be complex. First, immigrants are a potentially vulnerable

population, as they are exposed to a number of health risks prior to, during and after

immigration. Second, immigrants have disease profiles that differ from those of the

principal populations of their host countries. Finally, health service barriers in host

countries such as language barriers, cultural barriers, and unfamiliarity with the

health system may hinder immigrants’ access to care. For these reasons, immigrants’

health has emerged as a new discipline concerned with immigrant health and the

determinants thereof, as well as access to health care in host countries.

Immigrants’ access to health care services, such as ED services, and the outcomes

thereof have been widely studied in several countries. However, there are important

limitations in those studies. In some cases, there was little analysis of the factors that

may be related to health status and ED utilization, such as ethnicity, country of

origin, language proficiency, SES, and age (Buron et al., 2008; Cunningham, 2006;

Ku & Matani, 2001). Some examined specific groups of immigrants in particular

countries (Norredam et al., 2004; Norredam et al., 2007). Others looked at heath

service utilization in general, using data not collected specifically for ED care use

(Correa-Velez et al., 2007; Wen et al., 1996). In addition, limited literature has

shown whether the increased use of ED service is due to an increase in critical

conditions that required ED care or to inappropriate ED access. Identifying the

reasons for coming to the ED might provide additional insights about the different

motivations for ED use among immigrants.


In general, the majority of the studies about immigrants' utilization of health services

might not be applicable to Australia, as immigrants' characteristics in other countries

as well as their health systems might differ from those in Australia. At present, a

limited body of literature exists describing the use of ED care by immigrants from

NESBs in Australia, and no literature exists about the satisfaction with ED care

among immigrants from NESBs. Therefore, there is a need for further Australian

research focusing on hospital ED care utilization by immigrants from NESBs. This

would be helpful in the development of policies that ensure equity when planning

health care provision to immigrants.

This study may provide valuable new knowledge which may encourage more

research to follow and will aid in the development of educational interventions to

assist NESB patients with accessing the care that is most appropriate for their needs.

The study can also inform policy makers about locations needs to allocate more

NESB help resources and develop policies to increase the number of health care

providers from NESBs, in ED and GP settings, in certain areas. In addition, the study

may help in delivering health information in a culturally sensitive way using familiar

and accepted language.


Terminology and definitions

Emergency Department Information System (EDIS): The EDIS is an electronic

information record of the activities of public hospital EDs in QLD. The EDIS

provides information on mode of arrival (ambulance or walk-in, arriving via public

transport or otherwise), triage category, gender, age, country of birth, language

spoken at home and ED departure status (admission to hospital, did not wait, died or

discharged).

English Speaking Background (ESB): In this thesis, persons from an ESB are those

from the principal English-speaking countries (Australia, Canada, New Zealand, the

Republic of Ireland, South Africa, the United Kingdom and the United States) (ABS,

2013).

Immigrants: The literature is inconsistent in its definitions of migrants and

immigrants. Several terms have been used in the public and scientific debates

including guest workers, migrants, immigrants, refugees, ethnic groups, ethnic

minorities and racial groups. Morris (1981) defined an immigrant as a person who

migrates to another country with the intention of staying for some time or

permanently (Morris, 1981). In this study, I chose to use the word “immigrant” as an

umbrella term including everyone entering Australia with the intention to stay for

one year or more and who might use EDs, such as skilled immigrants, refugees and

international students. The study primarily focused on the first generation of NESB

immigrants.

Immigrants from refugee source countries (IRSC): Information about

immigration status and distribution of refugees is not available from the EDIS.

Therefore, the study used country of birth as a proxy indicator of refugee status

(Correa-Velez et al. 2007).


A cut-off was made from 1980 onwards to differentiate recent refugee countries from

former refugee countries, who entered to Australia through Refugee and

Humanitarian program (Correa-Velez et al. 2007). The new refugee source countries

as indentified by ABS are Afghanistan, Bosnia-Herzegovina, Burma, Eritrea,

Ethiopia, Iraq, Somalia, and Sudan (Correa-Velez et al. 2007).

The study examined whether disadvantaged immigrants born in refugee source

countries (IRSC), as part of NESB, are different in the use of ED in QLD from those

immigrants born in main English speaking countries (MESC), as part of EBS, and

other countries (IOC), as part of NESB, using the local population (LP) as the

reference group.

Different terms were sued for different studies due to the availability of the

information.

Immigrants from main English speaking countries (MESC): A main English-

speaking country (MESC) is used to describe people migrating from United

Kingdom, the Republic of Ireland, New Zealand, Canada, South Africa and the

United States of America, as per Australian Bureau of Statistics (ABS) (Australian

Bureau Statistics (ABS) 2013).

Non-English Speaking Background (NESB): Those from an NESB are defined by

the QLD Government (Equal Opportunity in Public Employment Act 1992) as “those

who have migrated to Australia and whose first language is a language other than

English and the children of those people.” Immediately after World War II, the

official term for immigrants was “new Australians.” This changed to “ethnic

Australians” or “migrant Australians” in the 1970s, and to those from a “non-English

speaking background” in the 1980s and 1990s. To emphasize that being from an

NESB was not associated with disadvantage, the federal government formally


replaced the term “NESB” with “culturally and linguistically diverse” (CALD) in

1996 (Garrett, Dickson, Whelan, & Whyte, 2010).

However, in this study, I chose to employ the term “NESB” to refer to the first

generation of immigrants and to indicate that patients from this group might be

disadvantaged in terms of access to appropriate health care facilities because of

language and cultural barriers.

Use of health service: “The use of a health service is defined as the process of

seeking professional health care and submitting oneself to the application of regular

health services, with a purpose to prevent or treat health problems” (Scheppers, Van

Dongen, Dekker, Geertzen, & Dekker, 2006). In the present study, I used the term

“ED service use” in a general sense to allow me to investigate whether ED service

utilization and outcomes in QLD differ between NESB and ESB patients.

Chapter 2: Literature Review 11

Chapter 2: Literature Review

Background

A number of studies have demonstrated inequities in health status among immigrants

in developed nations (Jeanine, 2005; Quan et al., 2006; Yeo, 2004). These studies

have shown that immigrants tend to underutilize health care services compared to the

host population (Correa-Velez, Sundararajan, Brown, & Gifford, 2007; Jenkins, Le,

McPhee, & Stewart, 1996; Stronks, Ravelli, & Reijneveld, 2001). Immigrants’ lower

utilization of health care services has also been explained by the “healthy immigrant

effect” which argues that immigrants are healthier than native residents, due to

factors such as the selectivity of the immigration process (health screening prior to

migration, education level, language proficiency and age), the healthier behaviours of

immigrants prior to migration and immigrant self-selection, whereby the healthiest

and wealthiest individuals are the most likely to migrate (Baum, 2008; Kennedy,

McDonald, & Biddle, 2006). However, the healthy immigrant effect might not apply

to some categories of immigrants, such as those with refugee status. Immigrants from

refugee backgrounds may have different reasons for underutilizing health services,

such as the fear of discrimination, poor education and a lack of knowledge about the

local health system (Davidson et al., 2004). Alongside the underutilization of health

care services, these barriers may lead to inappropriate access to health care among

immigrants, such as using EDs for non-urgent conditions (Davidson et al., 2004).

Several international studies have suggested that immigrants tend to use the ED

service for non-urgent conditions at the expense of primary health care services

(DeShaw, 2006; Norredam, Mygind, Nielsen, Bagger, & Krasnik, 2007; Rué et al.,

2008). According to the literature, immigrants seek treatment in EDs for diverse

12 Chapter 2: Literature Review

reasons besides having an urgent condition. These reasons might include the fact that

emergency services are free at the point of care in most developed countries and do

not require papers, which might represent an obstacle for illegal immigrants, they can

be obtained at any time without prior appointment and require fewer administration

steps to access, which can reduce the language, cultural and legal barriers (Cots et

al., 2007; DeShaw, 2006; Norredam et al., 2007). As a result, immigrants from all

categories might place additional burdens on already overcrowded EDs in Australia

by inappropriate access to those health care facilities.

It has been argued that ED presentations for non-urgent conditions are less likely to

involve preventive care and are costlier to the health care system than visits to a

general practice (GP) or primary care clinic (DeSalvo, Rest, Knight, Nettleman, &

Freer, 2000). Moreover, such presentations may result in prolonged LOS and

increased wait times in EDs for people with more urgent conditions; together, these

factors reduce the quality of the care provided, leading to an increased probability of

complications (Ackroyd-Stolarz, Guernsey, Mackinnon, & Kovacs, 2011; Bolton,

Tilley, Kuder, Reeves, & Schultz, 1991; Norredam et al., 2007; Pines, Pollack,

Diercks, Chang, Shofer, & Hollander, 2009). In addition, the use of EDs for non-

urgent conditions might result in ED overcrowding, which increases patient

dissatisfaction and the number of patients who leave the ED before being seen

(Baker, Stevens, & Brook, 1991; Rodi, Grau, & Orsini, 2006). Consequently, it is

worthwhile to reduce the demand for the ED service and encourage patients to use

primary care services for non-life threatening conditions.

Racial, ethnic and linguistic differences in ED use and outcomes have been widely

studied in several countries; however, to date, this topic has received little attention

in

Australia.


A literature review was conducted to investigate how immigrants use the ED service

in host countries, in terms of patterns of use, relevance, LOS in the ED and

satisfaction with the ED service provided.

In general, the search uncovered that most of the studies about ED service use by

immigrants were conducted in other countries; therefore, their results might not be

applicable to Australia, as the immigrants’ characteristics and the health care systems

in these countries might differ from those of Australia. There is also no literature

about the satisfaction with the ED service provided among immigrants from NESBs

in QLD or Australia.

Article 1: Immigrants and the utilization of hospital emergency departments

(literature review)

A full literature review was published in The World Journal of Emergency

Medicine (Mahmoud & Hou, 2012).

The full article is presented below.


World J Emerg Med, Vol 3, No 4, 2012 DOI: 10.5847/ wjem.j.1920-8642.2012.04.001

Review Article

Immigrants and the utilization of hospital emergency departments

Ibrahim Mahmoud, Xiang-Yu Hou

School of Public Health, Queensland University of Technology, Queensland,

Australia

Corresponding Author: Xiang-Yu Hou, Email: [email protected]

BACKGROUND: Immigrants with language barriers are at high risk of having poor

access to health care services. However, several studies have indicated that

immigrants tend to use emergency departments (EDs) as their primary source of care

at the expense of primary care. This may place an additional burden on already

overcrowded EDs and lead to a low level of patient satisfaction with

ED care. The study was to review if immigrants utilize ED care differently from host

populations and to assess immigrants’ satisfaction with ED care.

DATA SOURCES: Studies about immigrants' utilization of EDs in Australia and

worldwide were reviewed.

RESULTS: There are conflicting results in the literature about the pattern of ED

care use among immigrants. Some studies have shown higher utilization by

immigrants compared to host populations and others have shown lower utilization.

Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a

longer length of stay in EDs, and are less satisfied with ED care as compared to host

populations.

CONCLUSIONS: Immigrants might use ED care differently from host populations

due to language and cultural barriers. There is sparse Australian literature regarding

immigrants' access to health care including ED care. To ensure equity, further

research is needed to inform policy when planning health care provision to

immigrants.

KEY WORDS: Emergency department; Health service; Immigrants; Language;

Utilization.

World J Emerg Med 2012;3(4):245–250


INTRODUCTION

In recent decades, the world has experienced a dramatic increase in all types of

migration—legal, illegal, and asylum seekers—which has increased the linguistic

and cultural diversity in many countries. The number of immigrants increased around

the globe from 150 million in 2000 to 214 million in 2010, and this number could

reach 405 million by 2050.[1]

In Australia, migration is contributing significantly to

the national population growth; the proportion of migrants increased from 45.6% in

2004 to 59.5% in 2008. [2]

This steady rise was due to an increase in the number of

international students, prosperous economy, and attractive immigration

programmes.[1]

The results of the 2006 Census revealed that 4.75 million (24%) out

of the total Australian population of 20 million people were born overseas, which is

higher than in most Western countries.[3]

There are more than 260 languages spoken

in Australian homes, with over 3 million (15.8%) people speaking a language other

than English at home.[4]

Those who do not speak English well or not at all have

represented 2.8% of the total population in 2006.[5,6] This increase in language

diversity and people who do not communicate effectively in English has imposed

challenges in accessing public services.

Language is a key element for patients to access the health care system and to

communicate with their health care providers.[7]

Language is also the means by

which physicians and nurses can learn about patients' illnesses, concerns, and

emotions, which assists greatly in delivering effective health care management to the

patients. [7, 8]

Several studies have shown that language and cultural barriers may

affect how immigrants access health care, which may contribute to health disparities.

[8] However, little is known about how immigrants utilize and access emergency

department (ED) care. [9, 10]


The purpose of this literature review is to examine how immigrants from different

language backgrounds utilize hospital ED care in host countries.

METHODS

A literature search was conducted using MEDLINE, PubMed, and Google Scholar.

The following keywords were used to search the databases: emergency department,

immigrants/migrants, language, and utilisation/use. The search was limited to

English language articles from Australia, Canada, the United States of America, and

some European countries. A total of 56 articles were retrieved and reviewed.

LITERATURE REVIEW

The hospital ED plays a vital role in the health care system. EDs are designed to care

for emergencies, such as a life-threatening illness and major injuries, and to respond

to public health threats, such as natural disasters.[11]

Pressure on hospital EDs

Overcrowding in EDs has become a serious and growing problem confronting public

hospitals worldwide. Overcrowding refers to the situation where ED function is

impeded primarily because the number of ED patients waiting to be seen, undergoing

treatment process, or waiting to be discharged exceeds the physical or staffing

capacity of the ED.[12]

A report produced by the Australian Institute of Health and

Welfare (AIHW) for the period 2008–2009 showed a higher increase in the use of

public hospital EDs compared to other health care services. [13]

Further, the AIHW

report showed that there were over 7 million visits to EDs in 2008–2009, with an

average annual increase of 4.6% since 2004–2005.[13] The report also indicated that

almost 30% of the people visiting EDs were not seen in the recommended time for

their triage category.[13]

Moreover, ED overcrowding in Australia has resulted in

ambulance diversions from hospitals.[12]


Australia is not unique in its experience of overcrowded EDs, as ED care delivery

has also been increasing in other countries. In the United States, a study found that

92% of academic emergency medicine departments are overcrowded. [14]

In Canada,

the Canadian Association of Emergency Physicians (CAEP) and the National

Emergency Nurses' Affiliation (NENA) released a joint position statement on ED

overcrowding, declaring it a serious national issue.[15]

ED overcrowding has also

been reported in Spain and Taiwan of China.[16–18]

Derlet and Richards included language and cultural barriers as one of the most

common causes of ED overcrowding due to increased length of stay and wait

times.[19]

Patterns of ED care use

A number of studies have demonstrated inequities in access to health care services

among immigrants compared to the host population in developed nations. These

studies have shown that immigrants tend to underutilize health care services

compared to the host population.[8,20,21,23]

The lower utilization of health care services

by immigrants has also been explained by the "healthy immigrant effect", which

argues that immigrants are normally in better health than local born populations, due

to factors such as the selectivity of the immigration process (e.g. health screening

prior to migration, education level, language proficiency, and age), healthier

behaviours of immigrants prior to migration, and the financial and physical ability to

travel whereby the wealthiest and healthiest individuals are the most likely to

migrate.[3,24]

However, "the healthy immigrant effect" might not apply to some

categories of immigrants, such as those with refugee status.[25,26]

Immigrants from

refugee backgrounds may have different reasons for underutilizing health services,


such as fear of discrimination, poor education, and lack of knowledge about the local

health system.[26]

Alongside the underutilization of health care services, these

barriers may lead to inappropriate access to health care; for example, immigrants

may utilize ED care for non-urgent conditions that can be treated in primary care

settings.[8,27]

Correa-Velez and colleagues used a state-wide hospital discharge dataset to compare

differences in hospital services utilization between people born in refugee source

countries and the Australian born population in Victoria.[25]

Their study showed that

people born in refugee source countries have lower or similar rates of hospital

services utilization in Victoria to the Australian born population.[25]

They concluded

that patients from the Refugee and Humanitarian Program do not currently place a

burden on the Australian hospital system in general.[25]

However, their study found

that people living in Victoria who were born in refugee source countries have a

higher rate of ED care use (113.2, 95%CI: 108.2–118.4, per 1 000) than the

Australian born population (100.9, 95%CI: 99.6–102.2, per 1 000). A similar finding

of high ED care use among immigrants was found in two Danish studies.[27,28]

The

first study showed a highly significant association between rates of ED service use

and country of birth (chi2=79.1, df=8, P<0.0001).[28]

The study revealed that people

born in Somalia, Turkey, and the former Yugoslavia had higher utilization rates

(RR=1.46, 1.36, and 1.23, respectively) than Danish born residents.[28]

The second

study found more inappropriate ED care use by immigrants of Middle Eastern origin

and other non-Western origins compared to patients of Danish origin (92%, 82%,

73%, P<0.01, respectively).[27]

Another study from Spain found that immigrants from

low income countries use ED care more than the Spanish born population (RR=1.42

(1.38–1.47) and 2.19 (2.13–2.26) for men and women, respectively).[29]


Additionally, a Swedish study showed that immigrants from Chile, Iran, and Turkey

were more likely to have used ED care compared to the Swedish born population:

odds ratios (ORs) 1.4, 95%CI: 1.2–1.7; 1.3, 95%CI: 1.1–1.7; and 1.5, 95%CI: 1.3–

1.9, respectively. [30]

On the other hand, two studies conducted in the United States found that immigrants

tend to underutilize ED care compared to American citizens.[31,32]

Ku and Matani [32]

found that non-citizens were, less likely to visit EDs than American citizens (9.2,

P<0.01). Additionally, Cunningham [31]

found that non-American citizens were less

likely to use ED care than American citizens (10.2, P<0.05). The authors explained

that this was due to insurance, socioeconomic status (SES), and possible fears among

undocumented (illegal) immigrants about being asked about their immigration status

in the ED.[31,32]

Another study[33]

from Spain showed a similar result of low ED care

use among immigrants, with relative risk (RR) of 0.62 (95% CI: 0.52%–0.74%) for

foreign born compared to Spanish born residents. The authors explained that this was

probably due to the "healthy immigrant effect". However, this study did not adjust

for SES and the length of stay in the host country. In addition, a study from Ontario,

Canada, showed lower use of ED care by immigrants compared to Canadian citizens.

[34] However, this study used the general Ontario Health Survey (OHS), without

adjusting for any determinants of utilization.

Another Australian study [10]

showed no difference in ED care use between infants

from non-English speaking backgrounds (NESBs) and infants from English speaking

backgrounds (ESBs) (OR 0.86, 95%CI: 0.57–1.28). The authors argued that the

lower rates of ED care utilization during the first 12 months of life may have resulted

in insufficient power to detect a difference in ED service use between NESB and

ESB infants. [10]


In summary, there are conflicting results in the literature about ED care use among

immigrants, which may be due in part to differences in immigrants' characteristics

and the health systems in different countries. For example, in the United States,

having health insurance is crucial for accessing primary health care, unlike in

Australia, where Medicare is available for all Australians and permanent residents.

Furthermore, Australia's borders and geography provide natural protection against

illegal immigration, unlike other countries such as the United States and Spain.

Inappropriate use of ED care

Several studies have suggested that immigrants tend to use ED care for non-urgent

conditions at the expense of primary health care services.[27,35,36]

It has been argued

that the utilization of EDs for non-urgent conditions can have serious implications. It

may result in prolonged LOS and increased wait times in EDs which together reduce

the quality of care provided, leading to an increased probability of complications for

urgent conditions. [27, 37, 38]

Further, the research has shown that the use of EDs for

non-urgent conditions adds to increased patient dissatisfaction and can lead to

frustration among ED care providers and administrators due to overcrowding and

delay in treatment.[39]

Moreover, ED presentations for non-urgent conditions are less

likely to involve preventive care and are more costly than visits to primary health

care clinics.[27,40]

Exacerbating the situation, overcrowded conditions in EDs may

result in prolonged pain and suffering, ambulance diversions, decreased physician

productivity, violence associated with prolonged wait times, and miscommunication

because of increased patient volumes.[15]

According to the literature, immigrants seek treatment in EDs for diverse reasons

other than the urgency of their conditions. [27, 41]

These reasons might include the fact

that emergency services are free to consumers at the point of care in most developed


countries and do not require papers, which might be an obstacle for illegal

immigrants, can be obtained at any time without prior appointment, and require less

administration steps to access, which can reduce language, cultural, and legal

barriers. [27, 42]

Therefore, immigrants may be disadvantaged by a lack of access to

primary health care facilities and thus place additional burden on ED care due to

inappropriate access. On the other hand, immigrants might also be disadvantaged in

the modes of access to critical ED care when needed. Sheikh and colleagues [9]

found

that newly arrived refugees to Australia do not call an ambulance when required,

despite their ability to make such a call. The study revealed that one of the reasons

why these people do not call an ambulance is previous experiences in their home

countries, where the police would come as well when they hear the ambulance sirens.

[9]

Length of stay in EDs

Length of stay (LOS) in EDs is defined as the time from a patient's registration until

that patient's departure from the ED. [43, 44]

LOS is a marker of ED overcrowding and

a key component of ED quality assurance monitoring.[45,46]

LOS can be associated

with ED overcrowding, decreased patient satisfaction with ED care, ambulance

diversion, and poor clinical outcomes.[43,45]

An association with a long LOS in the

ED has also been found with language differences between health care providers and

patients. [8, 47]

The high number of immigrants with language barriers can increase the LOS by the

need for extra time to get an interpreter and more time for interaction between the

patient and care providers. [19]


Satisfaction with ED care

The quality of medical care is increasingly being measured by a range of

perspectives, including clinical and economic perspectives, and more recently, by

patients' opinions. [48–50]

The emphasis on patient satisfaction with health and medical

care has increased in recent years. Patient satisfaction has been defined as occurring

when the patient's expectations of treatment and care are met (or exceeded). [51]

There

are several reasons for considering patient satisfaction as an important ED goal. [51]

Patient satisfaction is an important indicator of the quality of care provided by the

ED. It also shapes patients' first impression of their future actions towards medical

services. Moreover, it has been shown to increase compliance with discharge

instructions and improve job satisfaction among the physicians and other ED staff.

[48]

Despite the growing recognition of language as a barrier to accessing health care,

little data exist about patient satisfaction among immigrants and particularly among

non-English speaking immigrants. Most studies on patient satisfaction have focused

on participants from the host country. [51]

Thus, most of these studies have chosen to

exclude immigrants to prevent the introduction of translation and cultural biases. [51]

Although a few studies have examined health care satisfaction among non-English

speakers in the United States, these studies have shown the negative impact of

language barriers and lack of proper communication on patients' satisfaction. A study

[52] from Arizona revealed that the language of interview was a significant variable in

determining satisfaction among Hispanic children patients. Furthermore, in another

study, [53]

it was suggested that language barriers may help explain the lower levels of

satisfaction among Asian Pacific Islanders compared to those of the white

population. A study [54]

conducted in a public hospital ED in the United States


showed that patients with limited English proficiency perceived their care provider as

less friendly, less polite, and less concerned for them as a person. Carrasquillo and

colleagues [55]

reported that non-English speakers were less satisfied as compared to

English speakers with their care they received in the ED, less likely to use the same

ED if they had a problem they felt required emergency care, and documented more

problems with emergency care.

Most of these studies were conducted in the United States and may be limited in the

extent to which the results can be applied in the Australian context, due to

differences in the health systems. For example, health insurance and immigrant status

might play vital roles in patient satisfaction. Moreover, most of these studies did not

address some of the cultural concepts among people from NESBs which may affect

patients' satisfaction. For example, some patients from certain backgrounds might

reject ED service in specific circumstances, such as embarrassment among some

women from the Middle East at being examined by a male doctor. In addition,

cultural concepts in rating satisfaction were not addressed. For example, some

cultural groups may consider a certain level of health care as "good" while other

cultural groups may consider the same level as "very good or excellent".[56] In

addition, the results of these studies might be confounded by the presence of an

interpreter, and some of them were a single-site study and used a phone survey,

which may have increased bias (e.g. females are more likely to answer the phone).

Gap in the knowledge and recommendations

There are important limitations in ED care use studies. In some cases, there was little

analysis of the factors that may be related to health status and ED utilization, such as

ethnicity, country of origin, language proficiency, SES, and age. [31–33]

Some

examined specific groups of immigrants in particular countries.[27, 28]

Others looked


at heath service utilization in general, using data not collected specifically for ED

care use.[25,34]

In addition, limited literature has shown whether the increased use of

ED service is due to an increase in critical conditions that required ED care or to

inappropriate ED access. Identifying the reasons for coming to the ED might provide

additional insights about the different motivations for ED use among immigrants.

In general , the majority of the studies about immigrants' utilization of health services

might not be applicable to Australia, as immigrants' characteristics in other countries

as well as their health systems might differ from those in Australia. At present, a

limited body of literature exists describing the use of ED care by immigrants from

NESBs in Australia, and no literature exists about the satisfaction with ED care

among immigrants from NESBs. Therefore, there is a need for further Australian

research focusing on hospital ED care utilization by immigrants from NESBs. This

would be helpful in the development of policies that ensure equity when planning

health care provision to immigrants.

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: Xiang-Yu Hou is a member of the editorial board of the

WJEM.

Contributors: Mahmoud I proposed the study and wrote the paper. All authors

contributed to the design and interpretation of the study and to further drafts.


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Received April 16, 2012

Accepted after revision October 7, 2012

Chapter 3: Research Design and Methodology 31

Chapter 3: Research Design and Methodology

Framework and Research Questions

Anderson’s model (Fig. 1) was developed to assist in the understanding of why

families (individuals) use health services; to define and measure equitable access to

health care; and to assist in developing policies to promote equitable access

(Andersen, 1995). According to Fig. 1, the environment includes the health care

system (policies, resources and organisation) and external environment (general legal

and political frameworks of the society). Population characteristics cover

predisposing characteristics (socio-demographic factors including ethnicity and

migration status, health beliefs and genetic factors), enabling resources (financial

ability and insurance status) and need, reflecting that the problem is judged to be of

sufficient importance to seek professional help. The environment and population

characteristics are seen as determinants of health behaviour, which includes personal

health practice (diet, exercise) and the use of health services (type, reason, time).

These health behaviours may result in health outcomes including perceived health

status, evaluated health status and consumer satisfaction.

This study used Anderson’s model as an analytical guide (Fig. 1) because it provides

a whole system approach. The study focused on three elements of Anderson’s model:

1) Use of health services, under the health behaviour indicator

2) Personal reasons for the use of health services, under the health behaviour

indicator

3) Consumer satisfaction, under the outcomes indicator

Anderson’s model was used as an analytical guide to answer this study’s research

questions:

32 Chapter 3: Research Design and Methodology

1) Are the utilization rates and outcomes of NESB ED patients similar to or

different from those of ESB patients? The measures include the following:

a) Utilization rate

b) ED arrival mode, such as the use of ambulance service

c) Departure status including admission rate

d) LOS in the ED

2) Do the primary reasons for ED service use by NESB patients differ from

those of ESB patients? Possible problems may be as follows:

a) I do not have a GP

b) GPs charge extra fees

c) My GP does not speak my language

d) It would take a long time to get an appointment with a GP

e) The ED is closer than my GP

f) The ED can deal with the problem better than my GP can

g) I generally prefer the ED

3) Are NESB patients less satisfied with the ED service than ESB patients? The

measures include the following:

a) Staff skills

b) Courtesy and respect from staff

c) Explanation of what is being done

d) Waiting time

e) Time with the doctor

f) Communication (including interpreter use)

g) Quality of care

h) Overall rating of the ED service


Fig. 1. Anderson’s model of access to medical care

Source: Anderson (1995)

Hypothesis

The study hypothesized that:

1) There is no difference in use of ED among NESB patients and ESB patients in

term of utilisation rate, use of ambulance service, and length of stay in ED.

2) The primary reasons of ED use are same among people from NESB compared to

people from ESB.

3) NESB patients and ESB patients have same level of satisfaction with ED service.

Methodology

The study used a cross-sectional design. An epidemiological analysis was conducted

on how NESB people utilize the EDs of QLD public hospitals, their subjective

reasons for such use and their satisfaction with the ED service. In effect, the study

had access to a large secondary data source (EDIS), and also undertook primary data

collection from a tertiary hospital in the Brisbane metropolitan area.

The research contains three studies:


Descriptive studies (Studies I & II): These involved secondary analysis of EDIS

data (secondary data).

Study III: Used a cross-sectional survey strategy to explore the subjective reasons

for ED service use and satisfaction with the services provided among NESB and

ESB patients (primary data).

Participants

Study I: Patients who attended the ED at the Royal Brisbane Women’s Hospital

(RBWH) from 1 January to 31 December 2009, which includes 67,727 (97.5%)

patients who speak only English at home and 1,281 (1.80%) patients who do not

speak only English or who speak another language at home.

Study II: Patients who attended all public hospital EDs in QLD from 1 January 2008

to 31 December 2010. There were 2,905,204 (98.4%) patients who speak only

English at home and 48,527 (1.6%) who speak another language at home.

Study III: Given the proportions of the two populations within the study and the

utilization of a two-tailed alpha of 0.05 and a beta of 0.10, it was estimated that 150

NESB patients and 590 ESB patients would be required for the study to have 90%

power to identify a significant difference between the two groups (ABS, 2006). A

total of 828 patients—597 (72.1%) ESB and 231 (27.9%) NESB—who had attended

the PAH ED were interviewed over a four-month period from 27 August to 28

December 2012.

Instruments

Study I: This study used data accumulated over one year (1 January to 31 December

2009) from the ED of RBWH (secondary data).


Study II: This was a population-based analysis. The study used three years of EDIS

data (1 January 2008 to 31 December 2010) from all QLD public hospitals

(secondary data).

Data for study I and II were sourced from the Emergency Department Information

System (EDIS). EDIS is an electronic information system for public hospital EDs in

Queensland. It provides data such as modes of arrival (ambulance, walking-in

including via public transport and others), triage category, gender, age, language

spoken at home, and ED departure status (admission to hospitals, did not wait, died

or discharge).

Study III: This study used a cross-sectional survey strategy to explore the subjective

reasons for ED service use and satisfaction with the services provided among NESB

and ESB patients (primary data). The questionnaire was developed in the English

language and the questions were adapted from the existing literature and validated

questionnaires on patient satisfaction (Carrasquillo, Orav, Brennan, & Burstin, 1999;

Norredam et al., 2007; Woods, Bivins, Oteng, & Engel, 2005). The questionnaire

consisted of two parts. The first part, which solicited demographic information and

the reasons for visiting the ED, was completed by the patient prior to treatment. The

patients were then asked to keep the questionnaire to fill out the second part, which

assessed patient satisfaction after treatment, before leaving the ED. The completed

questionnaires were collected by the principal investigator or were left by the patient

at the nursing station. The responses to the questions were rated on a 5-point Likert

scale, ranging from 1 (poor) to 5 (excellent). The patients were asked to rate the

staff’s skills, compassion, courtesy and respect, communication, time with the

doctors, quality of the care they received and their overall satisfaction. At the end of

the questionnaire, the patients were asked an open question about what they thought


was the most important element of their ED service. The questionnaire was

administered with self-completion or a face-to-face interview for both parts 1 and 2.

An interpreter was used when required.

The questionnaire and information sheet are presented in Appendix A.

Analysis

Study I: The patients were divided into two groups on the basis of the language

spoken at home: patients who speak only English at home (SEO) and patients who

do not speak only English or who speak another language at home (NSEO). Chi-

square and t-test were used to compare the two groups using the Statistical Package

for the Social Sciences (SPSS) version 18.

Study II: The patients were divided into groups on the basis of language spoken at

home. The study was limited to the languages most commonly spoken at home, as

specified by the EDIS, including English, Chinese, Vietnamese, Arabic, Spanish,

Italian, Hindi and German. The study also investigated the use of EDs among

Australian born patients, patients born in the main English speaking countries

(MESC) and patients born in refugee source countries.

The EDIS data were combined with data from the Australian Bureau of Statistics

(ABS) to calculate the utilization rate per 1,000 population for each language group.

Descriptive analysis was performed and 95% confidence intervals and P values were

calculated. Differences in the proportion of ambulance utilization as a mode of

arrival and admission to the hospital as a departure status were tested using Pearson’s

Chi-square test. Multiple logistic regressions were used, controlling for age, gender

and triage category (resuscitation, emergency, urgent, semi-urgent and non-urgent),

according to the Australasian Triage Scale (ATS) (Forero & Nugus, 2012). Multiple


linear regressions were used to calculate LOS in the ED, adjusting for age, gender,

interpreter use, and triage category.

The results were calculated using SPSS version 19 (IBM SPSS Statistics 19).

Study III: The participants were divided into two groups: patients from main

English speaking countries (Australia, Canada, New Zealand, Republic of Ireland,

South Africa, the United Kingdom and the United States) and patients from other

countries where English is not the principal language.

Descriptive statistics were used to describe the demographic characteristics of the

two groups. The levels of satisfaction among ESB and NESB patients were

compared by conducting Pearson’s X 2 test.

To examine the potential confounding effects of socioeconomic factors, multivariate

logistic regression analyses were performed to reveal the differences between the two

groups in terms of their level of satisfaction. The study considered excellent, good

and very good as satisfied, and fair and poor as not satisfied, on the basis of a five-

point Likert scale (Carrasquillo et al., 1999; Woods et al., 2005).

Proportions were calculated to determine whether the NESB patients had considered

contacting a GP before attending the ED, and whether their decision had been

influenced by their visa status and LOS in Australia. To examine the potential

confounding effects of socioeconomic factors, multivariate logistic regression

analyses were performed to uncover the differences between the two groups in terms

of their reasons for choosing the ED instead of consulting with a GP.

Analyses were performed using SPSS version 19 (IBM SPSS Statistics 19).

Ethics

Study I: The Human Research Ethics Committees of the Queensland University of

Technology and Royal Brisbane Women’s Hospital assessed this research as meeting


the conditions for exemption from HREC review, and the research was approved in

accordance with section 5.1.22 of the National Statement on Ethical Conduct in

Human Research (2007).

Study II: Ethical approval to use unidentified data was obtained from Queensland

Health Central Ethics Unit (HREC/11/QHC/29).

Study III: Ethical clearance was sought from PAH’s District Human Research

Ethics Committee as well as from the Human Ethics Committee of the Queensland

University of Technology.

All ethics approvals are attached in Appendix B.

Chapter 5: Results (Articles) 39

Chapter 4: Results (Articles)

Study I: Pilot Study

The purposes of the pilot study were to examine the EDIS data and provide guidance

for conducting Study II. In addition, the work was done to determine the feasibility

of Study II.

Feasibility of the pilot study

This work initiated the exploration of the EDIS data in terms of access, analysis, how

to deal with missing data and the identification of variables that needed to be

included in the data analysis of Study II.

Article 2: Is language a barrier for quality care in hospitals?

An account of Study I was published in The Australasian Epidemiologist

[Mahmoud, I., Hou, X., Kevin, C., & Clark, M. (2011). Is language a barrier for

quality care in hospitals? Australasian Epidemiologist, 18(1), 6–9].

The article is presented below.

40 Chapter 5: Results (Articles)

Is language a barrier for quality care in hospitals?

A Case series from an Emergency Department of a teaching hospital in

Brisbane

Ibrahim Mahmoud1, Xiang-Yu Hou

1, 2, Kevin Chu

1, 2, Michele Clark

1

1 School of Public Health, Queensland University of Technology, Brisbane, Australia

2 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital,

Brisbane, Australia

Corresponding author: Xiang-Yu (Janet) Hou

School of Public Health


Victoria Park Road, Kelvin Grove, 4059 Queensland, Australia

Tel: (61) 7 3138 5596

Fax: (61) 7 31383369

Email: [email protected]

Short Running Title: Language and quality care in hospitals

Abbreviations :

EDIS: Emergency Department Information System

ED: Emergency Department

SEO: patients who speak English only at home

NSEO: patients who do not speak English only or speak other language at home


Abstract

Aim: The aim of this pilot study is to describe the use of an Emergency Department

(ED) at a large metropolitan teaching hospital by patients who speak English or other

languages at home.

Methods: All data were retrieved from the Emergency Department Information

System (EDIS) of this tertiary teaching hospital in Brisbane. Patients were divided

into two groups based on the language spoken at home: patients who speak English

only at home (SEO) and patients who do not speak English only or speak other

language at home (NSEO). Modes of arrival, length of ED stay and the proportion of

hospital admission were compared among the two groups of patients by using SPSS

V18 software.

Results: A total of 69,494 patients visited this hospital ED in 2009 with 67,727

(97.5%) being in the SEO group and 1,281 (1.80%) in the NSEO group. The

proportion of ambulance utilisation in arrival mode was significantly higher among

SEO 23,172 (34.2%) than NSEO 397 (31.0%), p <0.05. The NSEO patients had

longer length of stay in the ED (M = 337.21, SD = 285.9) compared to SEO patients

(M= 290.9, SD = 266.8), with 46.3 minutes (95%CI 62.1, 30.5, p <0.001) difference.

The admission to the hospital among NSEO was 402 (31.9%) higher than SEO

17,652 (26.6%), p <0.001.

Conclusion: The lower utilisation rates of ambulance services, longer length of ED

stay and higher hospital admission rates in NSEO patients compared to SEO patients

are consistent with other international studies and may be due to the language

barriers.


Background

The number of immigrants is increasing around the globe. It was estimated at 191

million in 2005, with 60% of these migrating from developing countries to developed

countries. 1 Australia is not isolated from this phenomenon. Its population has grown

rapidly as a result of immigration over the past five decades, increasing the cultural

and linguistic diversity of the country. At the 2006 Census, out of a population of 20

million, 4.75 million or approximately 24% were born overseas, higher than most

Western countries. 2,3

Furthermore, over 50% of these were born in non-English

speaking countries. 4 Australia is one of the countries that accepts immigrants under

the United Nations High Commissioner for Refugee program. Each year, 13,000

immigrants under refugees status are resettled in Australia it the second largest intake

worldwide, in proportion to its population. 5 Since 2001, the greatest number of

immigrants has been from sub-Saharan African and Asian origins. 2,6

There is

increasing evidence of poorer health status and high prevalence of a range of health

problems among recently arrived immigrants with refugee status in Australia. This

population is also more likely to have low socio-economic status including low

education level and poor English proficiency.7 The recent increase in the number of

disadvantaged immigrants to Australia represents a particular challenge for the

healthcare system. The equitable provision of access to health care service to all

those in need, irrespective of their language, ethnicities and social characteristics, is

one of the central value within the Australian health care system.

A number of international studies have demonstrated inequities in health among

immigrants in developed nations as a result of financial, language and cultural


barriers. 6,8,9

These studies have shown that language and cultural barriers are

associated with longer visit time and less frequent visits to healthcare facilities,

inadequate assessment, less understanding and misunderstanding of treatment, more

laboratory tests, less follow up, lack of access to day surgery, less use of cancer

screening service, higher readmission rates, more use of ED services, less

satisfaction and poor health outcomes. 6,9

These studies were suggesting that

immigrants tend to use ED service for non-urgent conditions at the expense of

primary health care services. 9,10

Immigrants are seeking treatment in EDs for diverse

reasons, for example emergency services are almost free in most developed

countries, do not require papers which might be an obstacle for illegal immigrants,

can be obtained at any time without prior appointment and require less

administration steps to access which reduce language, cultural and legal barriers.11,12

ED usage for non-urgent care is more costly than visits to primary health care clinics.

13-15 Moreover, utilisation of ED for non-urgent conditions can be serious, as it

results in prolonged length of stay and increased wait time which together reduce

quality of care provided and lead to increased probability of complications for urgent

conditions. 16

Also, research has shown that it adds to increased patient

dissatisfaction and an increase in the number of patients who leave before being

seen. 17

ED visits among the general population has been rising in many countries, with

estimates of more than 70% of these visits being made for non-urgent

conditions.12,18

A report produced by the Australian Institute of Health and Welfare

(AIHW) for 2008-09, showed that there was a higher increase in the use of public

hospital EDs compared to other health care services.19

The AIWH’s report showed

that there were over 7 million visits to emergency departments in 2008-09, with


average annual increase 4.6% since 2004-05.19

The report indicated that almost 30%

of people visiting EDs were not seen in the recommended time for their urgency

category. 19

Furthermore, the number of ED presentations is expected to rise

dramatically with the rapid increase of population. Providing high quality medical

care in an overcrowding ED, with limited inpatient bed capacity, an aging and higher

acuity patient population, deficiencies in primary care access, and financial cutbacks,

has become increasingly challenging. 20

As a result, health policy makers have

always tried to reduce the number of ED visits and move patients towards using

primary health care services for non-life threatening conditions.21

Therefore, the use of ED services by immigrants for non-urgent condition may lead

to higher health care cost, add more burdens to already overcrowded EDs and delay

treatment. The majority of studies on ED use by immigrants are conducted in

countries that differ to Australia in terms of health care system and the characteristics

of the migrants which limit their application to Australia. Therefore, the aim of this

pilot study is to describe the use of an Emergency Department (ED) at a large

metropolitan teaching hospital by patients who speak English or other languages at

home.

Methods

Emergency Department Information System (EDIS) was employed to retrieve

patients’ information from January 1st 2009 to December 31

st 2009. Patients were

divided in to two groups based on the language spoken at home: patients who speak

English only at home (SEO) and patients who do not speak English only or speak

other language at home (NSEO). Chi-square and t-test were used to compare the two

groups using the SPSS V18.


The Human Research Ethics Committee of the Queensland University of Technology

(QUT) assessed this research as meeting the conditions for exemption from HREC

review and the research was approved in accordance with section 5.1.22 of the

National Statement on Ethical Conduct in Human Research (2007).

Results

A total of 69,494 patients attended the hospital’s ED from the 1st January to 31

th

December, 2009, which includes 67,727 (97.5%) SEO patients, and 1,281 (1.80%)

NSEO patients. There were 486 (0.70%) patients who did not specify their language

at home, so they were not included in any data analysis. There were 32,146(47.5%)

females and 35,579 (52.5%) males among the SEO group in comparison to 800

(62.5%) females and 481 (37.5%) males among the NSEO group (Table 1). The use

of ambulance and length of ED stay (from Arrival Date & Time to Actual Departure

Date & Time) in the two groups of patients are presented in Tables 2 and 3. The

patients’ departure status including the rate of admission to the hospital showed that

NSEO patients are more likely to be admitted to hospital than SEO patients (see table

4). An interpreter service was used on 153 (0.2%) occasions. On 75 (0.1%) occasions

an interpreter was used for SEO patients, with 23 of these being Auslan (the sign

language of the Australian deaf community) interpretation. An interpreter was used

on 78 (6.1%) occasions for NESO, and 20 of these were for Auslan (Table 5).


Table 1: Sex and age distribution among the NSEO & SEO

NSEO SEO

SEX, N (%)

Male 481 (37.5%) 35,579 (52.5%)

Female 800 (62.5%) 32,146 (47.5%)

Total 1281(100.0%) 67722 (100.0%)

AGE (yrs), N (%)

0-14 24 (1.9%) 922 (1.4%)

15-64 844 (65.9%) 57,266 (84.5%)

65+ 413 (32.2%) 9,579 (14.1%)

Total 1281(100.0%) 67722 (100.0%)

Table 2: Chi-square of modes of arrival to ED among NSEO and SEO

Variable N Language spoken at home X2

P

Mode of

arrival

NSEO SEO 5.81 0.05

Other than

ambulance

45,439 884(69.0%) 44,555 (65.8%)

Ambulance 23,569 397 (31%) 23,172 (34.2%)

Totals 69,008 1,281(100%) 67,727 (100%)


Table 3: t-test of length of stay (LOS) at ED in minutes among NSEO and SEO

Language

spoken at

home

N

Length of

stay (mins)

Mean+SD

Means

difference

95% CI

P

NSEO 1,281 337.2 ± 285.9 46.3 62.1, 30.5 0.001

SEO 67,727 290.9 ± 266.8

Table 4: Chi-square of departure status from ED among NSEO and SEO

Variable N Language spoken at home X2

P

Departure

status

NSEO SEO 18.41 0.001

Other than

admission

50,954 879 (68.6%) 50075 (73.9%)

Admitted 18,054 402 (31.4%) 17,652 (26.1%)

Totals 69,008 1,281(100%) 67,727 (100%)

Table 5: Interpreter requirement among NSEO & SEO

Variable N Language spoken at home

Interpreter required NSEO SEO

YES 153 78 (6.1%) 75 (0.1%)

NO 68,855 1,203 (93.9%) 67,652 (99.9%)

Auslan 20 23

Totals 69,008 1,281 (100.0%) 67,727 (100.0%)


Discussion

To our knowledge, this is the first study to examine the role that language plays in

accessing acute care in Queensland hospitals. This descriptive pilot study could

provide a guide for further studies.

This study found that compared to patients who speak English at home, NSEO

patients are less likely to use less ambulance services, have longer ED stays and have

higher rates of hospital admission. These results are consistent with other

international studies. 9,22,23

It is expected that longer ED stays are due to communication issues between staff

and NSEO patients. However, our results showed that only 6% of the NSEO patients

had an interpreter during their ED visits. Therefore, other factors may be in play that

account for the longer time that NSEO patients spend EDs compare the SEO

patients. For example, it could be possible that NSEO patients attend EDs with more

advanced illness or complex conditions which require longer assessment and

treatment times. This contradicts the notion of the “healthy immigrant effect” which

discussed in the literature. The “healthy immigrant effect”, suggests that immigrants

are healthier than native born residents due to the selectivity of immigration process

(health screening prior to migration, education level, language proficiency and age),

healthier behaviour of immigrants prior to migration, and immigrant self-selection

whereby the healthiest and wealthiest individuals are the most likely to migrate. 4,24


However, it needs to be noted that some NSEO patients would have entered

Australia under humanitarian visas and may have experienced the ill-effects of the

conditions in refugees’ camps thus arriving with existing health problems. These

patients could be more vulnerable to illness and may attend EDs with advanced

illness. The distribution of NSEO patients, regarding how many of the NSEO

patients had entered Australia via humanitarian visa, is not available for this pilot

study, and warrants future research in this area.

In addition to the possible advanced illness among the NSEO patients,

communication may still be a factor for our results. Some studies showed that

communication difficulty in terms of language or cultural background might results

in less use of ambulance services, longer waiting times due to the need for an

interpreter, more laboratory tests ordered and high rates of hospital admission. 6,9

Our data also showed that some patients claimed that they speak English at home and

classified as SEO required an interpreter (this finding excluded patients who are

deaf). Although this finding might be due to data entry errors, it is possible that some

patients may prefer to use their less proficient English language to communicate with

health care providers rather than waiting for an interpreter.

It was reported that trying to communicate to health providers in lower proficient

English language or using a family member or a friend with minimal ability in

medical terminology might result in serious consequences, including less

understanding of patient’s problems, un-necessary diagnostic tests, wrong diagnosis,

wrong treatment, complications and frequent ED visits. 9 This may lead to higher

health care cost, add more burdens to already overcrowded EDs and delay treatment.


This study was confined to a tertiary teaching hospital in Brisbane so is not a

representative study regarding NSEO patients visiting hospital EDs. The catchment

area of this hospital is from high and middle-class areas in the north side of Brisbane

while the majority of disadvantaged NSEO live in the south side of Brisbane. 25

The

final results were not adjusted for age, sex, socio-economic class or triage

classification due to the small number of NSEO patients in this pilot study.

The lower utilisation of ambulance services, longer ED lengths of stay and higher

hospital admission rates among NSEO are consistent with other international studies.

Further studies need to investigate the contributing factors such as language barriers

and knowledge of the local health system, so that interventions can be recommended

to achieve the health equity in our society.


References

1. Ratha D, Shaw W. South-South migration and remittances: World Bank

Publications; 2007.

2. Thomas P, Beckmann M, Gibbons K. The effect of cultural and linguistic

diversity on pregnancy outcome. Australian and New Zealand Journal of Obstetrics

and Gynaecology 2010;50:419-22.

3. Australian Government. Australian Demographic Statistics. In: Department

of Economic and Statistical Research, ed.; 2009.

4. Baum F. The New Public Health. Melbourne: Oxford University Press; 2008.

5. Correa-Velez I, Sundararajan V, Brown K, Gifford S. Hospital utilisation


Victoria, 1998-2004. Medical journal of Australia 2007;186:577.

6. Jeanine B. Equity in care for people of culturally and linguistically diverse

backgrounds. Australian Nursing Journal 2005;13:29.

7. Mendel J, Brolan C. Hospital utilisation among people born in refugee-source

countries. The Medical journal of Australia 2007;187:479.

8. Quan H, Fong A, De Coster C, et al. Variation in health services utilization

among ethnic populations. Canadian Medical Association Journal 2006;174:787.

9. Yeo S. Language barriers and access to care. Annual Review of Nursing

Research 2004: Eleminating Health Disparities Among Racial and Ethics Minorities

in the United States 2004:59.

10. Buron A, Cots F, Garcia O, Vall O, Castells X. Hospital emergency

department utilisation rates among the immigrant population in Barcelona, Spain.

BMC health services research 2008;8:51.


11. Cots F, Castells X, García O, Riu M, Felipe A, Vall O. Impact of immigration

on the cost of emergency visits in Barcelona(Spain). BMC health services research

2007;7:9.

12. Norredam M, Mygind A, Nielsen A, Bagger J, Krasnik A. Motivation and


The European Journal of Public Health 2007.

13. Norredam M, Krasnik A, Sorensen T, Keiding N, Michaelsen J, Nielsen A.

Emergency room utilization in Copenhagen: a comparison of immigrant groups and

Danish-born residents. Scandinavian journal of public health 2004;32:53-9.

14. DeSalvo A, Rest S, Knight T, Nettleman M, Freer S. Patient education and

emergency room visits. Clinical Performance and Quality Healthcare 2000;8:35-8.

15. Bolton M, Tilley B, Kuder J, Reeves T, Schultz L. The cost and effectiveness

of an education program for adults who have asthma. Journal of general internal

medicine 1991;6:401-7.

16. Horwitz L, Green J, Bradley E. US emergency department performance on

wait time and length of visit. Annals of emergency medicine 2010;55:133-41.

17. Rodi S, Grau M, Orsini C. Evaluation of a fast track unit: alignment of


for emergency department patients. Quality Management in Healthcare 2006;15:163.

18. Padgett D, Brodsky B. Psychosocial factors influencing non-urgent use of the

emergency room: a review of the literature and recommendations for research and

improved service delivery. Social Science & Medicine 1992;35:1189-97.

19. AIHW Report. Public EDs not coping with growing pressure. Australian

Medicine, AMA 2009;21.


20. Betty S-C. Emergency Department and Community Health Center Visits and

Costs in an Uninsured Population. Journal of Nursing Scholarship 2005;37:80.

21. Gill J, Mainous III A, Nsereko M. The effect of continuity of care on

emergency department use. Archives of family medicine 2000;9:333.

22. Lee ED, Rosenberg CR, Sixsmith DM, Pang D, Abularrage J. Does a

Physician-Patient Language Difference Increase the Probability of Hospital

Admission? Academic Emergency Medicine 1998;5:86-9.

23. Jacobs E, Chen AH, Karliner LS, Agger-Gupta N, Mutha S. The Need for

More Research on Language Barriers in Health Care: A Proposed Research Agenda.

The Milbank Quarterly 2006;84:111-33.

24. Kennedy S, McDonald J, Biddle N, Social MUPfRo, Population EDoaA. The

healthy immigrant effect and immigrant selection: evidence from four countries:

SEDAP Research Program; 2006.

25. ABS releases measures of socio-economic advantage and disadvantage. ABS,

2008. (Accessed 07/03/2011, 2011, at

http://www.abs.gov.au/ausstats/[email protected]/mediareleasesbytitle/87E66027D6856FD6

CA257417001A550A?OpenDocument.)


Study II: A Population-Based Study

A secondary data analysis of state-wide hospital EDIS data was used to examine the

role that language plays in ED service use in QLD public hospitals. The utilization

rate, ambulance use, hospital admission rate and LOS in the ED were analysed

(Articles I & II). The study also examined ED use by vulnerable immigrants from

refugee source countries (Article III). Three articles on this topic were published in

reviewed journals.

Article 3: Language and utilisation of emergency care in Queensland

Article 3 was published in Emergency Medicine Australasia [Mahmoud, I., Hou, X.,

Kevin, C., & Clark, M. (2013). Language and utilisation of emergency care in

Queensland. Emergency Medicine Australasia, 25(1), 40–45].

The article is presented below.


Emergency Medicine Australasia (2013) 25, 40–45 doi: 10.1111/1742-6723.12017

ORIGINAL RESEARCH

Language and utilisation of Emergency Care in Queensland

Ibrahim Mahmoud1, Xiang-Yu Hou

2, Kevin Chu

3, Michele Clark

4

Authors’ Information:

1,2,4 School of Public Health, Queensland University of Technology, Brisbane,

Australia

2,3 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital,

Brisbane, Australia

Author's contribution:

1 Design, acquisition of data, analysis and interpretation of data;

2 Assist and supervising the study design, data interpretation & discussion, and the

drafts revision.

2,3,4 Critical review of the manuscript.

Corresponding author:

Dr. Xiang-Yu (Janet) Hou

School of Public Health and Social Work



Tel: 07 31389240 Fax: (61) 7 31383369

Email: [email protected]

Short Running Title: Language and emergency care utilisation

Word count: 1602


ABSTRACT

Objective: To compare access and utilisation of emergency departments (EDs) in

Queensland public hospitals between people who speak only English at home and

those who speak another language at home.

Methods: A retrospective analysis of a Queensland state-wide hospital ED dataset

(ED Information System) from 1-1-2008 to 31-12-2010 was conducted. Access to

ED care was measured by the proportion of the state’s population attending EDs.

Logistic regression analyses were performed to determine the relationships between

ambulance use and language, and between hospital admission and language, both

after adjusting for age, sex and triage category.

Results: The ED utilisation rate was highest in English only speakers (290 per 1000

population), followed by Arabic speakers (105), and lowest among German speakers

(30). Compared with English speakers, there were lower rates of ambulance use in

Chinese (OR 0.50, 95%CI, 0.47–0.54), Vietnamese (0.87, 0.79–95), Arabic (0.87,

0.78–0.97), Spanish (0.56, 0.50–0.62), Italian (0.88, 0.80–0.96), Hindi (0.61, 0.53–

0.70), and German (0.87, 0.79–0.90) speakers. Compared with English speakers,

German speakers had higher admission rates (OR 1.17, 95%CI, 1.02–1.34), whereas

there were lower admission rates in Chinese (0.9, 0.86–0.99), Arabic (0.76, 0.67–

0.85), and Spanish (0.83, 0.75–0.93) speakers.

Conclusion: This study showed that there was a significant association between

lower utilisation of emergency care and speaking languages other than English at

home. Further researches are needed using in depth methodology to investigate if

there are language barriers in accessing emergency care in Queensland.

Key Words: emergency care, immigrants, language barriers, utilisation


INTRODUCTION

In recent decades, the world has experienced a dramatic increase in all types of

migration—legal, illegal, and asylum seekers—which has increased the linguistic

and cultural diversity in many countries.

In Australia, migration is contributing significantly to the national population

growth; the proportion of migrants increased from 45.6% in 2004 to 59.5% in 2008

[1]. This steady rise was due to an increase in the number of overseas students, the

resilience of the Australian economy, and large migration programmes[1]

. The results

of the 2006 Census revealed that 4.75 million (24%) out of the total Australian

population of 20 million people were born overseas, which is higher than in most

Western countries [2]

. There are more than 260 languages spoken in Australian

homes, with over 3 million (15.8%) people speaking a language other than English at

home [3]

. Those who do not speak English well or not at all has represented

approximately 3% of total population of Australia and 1.2% of total of population of

Queensland (QLD) in 2006 [4, 5]

. This increase in language diversity and people who

do not communicate effectively in English has imposed challenges in accessing

public services.

Language is a key element for patients to access the health care system and to

communicate with their health care providers [6]

. Language is also the means by

which physicians and nurses can learn about patients’ illnesses, concerns, and

emotions, which assists greatly in delivering effective health care management to the

patients [6, 7]

.

To date, a limited body of literature exists describing the role of language in

utilisation of health care particularly ED care in Australia[8, 9]

. Ou and colleagues

found that infants from a non-English speaking background (NESB) accessed


significantly less of the most frequently used health care services compared with

infants from an English speaking background [8]

. The Ou et al.’s study used data

from the Longitudinal Study of Australian Children and was limited only to infants

[8]. Correa-Velez et al.’s study showed that use of hospital services among people

born in refugee-source countries is not higher than that of the Australian-born

population [10]

. However, the study used a state-wide hospital discharge dataset from

Victoria and was limited to refugees without looking into the role of language in

hospital care use [10]

.

The aim of this study is to investigate the utilisation of emergency care among the

people who speak a language other than English at home compared with those who

speak English at home in Queensland. Such a study may provide unique information

about whether there is any role of language on utilisation of emergency care and

encourage further in depth research in Queensland and Australia.

METHODS

Study Design and Setting

Analysis of the Queensland public hospitals ED dataset for the 3 calendar years,

from 1 January 2008 to 31 December 2010 was undertaken. Queensland is the

second-largest in land mass and third-most populous state of Australia, located in the

northeast of the country.

Data Collection

Data were sourced from the Emergency Department Information System (EDIS).

EDIS is an electronic information system for public hospital EDs in Queensland. It

provides data such as modes of arrival (ambulance, walking-in including via public

transport and others), triage category, gender, age, language spoken at home, and ED

departure status (admission to hospitals, did not wait, died or discharge).


Ethical approval to use unidentified data was obtained from Queensland Health

Central Ethics Unit (HREC/11/QHC/29).

Study population

Patients were divided into groups based on language spoken at home. The study was

limited to the languages most commonly spoken at home as specified by EDIS,

including: English (2,905,204), Chinese (5082), Vietnamese (2547), Arabic (2241),

Spanish (2047), Italian (2013), Hindi (1530), and German (1281).

Data analysis

The EDIS data were combined with data from the Australian Bureau of Statistics to

calculate the utilisation rate per 1000 population for each language group.

Descriptive analysis was performed, and 95% confidence intervals and P values were

calculated. Differences in the proportion of ambulance utilisation as a mode of

arrival and admission to the hospital as a departure status were tested using Pearson

X2-test test. Multiple logistic regressions were used, controlling for age, gender, and

triage categories (resuscitation, emergency, urgent, semi-urgent, and non-urgent),

according to the Australasian Triage Scale (ATS) [11]

. Results were calculated using

Statistical Package for the Social Sciences (SPSS) version 19 (IBM SPSS Statistics

19, IBM Centre, Sydney, NSW, Australia).


RESULTS

Among the total of 2 953 731patients attending all public hospital EDs in

Queensland from 1 January, 2008 to 31 December 2010, 2,905,204 (98.4%) spoke

English only at home and 48,527 (1.6%) spoke another language at home.

In general, this study showed lower utilisation of ED care, lower use of ambulance,

and lower admission to hospital among patients who speak languages other than

English at home in Queensland.

Figure 1 shows the top language groups of patients who visited EDs. The crude ED

utilisation rate per 1000 population was much higher among English only patients

compared to patients who spoke another language (Table 1).

Table 2 and 4 describes the proportions of the modes of arrival to the ED (Chi-

squared=3049.6, p<0.001). Patients who spoke Chinese, Vietnamese, Arabic,

Spanish, Italian, Hindi, and German at home were significantly (p<0.05) less likely

to use an ambulance compared to patients who spoke English only (Table 3).

Table 4 describes the proportions of the departure status of the ED patients (Chi-

squared=3236.9, p<0.001). Lastly, Table 5 shows the differences in admission to

hospitals between patients who speak another language at home and patients who

speak English only.


Fig.1 Distribution of the language groups that visited hospital EDs per 1000

population, QLD 2008–2010

Table 1. Number of presentations to ED by languages spoken at home, QLD

2008–2010

Languages Total no. of

presentations

Per 1000 weight population

2008 2009 2010 Total

English only 2905204 268 293 301 862

Chinese* 5082 33 39 40 112

Vietnamese 2547 49 49 51 149

Arabic 2241 93 108 106 307

Spanish 2047 55 61 65 181

Italian 2013 28 31 32 91

Hindi 1530 53 69 70 192

German 1281 31 28 28 87

Total 610 978 693 1981

*Including Cantonese and Mandarin

0

100

200

300

400

500

600

700

800

900

1000

Per 1000 population


Table 2. Modes of arrival to ED by languages spoken at home, QLD 2008–2010 a

Languages Modes of arrival

Ambulance Walk in Others Total

English only 778860 (26.8,

26.7 – 26.9)

2096538 (72.2,

72.1 –72.2)

29806 (1.0,

1.0–1.0)

2905204

(100)

Chinese* 1049 (20.6,

19.6 – 21.8)

3998 (78.7,

77.5 –79.8)

35 (0.7,

0.5–1.0)

5082

(100)

Vietnamese 878 (34.5,

32.7 –36.3)

1631 (64.0,

62.2–68.9)

38 (1.5,

1.1–2.0)

2547

(100)

Arabic 514 (22.9,

21.2 –24.7)

1705 (76.1,

74.3–77.8)

22 (1.0,

0.7–1.5)

2241

(100)

Spanish 564 (27.6,

25.7 –29.5

1470 (71.8,

70.0–74.0)

13 (0.6,

0.4–1.1)

2047

(100)

Italian 1026 (51.0,

48.8 –53.2)

975 (48.4,

46.3–50.6)

12 (0.6,

0.3–1.0)

2013

(100)

Hindi 356 (23.2,

21.2 –25.5)

1161 (75.9,

73.7–78.0)

13 (0.9,

0.5–1.5)

1530

(100)

German 465 (36.3,

33.7 –39.0)

807 (63.0,

60.3–65.6)

9 (0.7,

0.4–1.3)

1281

(100) a Values outside the brackets are numbers of ED presentations. Values in the brackets

are proportions and their 95% confidence intervals.


Table 3. Logistic regression model (ORs and 95%CI) for ambulance utilisation

among main language spoken at home, adjusted for sex, age, and triage

categories , QLD 2008–2010

Languages OR (95%) P

Reference group : English only

Chinese* 0.50 (0.47–0.54) 0.001

Vietnamese 0.87 (0.79–0.95) 0.003

Arabic 0.87 (0.78–0.97) 0.014

Spanish 0.56 (0.50–0.62) 0.001

Italian 0.88 (0.80–0.96) 0.006

Hindi 0.61 (0.53–0.70) 0.001

German 0.87 (0.76–0.90) 0.049


Table 4. Departure status by language spoken at home, QLD 2008–2010 a

Languages Departure


status

Admitted Discharged Did not wait Died Total

English only 697169 (24.0,

24.0–24.1)

1984087

(68.3,

68.2–68.4)

221551

(7.6,

7.6–7.7)

2397 (0.1,

0.1–0.1)

2905204

(100)

Chinese* 1341(26.4,

25.2–27.6)

3356 (66.0,

64.7–67.3)

381 (7.5,

6.8–8.3)

4 (0.1

0.0–0.2)

5082

(100)

Vietnamese 893 (35.1,

33.2–36.9)

1478 (58.0,

56.1–60.0)

173 (6.8,

5.9–7.8)

3 (0.1,

0.0–0.4)

2547

(100)

Arabic 421 (18.8,

17.2–20.5)

1593 (71.1,

69.2–72.9)

225 (10.0,

8.9–11.4)

2 (0.1,

0.0–0.3)

2241

(100)

Spanish 629 (30.7,

28.8–32.8)

1285 (62.8,

60.7–64.8)

129 (6.3,

5.3–7.4)

4 (0.2,

0.1–0.5)

2047

(100)

Italian 981 (48.7,

46.6–50.9)

976 (48.5,

46.3–50.7)

55 (2.7,

2.1–3.5)

1 (0.1,

0.0–0.3)

2013

(100)

Hindi 444 (29.0,

26.8–31.3)

957 (62.5,

60.1–64.9)

128 (8.4,

7.1–9.9)

1 (0.1,

0.0–0.4)

1530

(100)

German 471 (36.8,

34.2–39.4)

762 (59.4,

56.8–62.1)

47 (3.7,

2.8–4.8)

1 (0.1,

0.0–0.4)

1281

(100) a Values outside the brackets are numbers of ED presentations. Values in the brackets

are proportions and their 95% confidence intervals.


Table 5, Logistic regression model (ORs and 95%CI) for admission to hospitals

among main language spoken at home, adjusted for sex, age, and triage

categories , QLD 2008–2010

Languages OR (95%) P


Chinese* 0.93 (0.86–0.99) 0.03

Vietnamese 1.09 (0.99–1.19) 0.08

Arabic 0.76 (0.67–0.85) 0.001

Spanish 0.83 (0.75–0.93) 0.001

Italian 1.03 (0.94–1.14) 0.51

Hindi 1.04 (0.91–1.18) 0.56

German 1.17 (1.02–1.34) 0.02



DISCUSSION

To our knowledge, this is the first study to describe the role of language in utilisation

of emergency care in Queensland in terms of utilisation rate, ambulance utilisation,

mode of arrival and departure status using a state-wide whole population dataset.

The study showed that there is an association between lower ED utilisation rate,

lower ambulance utilisation, and lower admission to hospital and speaking languages

other than English at home. These results are consistent with a number of other

studies that have shown lower utilisation of ED care among immigrants from

different language backgrounds and those born in the host countries[12-14]

.

The findings also concur with the notion of the “healthy immigrant effect”, which

suggests that immigrants are healthier than native-born residents due to the

selectivity of the immigration process (health screening prior to migration, education

level, language proficiency, and age), the healthier behaviour of immigrants prior to

migration, and immigrant self-selection, whereby the healthiest and wealthiest

individuals are the most likely to migrate [2, 12]

.

Several international studies have shown that language barriers might be the reason

for poor access to health care including emergency care and may contribute to health

disparities [7, 13, 14]

. In the United States, Ponce and colleagues found that adults who

speak another language at home were almost two and half times more likely to have

poor access to care and poor health status compared to those who speak English only

at home [14]

. Also, another study showed that Spanish-speaking Hispanics reported

far worse health status and access to care than did English-speaking Hispanics [15]

.

Similar evidence of poor access to health care by linguistic minorities was also found

in Canada and Europe [13, 16, 17]

. However, these studies might not be applicable to


Australia, as immigrants’ characteristics in these countries as well as their health

systems might differ from those in Australia.

Despite that our data showed significant association between language spoken at

home and utilisation of emergency care, the limitation of the data preclude any

determination of the reasons for the observed association. Moreover, there is paucity

of empirical studies on utilisation of emergency care among non-English speaking

background patients in Queensland and Australia. However, assuming the population

in Queensland is similar to the population studied in the literature, the contributing

factors may also be similar, which include language barriers, unfamiliarity with

health system, lack of knowledge, and fear of high cost [9, 18]

. Further research is

recommended to explore utilisation of emergency care by non-English speaking

background immigrants in Australian context using mixed methodology.

This study has a number of limitations. First, the data for the study originated from

routinely collected state-wide data (EDIS) and provide only limited information on

the characteristics of the patients. Therefore, the study dataset did not allow for the

inclusion of all influential factors of ED care utilisation that were identified in the

literature, such as socio-economic status, refugee status, and having a usual source of

care.

Second, the ED patients were de-identified, which did not allow analyses by

individual patients. As such, there might be some patients with multiple visits to ED.

Lastl, the percentages of the study population might be inconsistent with Australian

Bureau of Statistics figures for language spoken at home, which indicated in the

2006 census that 303,160 (7.8%) of the Queensland population speak a language

other than English at home [3]

. This could be due to the usual limitations of large

secondary datasets such as adequacy, accuracy, and completeness [19]

. However, the


figures of this study may be representative of limited English proficiency people,

which were estimated to be 47,946 (1.2%) of Queensland population in the 2006

census [3]

.

In conclusion, the study showed lower utilisation of ED care among those who speak

languages other than English at home in Queensland, and part of that could be due to

the “healthy immigrant effect”. However, further research using in depth

methodology is needed to explore the role of language in access to ED care, such as

the reasons for use of ED care by non-English speaking background patients,

interpreter usage, length of stay at ED, and satisfaction with ED care.

ACKNOWLEDGEMENTS

The authors are grateful to the Hospital Access Analysis Team (HAAT) of

Queensland Health, the data custodians of the EDIS data, and particularly Jean

Sloan, who extracted and provided the data.


REFERENCES

1 Department of Immigration and Citizinship (DIAC). Annual report 2008–09.

Canberra: DIAC; 2009 [cited 2011 Sep. 06]; Available from:

http://www.immi.gov.au/about/reports/annual/2008-09/html/.

2 Baum F. The New Public Health. Melbourne: Oxford University Press; 2008.

3 Australian Bureau Statistics (ABS). Language Spoken at Home (LANP).

Canberra: ABS2006 [cited 2011 Sep. 06]; Available from:


2B1?opendocument.


Canberra2001.


Canberra: ABS2006.

6 Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language

barriers in medicine in the United States. JAMA. 1995;273(9):724-8.

7 Yeo S. Language barriers and access to care. Annu Rev Nurs Res.

2004;22(1):59-73.

8 Ou L, Chen J, Hillman K. Health services utilisation disparities between

English speaking and non-English speaking background Australian infants. BMC

Public Health. 2010;10(182).

9 Sheikh M, Nugus PI, Gao Z, Holdgate A, Short AE, Al Haboub A, et al.

Equity and access: understanding emergency health service use by newly arrived

refugees. Med J Aust. 2011;195(2):74-6.


10 Correa-Velez I, Sundararajan V, Brown K, Gifford SM. Hospital utilisation


Victoria, 1998-2004. Med J Aust. 2007;186(11):577-80.

11 Forero R, Nugus P. Literature Review on the Australasian Triage Scale

(ATS). Sydney: The Australasian College for Emergency Medicine (ACEM); 2012

[cited 2012 Jun. 17]; Available from: http://www.acem.org.au/home.aspx?docId=1.

12 Buron A, Cots F, Garcia O, Vall O, Castells X. Hospital emergency


BMC Health Serv Res. 2008;8(1):51.

13 Wen SW, Goel V, Williams JI. Utilization of health care services by

immigrants and other ethnic/cultural groups in Ontario. Ethn Health. 1996;1(1):99-

109.

14 Ponce NA, Hays RD, Cunningham WE. Linguistic disparities in health care

access and health status among older adults. J Gen Intern Med. 2006;21(7):786-91.

15 DuBard CA, Gizlice Z. Language spoken and differences in health status,

access to care, and receipt of preventive services among US Hispanics. Am J Public

Health. 2008;98(11):2021-8.

16 Lindert J, Schouler-Ocak M, Heinz A, Priebe S. Mental health, health care

utilisation of migrants in Europe. Eur Psychiatry. 2008;23:14-20.

17 Norredam M, Nielsen SS, Krasnik A. Migrants’ utilization of somatic

healthcare services in Europe—a systematic review. Eur J Public Health.

2010;20(5):555-63.

18 Razzak JA, Kellermann AL. Emergency medical care in developing

countries: is it worthwhile? Bull World Health Organ. 2002;80(11):900-5.


19 Sanders CM, Saltzstein SL, Schultzel MM, Nguyen DH, Stafford HS, Sadler

GR. Understanding the Limits of Large Datasets. J Cancer Educ. 2012;27:1-6.


Article 4: Language affects the length of stay in emergency departments in

Queensland public hospitals

Article 4 was published in The World Journal of Emergency Medicine [Mahmoud,

I., Hou, X., Kevin, C., & Clark, M. (2013). Language affects the length of stay in

emergency departments in Queensland public hospitals. World Journal of Emergency

Medicine, 4(1), 5–9].



World J Emerg Med, Vol 4, No 1, 2013 DOI: 10.5847/ wjem.j.1920–

8642.2013.01.001 World J Emerg Med 2013;4(1):5–9

Original Article

Language affects length of stay in emergency departments in Queensland public

hospitals

Ibrahim Mahmoud1, Xiang-yu Hou

1,2, Kevin Chu1

2, Michele Clark

1

1 School of Public Health, Queensland University of Technology, Brisbane,

Australia, 2 Department of Emergency Medicine, Royal Brisbane and Women's

Hospital, Brisbane, Australia

Corresponding Author: Xiang-yu (Janet) Hou, Email: [email protected]

BACKGROUND: A long length of stay (LOS) in the emergency department (ED)

associated with overcrowding has been found to adversely affect the quality of ED

care. The objective of this study is to determine whether patients who speak a

language other than English at home have a longer LOS in EDs compared to those

whose speak only English at home.

METHODS: A secondary data analysis of a Queensland state-wide hospital EDs

dataset (Emergency Department Information System) was conducted for the period,

1 January 2008 to 31 December 2010.

RESULTS: The interpreter requirement was the highest among Vietnamese speakers

(23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were

significant differences in the distributions of the departure statuses among the

language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers,

the Beta coefficient for the LOS in the EDs measured in minutes was among

Vietnamese, 26.3 (95%CI: 22.1–30.5); Arabic, 10.3 (95%CI: 7.3–13.2); Spanish, 9.4

(95%CI:7.1–11.7); Chinese, 8.6 (95%CI: 2.6–14.6); Hindi, 4.0 (95%CI: 2.2–5.7);

Italian, 3.5 (95%CI: 1.6–5.4); and

German, 2.7 (95%CI: 1.0–4.4). The final regression model explained 17% of the

variability in LOS.

CONCLUSION: There is a close relationship between the language spoken at home

and the LOS at EDs, indicating that language could be an important predictor of

prolonged LOS in EDs and improving language services might reduce LOS and ease

overcrowding in EDs in Queensland's public hospitals.

KEY WORDS: Emergency department; Language; Length of stay


INTRODUCTION

Overcrowding in emergency departments (EDs) is a serious and growing crisis

confronting Australia's public hospitals and may affect the quality of and access to

care.[1]

Length of stay (LOS) is a marker of ED overcrowding and a key component

of ED quality assurance monitoring.[2,3]

ED LOS is usually defined as the time from a

patient's registration until that patient's departure from the ED.[4,5] LOS can be

associated with ED overcrowding, decreased patient satisfaction with ED care,

ambulance diversion and poor clinical outcomes.[3,4]

An association with a long LOS

in the ED has also been found in differences in language between health care

providers and patients.[6,7]

In Australia, approximately 15.6% of the population

speaks a language other than English at home, with approximately 3% having limited

English proficiency.[8]

Some studies have suggested that patients from non-English

speaking backgrounds tend to use ED care as their primary source of care.[9–11]

Critical time can be lost in the ED due to a lack of ability to communicate effectively

in English, which contributes significantly to increased LOS. However, these studies

have been conducted in countries where the health system and patients'

characteristics differ from those in Australia. Currently, a limited body of literature

exists describing the effect of language on LOS in Australian EDs.

The aim of this study is to determine if patients who speak a language other than

English at home have a longer LOS than those who speak only English at home in

public hospital EDs in Queensland (QLD).


METHODS

Study design and setting

An analysis of the QLD public hospitals' ED dataset for the period from January 1,

2008 to December 31, 2010 was undertaken. QLD, located in Australia's northeast, is

the second-largest in land mass and third most populated state in the country.

Data collection

The data were sourced from the Emergency Department Information System (EDIS).

EDIS is an electronic information system for public hospital EDs in QLD. It provides

data such as arrival time, departure time, triage category, gender, age, language

spoken at home, and ED departure status (admission to hospitals, did not wait, died

or discharged).

Ethical approval to use unidentified data was obtained from QLD Health Central

Ethics Unit (HREC/11/QHC/29).

Study population

Patients were divided into groups according to the language spoken at home. Those

who had been admitted to hospital, transferred to another hospital, left without being

seen, left after the commencement of treatment, or died in ED were excluded. Only

patients who had completed their ED service and were discharged were included in

the analysis. The study was limited to the languages most commonly spoken at home

as specified by EDIS: English (1 984 087), Arabic (1 593), Chinese (3 356),

Vietnamese (1 478), Spanish (1 285), Italian (976), Hindi (957), and German (762).

Data analysis

Descriptive analysis was performed to test for the proportions of ED departure status

(admission to hospital, transferred, discharge, did not wait, or died) and interpreter

requirements. Two multiple linear regression models were used. The first model


controlled for age, gender, and triage categories, and interpreter requirement was

included to form the second model. The triage priority was measured using the

Australian Triage Scale (ATS), where resuscitation patients need to be seen

immediately, emergency patients within 10 minutes, urgent patients within 30

minutes, semi-urgent patients within 60 minutes, and non-urgent patients within 120

minutes.[12]

The results were calculated using Statistical Package for the Social Sciences (SPSS)

version 19 (IBM SPSS Statistics 19).

RESULTS

Among the total of 2 953 731 patients attending all public hospital EDs in QLD from

January 1, 2008 to December 31, 2010, 2 905 204 (98.4%) spoke only English at

home and 48 527 (1.6%) spoke another language at home. Table 1 describes the

proportions of the patients' departure status, including those whose ED service was

completed and were discharged. Table 2 shows the interpreter requirements among

the different language groups. Patients who spoke Chinese, Vietnamese, Arabic,

Spanish, Italian, Hindi, and German at home had a signifi cantly (P<0.05) longer

LOS compared to patients who spoke only English, controlling for gender, age, and

triage category (Table 3). Table 4 shows the differences in LOS after adding

interpreter requirement to the model.

The R2 for the first regression model was 0.12 and 0.17 for the final model,

suggesting that 12% and 17% of the variance, respectively, could be explained by

these two models.


Table 1. The Chi-square test for departure statuses from ED by language

spoken at home, QLD 2008–2010

Languages Departure status

Admitted/Referred

(%)

Discharged (%) Did not

wait (%)

Died (%) Total

English

only

697169 (24.) 1984087 (68.3) 221551

(7.6)

2397 (0.1) 2905204

(100)

Chinese* 1341(26.4) 3356 (66.0) 381 (7.5) 4 (0.1) 5082

(100)

Vietnamese 893 (35.1) 1478 (58.0) 173 (6.8) 3 (0.1) 2547

(100)

Arabic 421 (18.8) 1593 (71.1) 225 (10.0) 2 (0.1) 2241

(100)

Spanish 629 (30.7) 1285 (62.8) 129 (6.3) 4 (0.2) 2047

(100)

Italian 981 (48.7) 976 (48.5) 55 (2.7) 1 (0.1) 2013

(100)

Hindi 444 (29.0) 957 (62.5) 128 (8.4) 1 (0.1) 1530

(100)

German 471 (36.8) 762 (59.4) 47 (3.7) 1 (0.1) 1281

(100)

Other 10 649 (33.5) 18 962 (59.7) 2 062

(6.5)

113 (0.4) 31 786

(100)

Total 712 998 (24.1) 2013 456 (68.2) 224 751

(7.6)

2 526 (0.1) 2 953731

(100)


Table 2. Interpreter requirement in ED, QLD 2008–2010

Languages Total no. Interpreter required (%)

English only* 1 984 087 386 (0.0)

Chinese** 3 356 666 (19.8)

Vietnamese 1 478 342 (23.1)

Arabic 1 593 298 (18.7)

Spanish 1 285 208 (16.2)

Italian 976 114 (11.7)

Hindi 957 132 (13.8)

German 762 44 (5.8)

*: Auslan language; **: Including Cantonese & Mandarin.


Table 3. Multiple linear regression (ORs and 95%CI) for LOS in EDs among

main languages spoken at home, adjusted for sex, age, and triage categories,

QLD 2008–2010 Languages OR (95%) P


Chinese* 14.5 (9.3–19.6) 0.001

Vietnamese 28.4 (24.5–32.3) 0.001

Arabic 14.4 (11.9–16.8) 0.001

Spanish 11.4 (9.3–13.5) 0.001

Italian 3.4 (1.5–5.3) 0.001

Hindi 4.1 (2.5–5.7) 0.001

German 2.0 (0.5–3.5) 0.01

*: Including Cantonese & Mandarin.

Table 4. Multiple linear regression (ORs and 95%CI) for LOS in EDs among

main languages spoken at home, adjusted for sex, age, triage categories, and

interpreter requirement, QLD 2008–2010 Languages OR (95%) P


Chinese* 8.6 (2.6–14.6) 0.005

Vietnamese 26.3 (22.1–30.5) 0.001

Arabic 10.3 (7.3–13.2) 0.001

Spanish 9.4 (7.1–11.7) 0.001

Italian 3.5 (1.6–5.4) 0.001

Hindi 4.0 (2.2–5.7) 0.001

German 2.7 (1.0–4.4) 0.001

*: Including Cantonese & Mandarin.


DISCUSSION

This is the first study in Queensland to compare the length of stay (LOS) in public

hospital Emergency Departments (EDs) among patients whose primary language is

not English to those who speak only English at home. Our study showed that patients

who speak Vietnamese had a higher rate of interpreter use and a longer LOS than the

other language groups. The patients who speak a language other than English at

home had significantly longer LOS in the EDs. More specifically, patients who

spoke Vietnamese at home stayed the longest in the EDs (26.3 minutes), followed by

Arabic (10.3 minutes), Spanish speakers (9.4 minutes) and Chinese speakers (8.6

minutes), compared to those who spoke only English at home. These findings agree

with previous studies in other countries.[3,13,14]

Public hospital EDs in Queensland see patients who have little or no understanding

of English due to a high proportion of immigrants living in the state. Additional time

is needed to obtain an interpreter, and even when an interpreter is readily available,

the emergency physician requires additional time for this interaction.[15]

Thus, if a

patient with limited English proficiency requires an interpreter, this can prolong the

LOS. However, our first regression model explained only 12% of the variability in

LOS, controlling for language, triage category, gender, and age. That was improved

significantly to 17% when the interpreter requirement was added to the final model,

which suggests the importance of this factor. This also indicates that there are other

influential factors affecting LOS in EDs which were not captured by our study.

The first possible reason is that sometimes ED care providers use whoever bilingual

and available at the ED such as a family member or hospital staff to communicate

with patients, rather than use a professional interpreter.[13,16]

It was reported that

using nonprofessional interpreter might result in serious consequences including


breach of patient confidentiality, less understanding of the patient's problems, un-

necessary diagnostic tests, wrong diagnosis, wrong treatment, frequent ED visits, and

reduced quality of care.[16–18]

This would lead to higher health care costs, add greater

burden to already overcrowded EDs, and delay treatment.[18]

The second possible reason is that some disadvantaged immigrants, such as refugees,

might attend EDs with more advanced illnesses or complex conditions which require

longer assessment, additional diagnostic tests, and treatment times.[19]

Unfortunately,

patients' refugee status is not available for this study, and warrants future research in

this area.

The third possible reason is the clinical situation of these patients such as the number

of patients in the ED at that time, the laboratory tests ordered, the use of diagnostic

imaging, and specialty consultation.[2,6]

The fourth possible reason could be the cultural barriers. For example, women from

Islamic or Middle Eastern cultures prefer to be seen by a female doctor, which can

prolong their LOS or cause them to leave the ED without seeing the doctor.[20,21]

This specific culture could potentially explain the reason, at least partly, that Arabic

speakers had 10% higher than any other group who did not wait for their treatment to

be completed at EDs and left the EDs against the doctor's wish. Further research is

needed to confirm this assumption. This is important as the immigration data indicate

that there are increasing numbers of immigrants, refugees, and foreign students from

Arabic speaking countries coming to Australia.[22]

Several studies have shown that language barriers not only increased the LOS in

EDs, but also decreased patients' satisfaction.[3,13,14]

Carrasquillo et al[13]

reported that

compared to English speakers, non-English speakers were less satisfied with the care

they received in the ED as, were less willing to return to same ED if they had a


problem which they felt required emergency care, and reported more problems with

emergency care. Therefore, understanding why these patients are staying longer in

the ED is an important factor in enhancing the acute care delivered to these patients

in the EDs.

The limitations of this study are mainly the limitations of large secondary data

analysis such as adequacy, accuracy, completeness, and other measures of the quality

of the data.[23]

However, every humanly possible effort has been made to make sure

the process of retrieving the data is accurate and consistent.

In conclusion, patients who speak a language other than English at home had a

longer length of stay in Queensland public hospital emergency departments which

largely cannot be explained by the language itself.

Further research is needed to identify reasons behind the longer stay and provide

scientific evidence for effective future interventions so that everyone can access

acute care in time despite their language spoken at home.

ACKNOWLEDGEMENT


Queensland Health, the data custodians of the EDIS data, and particularly Jean

Sloan, who extracted and provided the data.

Funding: None.

Ethical approval: Ethical approval to use unidentified data was obtained from QLD

Health Central Ethics Unit (HREC/11/QHC/29).

Conflicts of interest: The authors have no financial or other conflicts of interest

regarding this article.

Contributors: Mahmoud I proposed and wrote the study. All authors read and

approved the final manuscript. Hou XY is the guarantor.


REFERENCES

1 Australian Institute of Health and Welfare. Public EDs not coping with growing

pressure. Aust Med 2009; 21: 3–4.

2 Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the

emergency department. CJEM 2003; 5: 155.

3 Herring A, Wilper A, Himmelstein DU, Woolhandler S, Espinola JA, Brown DFM,

et al. Increasing length of stay among adult visits to US emergency departments,

2001–2005. Acad Emerg Med 2009; 16: 609–616.

4 Forster AJ, Stiell I, Wells G, Lee AJ, Van Walraven C. The effect of hospital

occupancy on emergency department length of stay and patient disposition. Acad

Emerg Med 2003; 10: 127–133.

5 Gardner RL, Sarkar U, Maselli JH, Gonzales R. Factors associated with longer ED

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6 Goldman RD, Amin P, Macpherson A. Language and length of stay in the pediatric

emergency department. Pediatr Emerg Care 2006; 22: 640.

7 Yeo S. Language barriers and access to care. Annu Rev Nurs Res 2004; 22: 59–73.

8 Australian Bureau of Statistics. Language spoken at home (LANP). Canberra:

ABS; 2006. Available from:

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078F2B1?opendocument.

9 Rué M, Cabré X, Soler-González J, Bosch A, Almirall M, Serna MC. Emergency

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and Spanish-born populations. BMC Health Serv Res 2008; 8: 81.


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Eur J Public Health 2007; 17: 497.

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12 Forero R, Nugus P. Literature review on the Australasian Triage Scale (ATS).

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Emerg Med 1997; 15:397–399.

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medical interpreters in the emergency department: effects on services, subsequent

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Impact of interpreter services on delivery of health care to limited-English proficient

patients. J Gen Intern Med 2001; 16: 468–474.

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resource utilization in a pediatric emergency department. Pediatrics 1999; 103:

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health policy. Acad Emerg Med 2004; 11: 1311–1317.


19 Bener A, Rafie Alwash MD P, Miller CJ, Denic S, Dunn EV. Knowledge,

attitudes, and practices related to breast cancer screening: a survey of Arabic women.

J Cancer Educ 2001; 16:215–220.

20 Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital

emergency department without being seen by a physician. JAMA 1991; 266: 1085–

1090.

21 Australian Bureau of Statistics. 2006 Census of population and housing.

Canberra: ABS; 2006.

22 Kwok C, Sullivan G. Health seeking behaviours among Chinese-Australian

women: implications for health promotion programmes. Health 2007; 11: 401–415.

23 Sanders CM, Saltzstein SL, Schultzel MM, Nguyen DH, Stafford HS, Sadler GR.

Understanding the limits of large datasets. J Cancer Educ 2012: 1–6.

Received September 6, 2012

Accepted after revision January 19, 2013


Article 5: Utilisation of hospital emergency departments among immigrants

from refugee source-countries in Queensland

Article 5 was published in Clinical Medicine and Diagnostics [Mahmoud, I., &

Hou, X.-Y. (2013). Utilisation of hospital emergency departments among immigrants

from refugee source-countries in Queensland. Clinical Medicine and Diagnostics,

3(4), 88–91].



Clinical Medicine and Diagnostics 2013, 3(4): 88-91 DOI:10.5923/j.cmd.20130304.03

Utilisation of Hospital Emergency Departments among Immigrants from

Refugee Source-Countries in Queensland

Ibrahim Mahmoud*, Xiang-Yu Hou

School of Public Health & Social Work, Queensland University of Technology

(QUT), Brisbane, 4059, Australia

* Corresponding Author: Email: [email protected]

Abstract Despite the increasing number of immigrants, there is a limited body of

literature describing the use of hospital emergency department (ED) care by

immigrants in Australia. This study aims to describe how immigrants from refugee

source countries (IRSC) utilise ED care, compared to immigrants from the main

English speaking countries (MESC), immigrants from other countries (IOC) and the

local population in Queensland. A retrospective analysis of a Queensland state-wide

hospital ED dataset (ED Information System) from 1-1-2008 to 31-12-2010 was

conducted. Our study showed that immigrants are not a homogenous group. We

found that immigrants from IRSC are more likely to use interpreters (8.9%) in the

ED compared to IOC. Furthermore, IRSC have a higher rate of ambulance use (odds

ratio 1.2, 95% confidence interval (CI) 1.2–1.3), are less likely to be admitted to the

hospital from the ED (odds ratio 0.7 (95% CI 0.7–0.8), and have a longer length of

stay (LOS; mean differences 33.0, 95% CI 28.8–37.2), in minutes, in the ED

compared to the Australian born population. Our findings highlight the need to

develop policies and educational interventions to ensure the equitable use of health

services among vulnerable immigrant populations.

Keywords Emergency Department, Immigrants, Refugees, Utilisation


1. Introduction

A number of international studies have shown differences in the use of emergency

department (ED) care between immigrants and local populations [1-5]. Currently, a

limited body of literature exists describing the use of ED care by immigrants in

Australia. This is despite the 2011 Census showing that over 6 million (27%) of

Australia’s people were born overseas [6]. However, immigrants are not a

homogeneous group. Annually, Australia resettles about 13,000 refugees via the

Humanitarian Program [7]. People from refugee backgrounds may have experienced

the ill effects of the conditions in refugee camps, thus arriving with existing health

problems [8-10]. For those people, access to appropriate health care facilities after

their arrival in a new country is often limited by cultural, language, or financial

barriers [11,12]. Poor and inappropriate access to the health care services for this

vulnerable group might have serious implications for their health [13,14]. Several

studies have shown that some immigrants from refugee backgrounds tend to use ED

care as a primary source of health care [2,5]. This might be influenced by their

previous patterns of use in their origin countries [15,16]. Therefore, these immigrants

may be disadvantaged by a lack of access to preventive and primary health care

facilities and thus place an additional burden on ED care due to inappropriate access.

Immigrant access to healthcare services, such as ED services, and outcomes of such

interaction have been widely studied in a number of countries; however, the topics

have received little attention in Australia. Therefore, this study aims to describe how

immigrants from refugee source countries (IRSC) utilise ED care in terms of their

requirement of interpreters, ambulance use, admission to hospital, and length of stay


(LOS) in the ED, compared to immigrants from the main English speaking countries

(MESC), immigrants from other countries (IOC) and the local population in

Queensland. The study may provide original data to fill some of the gaps in this area.

2. Methods

2.1. Study Design and Setting

An analysis of the Queensland public hospitals’ ED dataset for the three calendar

years, from 1 January 2008 to 31 December 2010, was undertaken. Queensland,

located in northeast Australia, is the second-largest in land mass and third-most

populous state of Australia.

2.2. Data Source

The data were sourced from the Emergency Department Information System (EDIS).

The EDIS is an electronic information system for public hospital EDs in Queensland.

It provides data such as modes of arrival (ambulance, walk-in including via public

transport and others), triage category, gender, age, country of birth, and ED departure

status (admission to hospital, did not wait, died, or discharge). Ethical approval to

use unidentified data was obtained from the Queensland Health Central Ethics Unit

(HREC/11/QHC/29).

2.3. Data Analysis

The proportions of interpreter use were calculated using Pearson’s chi-square test.

Logistic and multiple linear regression analyses were performed to determine the

relationships between ambulance use and country of birth, admission status and

country of birth, and LOS in the ED and country of birth. The analyses were adjusted

for gender, age, interpreter use, and triage categories (resuscitation, emergency,

urgent, semi-urgent, and non-urgent), according to the Australasian Triage Scale


(ATS)[17]

. The results were calculated using Statistical Package for the Social

Sciences (SPSS) version 19 (IBM SPSS Statistics 19).

2.4. Immigrants’ Countries of Origin

The term main English-speaking country (MESC) is used to describe people

migrating from the United Kingdom, the Republic of Ireland, New Zealand, Canada,

South Africa, and the United States of America, according to the Australian Bureau

of Statistics (ABS)[18]. Information about immigration status and distribution of

refugees is not available from the EDIS. Therefore, we used the same approach used

by [19] in their study on the Victorian Admitted Episodes Dataset (VAED)[19]. They

used country of birth as a proxy indicator of refugee status [19]

. Refugee source

countries are those countries where significant numbers of people have been forcibly

displaced due to persecution, violence, and war [19]. A cut-off was made from 1980

onwards to differentiate recent refugees from former refugees, who entered Australia

through the Refugee and Humanitarian Program. The new refugee source countries,

as indentified by [19], are Afghanistan, Bosnia-Herzegovina, Burma, Eritrea,

Ethiopia, Iraq, Somalia, and Sudan [19]. We excluded from the analysis those people

who did not state their country of birth.

3. Results

Of the total of 2,953,731 visits to Queensland public hospital EDs between January

2008 and December 2010, 2,395,382 (81.1%) were born in Australia, 292,138

(9.9%) were born in MESC, 9,935 (0.3%) were born in refugee source countries,

216,074 (7.3 %) were born in other countries, and 40,202 (1.4%) did not state their

country of birth. Overall, people from MESC and IOC had very similar rates of ED

care use and LOS in ED, with little difference from people born in Australia.


Table 1 shows the higher use of interpreters by IRSC compared to IOC (Chi-squared

= 5,347.1, p < 0.001). Table 2 compares the use of ambulances as a mode of arrival

to the ED among different immigrant groups to the local population. IRSC had

statistically higher (p < 0.05) ambulance use compared to the Australian born

population and other immigrant groups. IRSC also had lower admission to hospital

from the ED (0.7; 95% CI 0.7–0.8) than MESC (0.9; 95% CI 0.9–0.9) and IOC (0.8;

95% CI 0.8–0.9) when compared to the local population (Table 3). Table 4 shows the

prolonged LOS in minutes in the ED for IRSC (33.0; 95% CI 28.8–37.2), compared

to the Australian born population. Lastly, Table 5 presents the LOS among people

from the eight refugee source countries compared to the Australian born population.


Table 1. Interpreter use among immigrants in EDs, QLD 2008–2010

Born country Total no. Interpreter use (%)

IRSC 9,935 885 (8.9)*

IOC 216,074 5362 (2.5)*

*(Chi-squared 1,459.486, p 0.001)

Table 2. Logistic regression model (ORs and 95%CI) for ambulance use among

immigrants, adjusted for sex, age, and triage categories, QLD 2008–2010

Country of birth OR (95% CI) P

Reference group: Australia

IRSC 1.2 (1.2–1.3) 0.001

MESC 0.7 (0.7–0.7) 0.001

IOC 0.7 (0.7–0.7) 0.001

Table 3. Logistic regression model (ORs and 95%CI) for admission status from

ED among immigrants, adjusted for sex, age, and triage categories, QLD 2008–

2010

Country of birth OR (95% CI) P


IRSC 0.7 (0.7–0.8) 0.001

MESC 0.9 (0.9–0.9) 0.001

IOC 0.8 (0.8–0.9) 0.001


Table 4. Multiple linear regression (Mean differences and 95% CI) for LOS in

ED among immigrants, adjusted for sex, age, triage categories, and interpreter

use, QLD 2008–2010

Country of birth Mean differences (95% CI) P


IRSC 33.0 (28.8–37.2) 0.001

MESC 6.6 (5.8–7.4) 0.001

IOC 9.4 (8.5–10.4) 0.001

Table 5. Multiple linear regression (Mean differences and 95% CI) for LOS in

ED among patients from refugee source countries, adjusted for sex, age, triage

categories, and interpreter use, QLD 2008–2010

Country of birth Mean differences (95% CI) P


Afghanistan 23.4 (11.6–35.1) 0.001

Bosnia 28.9 (20.4–37.4) 0.001

Burma 21.0 (5.0–37.0) 0.010

Eretria 52.5 (17.6–87.4) 0.003

Ethiopia 58.2 (40.0–76.4) 0.001

Iraq 8.9 (-3.3–21.1) 0.155

Somalia 35.5 (18.5–52.6) 0.001

Sudan 46.1 (38.6–53.5) 0.001


4. Discussion

Our study showed heterogeneity in the use of ED care among immigrants in

Queensland. The study found that people born in refugee source countries have

higher interpreter use, higher ambulance use, lower admission to hospital, and longer

LOS in the ED than immigrants from other countries, using the Australian born

population as a reference group. Understanding that immigrants are not one group,

their patterns of ED care use are vital in terms of policy planning and the

development of educational interventions to provide equitable health care to

disadvantaged immigrants. People from refugee source countries might use ED care

as their the principal provider of their health care instead of primary care due to

several barriers [2,5]. General practitioners who do not speak the patients’ languages

and the unavailability of interpreters in general practice settings might be two of the

reasons why patients with limited English proficiency seek care in hospital Eds[20].

Furthermore, a lack of transport might encourage low socio-economic refugees to

use ambulance service for transport to hospital EDs for non-critical conditions[14].

However, a study from the Liverpool Hospital ED in Sydney that found that recently

resettled refugees were afraid of calling for an ambulance, despite their ability to do

so and their conviction that such a call was needed[16]. However, their study was a

single site study with a small sample size, which limits its applicability to the

Australian refugee population. Unfortunately, Our study was not able to determine

whether the high use of ambulances among IRSC is due to the vulnerability of this

group to illness, and attending EDs with advanced illness requires an ambulance, or

due to a lack of transport. To date, there has been a paucity of empirical studies on

how immigrants in Australia use ambulances. Thus, this topic warrants further

investigation.


LOS is a marker of ED overcrowding and a key component of ED quality assurance

monitoring [21,22]. Our study found a significant prolonged LOS in the ED among

people from refugee source countries, particularly those from Sudan, Bosnia,

Afghanistan, and Burma, compared to the Australian born population. These findings

agree with other studies that showed an association between longer LOS in the ED

and differences in language between health care providers and patients[23,24].

Although our regression model controlled for interpreter use and triage priority, it

explained only 16.5% of the variability in LOS. This indicates that there are other

significant factors influencing LOS in EDs, besides language and the severity of the

condition, which were not captured by our study. Our study has some limitations. It

originated from routinely collected state-wide data (EDIS) and provides only limited

information on the characteristics of the patients. Therefore, the study dataset did not

allow for the inclusion of all important factors of ED care use, such as socio-

economic status, immigration status, and LOS in Australia. Another limitation is that

the EDIS data were de-identified, which did not allow analyses of individual

patients. As such, some patients might have made multiple visits to the ED. There are

also limitations when conducting a large secondary data analysis, such as adequacy,

accuracy, and completeness [25]. However, every humanly possible effort was made

to ensure accuracy and consistency in the data retrieval process.

5. Conclusions

Our findings regarding ED care use may reflect some barriers that IRSC face when

accessing primary health care services. We recommend further research using mixed

methodologies to investigate why IRSC use ED care differently from others. This

could help in developing educational intervention programs for this population and

making policies that favour their access to primary care as well as ED care.


ACKNOWLEDGMENTS


Queensland Health, the data custodians of the EDIS data. The authors are also

grateful to Dr Ignacio Correa-Velez for his invaluable comments on the manuscript.


REFERENCES

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S. Nielsen, 2004, Emergency room utilization in Copenhagen: A comparison of

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[3] M. Rué, X. Cabré, J. Soler-González, A. Bosch, M. Almirall, and M. C. Serna,

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[4] A. Buron, F. Cots, O. Garcia, O. Vall, and X. Castells, 2008, Hospital emergency


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[13] K. P. Derose, J. J. Escarce, and N. Lurie, 2007, Immigrants and health care:

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[23] R. D. Goldman, P. Amin, and A. Macpherson, 2006, Language and length of

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Study III: A Cross-sectional Survey

This study involved primary data collection to explore the principal reasons for ED

service use (Article II) and to explore satisfaction with the ED service (Article I)

among NESB patients. The approach was to conduct a cross-sectional survey of ED

patients in a tertiary teaching hospital.

Article 6: Satisfaction with emergency department service among non-English

speaking background patients

An article about satisfaction with ED service has been submitted to Emergency

Medicine Australasia [Mahmoud, I., Hou, X., Chu, K., Clark, M., & Eley, R.

(Accepted). Satisfaction with emergency department service among non-English

speaking background patients. Emergency Medicine Australasia].

The submitted article is presented below.


Satisfaction with Emergency Department Service among Non-

English Speaking Background Patients Ibrahim Mahmoud

1, Xiang-Yu Hou

2, Kevin Chu

3, Michele Clark

4, Rob Eley

5 Authors’ Qualifications:

1MBBS, MSc., MPH, GCert (Epi), PhD Candidate

2 BMed, MMed, PhD, Senior Lecturer

3MBBS, MS FACEM, Emergency Physician

4 BOccThy (Hons), BA, PhD, Director

5BSc, MSc, PhD CBiol FSB, Academic Research Manager

Authors’ Information:

1,2,4 School of Public Health and Social Work, Queensland University of Technology,

Brisbane, Australia

3 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital,

Brisbane, Australia

5 The University of Queensland – Princess Alexandra Hospital, Brisbane, Australia

Author's contribution:

1 Design, acquisition of data, analysis and interpretation of data;

2, 5 Assist and supervising the study design, data interpretation & discussion, and the

drafts revision.

2,3,4,5 Critical review of the manuscript.


Ibrahim Mahmoud

School of Public Health and Social Work, Queensland University of Technology


Tel: (61) 7 31383540 Mobile: (61) 403929967

E-mail: [email protected]

Short Running Title: Satisfaction with ED service

Word count: 1,962


Satisfaction with Emergency Department Service among Non-

English Speaking Background Patients ABSTRACT

Objective: To investigate non-English speaking background (NESB) patients’

satisfaction with hospital emergency department (ED) service and compare it to that

of English speaking background (ESB) patients.

Methods: A cross-sectional survey was conducted at the ED of an adult tertiary-

referral hospital in Queensland, Australia. Patients assigned an Australasian Triage

Scale score of 3, 4 or 5 were surveyed in the ED, before and after their ED service.

Pearson X2-test and multivariate logistic regression analyses were performed to

examine the differences between the ESB and NESB groups in terms of patient

reported satisfaction.

Results: In total, 828 patients participated in this study. Although the overall

satisfaction with the service was high—95.1% (ESB) and 90.5% (NESB)—the

NESB patients who did not use an interpreter were less satisfied with their ED

service than the ESB patients were (OR 0.5, 95% CI 0.3–0.8, p = 0.013). The

promptness of service received the lowest satisfaction rates (ESB 85.4% (82.4–88.0),

NESB 74.5% (68.5–79.7), p < 0.001), whilst courtesy and friendliness received the

highest satisfaction rates (ESB 98.8 (97.6–99.4), NESB 97.0 (93.9–98.5), p =0.063).

All participants reported the promptness of service (33.5%), quality and professional

care (18.5%), and communication (17.6%) as the most important elements of ED

service.

Conclusion: The NESB patients were significantly less satisfied than the ESB

patients with the ED service. Use of an interpreter improved the NESB patients’

level of satisfaction. Further research is required to examine what NESB patients’

expectations of ED service are.

Keywords: Emergency department, immigrants, satisfaction


Introduction

Patient satisfaction with health and medical care is becoming an increasingly

important element of quality in healthcare. Patient satisfaction has been defined as

occurring when the patient’s own expectations for medical treatment and care are

met or exceeded.1 In the hospital emergency department (ED), patient satisfaction is

considered an important indicator of quality care.2,3

It also reduces the numbers of

patient complaints and litigations and increases patients’ willingness to return to the

same ED if they need future emergency care.4,5

Moreover, patient satisfaction has

been shown to increase compliance with discharge instructions and improve job

satisfaction among the physicians and other ED staff.6,7

Despite the growing number of immigrants in Australia, scarce data exist concerning

their satisfaction with ED service. This is particularly the case for non-English

speaking immigrants. Several studies from the United States have shown that

compared to English speakers, non-English speakers are less satisfied with their ED

service and less willing to return to the same ED if they have a problem they feel

requires emergency care; non-English speakers have also reported poor

understanding of discharge instructions.5,8-10

On the other hand, some studies have

shown that patients whose language needs were met reported better understanding of

discharge instructions and were more compliant with medication taking.10,11

However, since these studies were conducted in the United States, the extent to

which their results can be applied to the Australian context may be limited due to

differences in the two countries’ health systems.

This study aimed to investigate the satisfaction among non-English speaking

background (NESB) patients compared to English-speaking background (ESB)


patients with the ED service at a metropolitan tertiary- referral teaching hospital in

Brisbane, Queensland, Australia.

Methods


This study used a cross-sectional survey to assess the ED of an adult, tertiary-referral

teaching hospital located in metropolitan Brisbane, Queensland, Australia. The ED

has an annual census in excess of 50,000 presentations. The study was conducted

over a four-month period from 27 August to 28 December 2012. The data were

collected by the principal author, who attended the ED from Monday to Saturday

between 12:00 pm and 8:00 pm.

Study population

A convenience sample was recruited. The inclusion criteria were patients with triage

categories of 3 (urgent), 4 (semi-urgent), or 5 (non-urgent), according to the

Australasian Triage Scale (ATS).12

The exclusion criteria were patients in triage

categories 1 (critical) and 2 (emergency), below 18 years of age, patients with

dementia, mental health patients, pregnant women with obstetrical complaints,

admitted patients, and patients who refused to participate in the research.

Questionnaire

We developed a questionnaire in the English language and adapted the questions

from the existing literature and validated questionnaires on patients’

satisfaction.5,13,14

The questionnaire consisted of two parts. The first part, which

solicited demographic information and the reasons for visiting the ED, was

completed by the patient prior to treatment. The patient was then asked to keep the

questionnaire to fill out the second part, assessing patient satisfaction after treatment,

before leaving the ED. The completed questionnaires were either handed to the


principal investigator or were left at the nursing station. The responses to the

questions were rated on a 5-point Likert scale; 1 (poor), 2 (fair), 3 (good), 4 (very

good), 5 (excellent). The patients were asked to rate the questions about the ED

staff’s skills, compassion, courtesy and respect, communication, time with the

doctor, the quality of the care they received, and their overall satisfaction. At the end

of the questionnaire, the patients were asked an open question about what they

thought was the most important element of ED service. The procedure for answering

the questionnaire was self-completion or a face-to-face interview for both parts. If

required a professional interpreter or a family member acted as an interpreter

throughout their ED visit. Patients were asked through the interpreter if they are

interested in participating in the study. If they agreed then the interpreter helped

them to fill the survey.

Prior to commencing the study, ethical approval was granted from the hospital’s

District Human Research Ethics Committee as well as from the Human Ethics

Committee of the Queensland University of Technology.

Sample size and data analysis

On the basis of their proportion among the study area population and utilizing a two-

tailed alpha of 0.05 and a beta of 0.10 with a power of 90%, we estimated that we

would require 150 NESB patients and 590 ESB patients, to find a significant

difference between the two groups regarding overall satisfaction .15

The participants

were divided into two groups: patients from main English speaking countries

(Australia, Canada, New Zealand, Republic of Ireland, South Africa, the United

Kingdom, and the United States) and patients from other countries where English is

not the principal language.16

Arguing that being from an NESB did not indicate

disadvantage, the federal government formally replaced the term NESB with


‘culturally and linguistically diverse’ (CALD) in 1996.17

However, we chose to

employ the old term ‘NESB’ to indicate that patients from this group might be

disadvantaged in terms of access to appropriate health care facilities due to language

and cultural barriers.


two groups. The levels of satisfaction among ESB and NESB patients were

compared by running Pearson’s X 2 test. The proportions were calculated to

determine where immigrants would seek help if they had developed the same

problem in their birth country and what they thought was the most important element

of ED service. To examine the potential confounding effects of socioeconomic

factors, multivariate logistic regression analyses were performed to reveal the

differences between the two groups in terms of the satisfaction items. “Good / Very

good / Excellent” responses were combined to denote satisfaction, and “Poor / Fair”

dissatisfaction.

The most important elements of the ED service question was grouped according to

the participants’ responses. The proportions of the most prevalent responses were

calculated from the total number of responses, including missing data.

Analyses were performed using Statistical Package for the Social Sciences (SPSS)


Results

A total of 828 patients—597 (72.1%) ESB and 231 (27.9%) NESB—were surveyed

during the study period. Table 1 provides the demographic characteristics of the

study population, showing differences in education levels and fortnightly income

between the two groups. Eighty-one patients (35.1%) used an interpreter for their

ED visit and that interpreter assisted them to fill the survey; specifically, 33 patients


(14.3%) used a professional interpreter and 48 patients (20.8%) used a family

member or a friend as an interpreter (Table 2). As shown in Table 3, in both the

NESB and ESB groups, the highest satisfaction rates were attributed to staff courtesy

and friendliness, followed by staff skills. The lowest satisfaction rates were

associated with the promptness of service and the attention given to spiritual and

emotional needs (Table 3). Table 4 shows that there was no difference in satisfaction

between NESB patients who used an interpreter and ESB patients except for

Spiritual/emotional needs (OR 0.4 (0.2–0.9), P = 0.040). However, NESB patients

who did not use an interpreter were less satisfied in most of tested items than ESB

patients.

The majority of NESB patients reported they would seek help from a GP or private

doctor if they developed the same problem in their birth countries (Table 5). In

comparison overseas born ESB patients were more likely to attend the hospital ED

(Table 5).

All participants reported that the promptness of service (33.5%), quality and

professional care (18.5%), and communication (17.6%) as the most important

elements of ED service.


Table 1. Demographic characteristics of the participants (n, %)

ESB (%)

(N = 597)

NESB (%)

(N = 231)

Total (%)

(N = 828)

Sex

Female

Male

261 (43.7)

336 (56.3)

102 (44.2)

129 (55.8)

363 (43.8)

465 (56.2)

Age (years)

18–39

40–64

65+

267 (44.7)

240 (40.2)

90 (15.1)

118 (51.1)

76 (32.9)

37 (16.0)

385 (46.5)

316 (38.2)

127 (15.3)

Education (highest)

Did not complete secondary school

Completed secondary school

Completed tertiary education

118 (20.1)

233 (39.6)

237 (40.3)

49 (21.2)

54 (23.4)

128 (55.4)

167(20.4)

287 (35.0)

365 (44.6)

Fortnight income (AUD)

400–999 177 (30.2) 103(44.6) 280 (34.2)

1,000–1,499 136 (23.2) 52 (22.5) 188 (23.0)

1,500–1,999 107 (18.2) 34 (14.7) 141 (17.2)

2,000+ 167 (28.4) 42 (18.2) 209 (25.6)

Table 2. Interpreter use (n, %) among the NESB patients according to gender

Gender Professional

(%)

Family member (%) Total (%)

Female

15 (14.7)

24 (23.5)

39 (38.2)

Male

Total

18 (14.0)

33 (14.3 )

24 (18.6 )

48 (20.8)

42 (32.6)

81 (35.1)


Table 3. Unadjusted satisfaction rates (%, 95% CI) among ESB and NESB patients

Satisfied% ESB

(N = 597)

Satisfied% NESB

(N = 231)

P

Staff skills 96.8 (95.1–98.8) 96.1 (92.7–98.0) 0.603

Nursing staff interest 96.0 (94.1–97.3) 94.4 (90.6–96.7) 0.315

Time with staff 92.3 (89.9–94.2) 84.9 (79.7–88.9) 0.001

Spiritual/emotional needs 91.1 (88.6–93.2) 76.6 (70.8–81.6) < 0.001

Encouragement to talk 95.0 (92.9–96.5) 90.0 (85.5–93.3) 0.009

Response in managing pain 94.5 (92.3–96.0) 85.3 (80.1–89.3) < 0.001

Concern for well-being 95.6 (93.7–97.0) 90.9 (86.5–94.0) 0.008

Respect for privacy 97.7 (96.1–98.6) 96.1 (92.8–97.9) 0.223

Courtesy and friendliness 98.8 (97.6–99.4) 97.0 (93.9–98.5) 0.063

Promptness 85.4 (82.4–88.0) 74.5 (68.5–79.7) < 0.001

Communication 96.2 (94.3–97.4) 87.9 (83.0–91.5) < 0.001

Time with doctor 94.6 (92.5–96.2) 87.9 (83.0–91.5) 0.001

Explanation of tests and procedures 95.6 (93.7–97.0) 89.6 (85.0–92.9) 0.001

Care quality 96.3 (94.5–97.6) 92.6 (88.5–95.4) 0.025

Expectation 96.0 (94.1–97.3) 89.2 (84.5–92.6) < 0.001

Overall satisfaction 95.1 (93.1–96.6) 90.5 (86.0–93.7) 0.012

Table 4. Logistic regression model (ORs and 95% CI) for satisfaction (highly

satisfied vs. less satisfied) among NESB according to interpreter use, adjusted for

sex, age, education, and income


OR (95% CI) P OR (95% CI) P

Reference group: ESB

Staff skill

NESB-Interpreter used

0.8 (0.2–3.7)

0.768

NESB-No interpreter used

0.6 (0.3–1.1)

0.085

Nursing staff interest 1.0 (0.2–4.5) 0.962 0.8 (0.4–1.8) 0.621

Time with staff 1.7 (0.4–7.4) 0.478 0.4 (0.2–0.7) 0.001

Spiritual/emotional needs 0.4 (0.2–0.9) 0.040 0.3 (0.2–0.5) < 0.001

Encouragement to talk 2.5 (0.3–19.1) 0.379 0.4 (0.2–0.8) 0.008

Response in managing pain 0.4 (0.2–1.1) 0.063 0.4 (0.2–0.6) < 0.001

Concern for well-being 0.5 (0.1–1.5) 0.188 0.5 (0.3–1.0) 0.060

Respect for privacy 4.4 (0.3–31.6) 0.993 0.5 (0.2–1.3) 0.165

Courtesy 2.0 (0.2–18.4) 0.998 0.4 (0.1–1.2) 0.092

Promptness 1.1 (0.4–2.7) 0.901 0.5 (0.3–0.7) < 0.001

Communication 2.1 (0.3–16.3) 0.473 0.3 (0.1–0.5) < 0.001

Time with doctor 1.3 (0.3–5.9) 0.714 0.4 (0.2–0.7) 0.003

Explanation of tests and

procedures

0.6 (0.2–1.9) 0.400 0.5 (0.2–0.9) 0.019

Care quality 1.9 (0.3–15.1) 0.525 0.5 (0.2–0.9) 0.031

Expectation 1.0 (0.2–4.3) 0.955 0.3 (0.2–0.6) 0.001

Overall satisfaction 2.6 (0.3–19.3) 0.375 0.5 (0.3–0.8) 0.013


Table 5. Where patients would seek help if they developed the same problem in their

birth country (Overseas born only) (n, %, 95%)

Hospital ED (%) GP (%) Private doctor

(%)

Other (%) Total

(%) ESB 107 (69.5, 61.8–76.2) 42 (27.3, 20.9–34.8 ) 5 (3.2, 1.2–7.4) 0 (0, 0.0–0.0 ) 154

(100)

NESB

Total

109 (47.4, 41.0–53.8)

216 (56.3, 51.3–61.1)

45 (19.6, 15.0–25.2 )

87 (22.7, 18.8–27.1 )

71 (30.9, 25.3–37.1)

76 (19.8, 16.1–24.1)

5 (2.2, 0.9–5.0)

5 (1.3, 0.6–3.0 )

230

(100)

384

(100)


Discussion

To the best of our knowledge, this is the first study in Australia to compare NESB

and ESB patients with respect to their stated satisfaction with the services in EDs.

Our study shows that both groups of patients were highly satisfied with the staff

courtesy and friendliness, skills, and respect for their privacy, and less satisfied with

the promptness of the service and the attention given to their spiritual and emotional

needs. However, the study also shows greater dissatisfaction among NESB patients

in most aspects investigated in the study. These results are consistent with previous

studies from the US and Europe that indicate that immigrants belonging to language

and ethnic minorities are less satisfied with their ED service than local populations

and immigrants with the same language background as that offered by the ED

service.5,13,18

Furthermore, our study assessed the satisfaction on site and

immediately after the ED service was completed, where the recall bias was greatly

reduced as compared to those previous studies.

Our study showed use of an interpreter improved the patients’ level of satisfaction.

Although some patients who did not use an interpreter had good command of the

English, this result might suggest the presence of other barriers, such as cultural ones

associated with communication. It is also possible that some these patients may

prefer to use their less proficient English language to communicate with health care

providers rather than waiting for an interpreter. 19

Among the patients who were triaged 3 to 5, there was a possibility that some of

them could have been treated by a GP. In our sample, over 50% of the NESB

patients indicated that they would go to a GP or private doctor if they were to


develop the same condition in their country of origin. It is possible therefore that

these patients’ had expectations of factors such as wait time. That these were not met

when they came to the ED may have affected their level of satisfaction .20

Subjective

reasons for attending ED among NESB patients might warrant further investigations.

Several studies have suggested that cultural and language barriers may cause

immigrants to use the ED as their primary source of care for problems that can be

treated by a GP.21,22

The use of ED service as a primary source of care has several

negative effects on patient care. It may result in prolonged length of stay and

increased wait times in EDs, which together reduce the quality of the care provided,

leading to an increased probability of complications for urgent conditions.14,23,24

All

of these factors may lead to decreased patient satisfaction and an increase in the

number of patients who leave the ED before being seen.25-27

Thus, further

investigations are warranted to determine whether there are barriers which prevent

NESB patients from accessing primary care in Australia.

The patients in our study were also asked what they think the most important element

in their ED care is. Despite the relevant low response rate (25.2%) to this question,

the patients in both groups mentioned promptness, quality and professional care, and

communication as important elements of ED service. The present findings seem

consistent with research from other sectors which has suggested the importance of

these factors to customer satisfaction.28-30

It is important to note that this study had several limitations. Firstly, it was a single

site study covering only the catchment area of one hospital, thereby limiting its

applicability to other areas. Secondly, we considered NESB patients as one group.

However, people from NESBs are not a homogenous group and their attitudes

towards ED service might differ due to their ethnicity, cultural needs, length of stay


in Australia, and immigration status. Thirdly, despite the low use of interpreter

services the English language only questionnaire, could potentially affect the ability

of patients of NESB to reliably understand and respond to the survey items. Fourthly,

the effect of interpreter services was not evaluated in detail.

Fifthly, triage category 1 and 2 patients or their relatives may interact more with ED

staff and use more ED services due to the severity of their clinical conditions. Since

these two groups of patients were omitted from this study, the results may not

represent the overall picture of ED service satisfaction. Finally, the use of a

convenience sample and the cross-sectional nature of the study limit the

generalisability of the findings.

Despite the six limitations noted above, the current study is one of the few in

Australia to highlight the importance of addressing NESB patients’ satisfaction with

ED service. Future studies on specific linguistic and ethnic minorities with a

representative sample using multi-lingual questionnaires might provide further

information about addressing their unique health needs and offer insight into their

barriers to satisfactory ED service.

Conclusion

Despite high overall satisfaction with ED service, NESB patients were significantly

less satisfied than ESB patients. Use of an interpreter improved the patients’ level of

satisfaction. Most NESB patients reported that they would seek help from general

practice or a private doctor if they developed the same condition in their country of

origin, and this may have affected their expectations and level of satisfaction. Further

research is required to examine why NESB patients are attending ED and what their

expectations are of the ED service.

Acknowledgements: The authors are grateful to the study participants.


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Article 7: Subjective reasons why patients from non-English speaking

backgrounds attend the emergency department

An article about subjective reasons for attending ED among patients has been

submitted to BMC Emergency Medicine [Mahmoud, I., Hou, X., & Eley, R.

Subjective reasons why patients from non-English speaking backgrounds attend the

emergency department].

Results for this article presented below.


Subjective reasons why patients from non-English speaking

backgrounds attend the emergency department

Ibrahim Mahmoud1, Rob Eley

2, Xiang-Yu Hou

3

1School of Public Health and Social Work, Queensland University of Technology,

Brisbane, Australia, [email protected]

2 The University of Queensland – Princess Alexandra Hospital, Brisbane, Australia,

[email protected]

3 School of Public Health and Social Work, Queensland University of Technology,

Brisbane, Australia, [email protected]


Ibrahim Mahmoud

School of Public Health and Social Work, Queensland University of Technology


Tel: (61) 7 31383540 Mobile: (61) 403929967

E-mail: [email protected]

Short Running Title: Reasons for attending emergency department


Subjective reasons why non-English speaking background patients

attending the emergency department

Abstract

Background: Patients from non-English speaking backgrounds (NESBs) might visit

a hospital’s emergency department (ED) for reasons other than an urgent medical

condition. The objective of this study was to examine the reasons why NESB

patients visit the ED, as compared to English-speaking background (ESB) patients.

Methods: A cross-sectional survey was conducted at the ED of a tertiary hospital in

metropolitan Brisbane, Queensland, Australia. Patients who were asssigned an

Australasian Triage Scale score of 3, 4 or 5 were surveyed over a four-month period.

Pearson chi-square test and multivariate logistic regression analyses were performed

to examine the differences between the ESB and NESB patients’ reported reasons for

attending the ED.

Results: A total of 828 patients participated in this study. Compared to ESB patients

significantly fewer NESB patients had considered contacting a general practitioner

(GP) before attending the ED, (39.8% v 56.6%; Chi-square 18.81, p < 0.05).

Compared to the ESB patients, the NESB patients were far more likely to report that

they had visited the ED either because they do not have a GP (OR 4.0, 95% CI 2.1–

7.4, p <.001) or thought it would take extended period to make an appointment to

consult a GP (OR 7.1, 95% CI 3.4–13.3, p < 0.05). The ESB patients were more

likely than the NESB patients to state that they thought the ED is better equipped to

deal with their problem (OR 0.4, 95% CI 0.2–0.7, p = 0.001).

Conclusion: NESB patients were the least likely to consider contacting a GP before

attending hospital EDs. Educational interventions may help direct NESB people to

the appropriate health services and therefore reduce the burden on tertiary hospitals

ED.

Keywords: emergency department, general practitioner, immigrants


Introduction

Several international studies have suggested that immigrants might use emergency

departments EDs inappropriately.[1-3]

These studies suggested that the ease of access

to emergency services, the unawareness of service availability, a lack of knowledge

about the services in the new country, language barriers, and cultural barriers are

likely to be the barriers confronting immigrants when accessing health care. It has

been argued that emergency department (ED) presentations for non-urgent conditions

are less likely to involve preventive care and are costlier to the healthcare systems

than visits to general practitioner (GP) clinics.[4]

Moreover, such presentations may

result in prolonged length of stay and increased wait times in EDs, for people with

more urgent conditions which together reduce the quality of the care provided,

leading to an increased probability of complications.[2, 5-7]

In addition, the use of EDs

for non-urgent conditions might result in ED overcrowding which increases patient

dissatisfaction and the number of patients who leave the ED before being seen.[8, 9]

Consequently, it is worth to reduce the demand for ED use and encourage patients

towards using primary care services for non-life threatening conditions. However, in

Australia, no studies have been conducted on either the reasons of non-English

speaking background (NESB) patients for seeking medical care from the ED or the

barriers they face when accessing health services in general. Understanding these

reasons might help in developing policies and educational interventions that promote

NESB patients’ access to appropriate health care facilities that meet their needs.

This study aimed to investigate the subjective reasons why NESB patients, compared

to English-speaking background (ESB) patients, attend the tertiary hospital ED at

Brisbane, Australia.


Methods


A cross-sectional survey was conducted in the ED of Princess Alexandra Hospital

(PAH), an adult, tertiary-referral teaching hospital located in metropolitan south

Brisbane, Queensland, Australia. The ED has an annual census in excess of adult

50,000 presentations. The majority of NESB population in Queensland lived in

metropolitan areas. [10]

The South Brisbane region held the largest number of people

who identified as being NESB, higher than any other region in the State. [11]

The study was carried over a four-month period from 27 August to 28 December

2012. The data were collected by the main author, who attended the study hospital

ED from Monday to Saturday between 12:00 pm and 8:00 pm. These times were

chosen because, during this period, patients are also more likely have a choice to go

to a general practitioner (GP) or the ED.

Study population

A convenience sample was recruited. The inclusion criteria were patients aged 18

years and over, and their triage categories were 3 (urgent), 4 (semi-urgent) or 5 (non-

urgent), according to the Australasian Triage Scale (ATS).[12]

The exclusion criteria

were patients in triage categories 1 (critical) and 2 (emergency), those below 18

years of age, patients with dementia, mental health patients, pregnant women with

obstetrical complaints and admitted patients.

Questionnaire

We developed a questionnaire in the English language with questions adapted from

the existing literature and validated questionnaires.[2, 13, 14]

The patients were asked

about whether they considered contacting the GP before attending the ED and if not


why they chose to come to the ED. The patients were asked also where they would

go if they develop same condition in their birth country.

The questionnaire was administered by self-completion or a face-to-face interview.

An interpreter was used when required.

The study received ethical clearance from the Human Ethics Committee of both the

hospital and the Queensland University of Technology.

Sample size and data analysis

Given the proportions of the two populations within the study area and utilizing a

two-tailed alpha of 0.05 and a beta of 0.10, we estimated that we would require 150

NESB patients and 590 ESB patients, for the study to have 90% power to identify a

significant difference between the two groups.[15]

The participants were divided into

two groups as defined by the Australian Bureau of Statistics (ABS): patients born in

the main English-speaking countries (Australia, Canada, New Zealand, Republic of

Ireland, South Africa, the United Kingdom, and the United States) and patients from

other countries where English is not the principal language.[16]

Arguing that being

from an NESB did not indicate disadvantage, the federal government formally

replaced ‘NESB’ with ‘culturally and linguistically diverse’ (CALD) in 1996.[17]

However, we chose to employ the old term ‘NESB’ to indicate that patients from this

group might be disadvantaged in terms of access to appropriate health care facilities

specifically due to language and cultural barriers.


two groups. Proportions were calculated to determine whether the NESB patients had

considered contacting the GP before attending the ED, and whether their decision

had been influenced by their visa status and length of stay in Australia. To examine

the potential confounding effects of socioeconomic factors, multivariate logistic


regression analyses were performed to uncover the differences between the two

groups in terms of their reasons for choosing the ED instead of consulting with a GP.

Analyses were performed using Statistical Package for the Social Sciences (SPSS)


Results

A total of 828 patients—597 (72.1%) ESB and 231 (27.9%) NESB—were

interviewed during the study period. Table 1 provides the demographic

characteristics of the study population, showing differences in educational levels and

fortnightly income between the two groups. Table 2 reveals that NESB patients on

student visa (31.6%, 95% CI 19.1–47.5) and refugee visa (36.1%, 95% CI 25.2–48.6)

were the least likely to consider contacting a GP before attending the ED, similar to

the patients on a short stay in Australia 7 (15.6%, 07.8–28.8).

Compared to the ESB patients, the NESB patients were less likely to consider

contacting a GP before attending the ED (OR 0.5, 95% CI 0.3–0.7) (Table 3). The

NESB patients were far more likely than the ESB patients to report not having a GP

or that a long delay to see a GP as the reasons for coming to the ED (OR 4.0, 95%

CI 2.1–7.4, p = 0.000; OR 7.1, 95% CI 3.4–13.3, p = 0.000) (Table 3). However, the

NESB patients did not think that the ED was better equipped to deal with the

problem than a GP (OR 0.4, 95% CI 0.2–0.7, p= 0.001) (Table 3). Table 4 shows

where overseas born patients would seek help if they developed the same problem in

their birth countries.


Table 1. Demographic characteristics of the participants

Variable

ESB (%)

(N = 597)

NESB (%)

(N = 231)

Total

(%)

(N = 828) Sex

Females

Males

261 (43.7)

336 (56.3)

102 (44.2)

129 (55.8)

363 (43.8)

465 (56.2)

Age (years)

18–39

40–64

65+

267 (44.7)

240 (40.2)

90 (15.1)

118 (51.1)

76 (32.9)

37 (16.0)

385 (46.5)

316 (38.2)

127 (15.3)

Education (highest)

Did not complete secondary school

Completed secondary school

Higher education

118 (20.1)

233 (39.6)

237 (40.3)

49 (21.2)

54 (23.4)

128 (55.4)

167(20.4)

287 (35.0)

365 (44.6)

Fortnight income (AUD$)

400–999 177 (30.2) 103(44.6) 280 (34.2)

1,000–1,499 136 (23.2) 52 (22.5) 188 (23.0)

1,500–1,999 107 (18.2) 34 (14.7) 141 (17.2)

2,000+ 167 (28.4) 42 (18.2) 209 (25.6)


Table 2. Proportions of NESB patients who had considered contacting a GP before

attending the ED, according their visa status and length of stay in Australia

Variable

Yes

No

Total (%)

(N = 231)

Visa status Skilled migrant

Refugee (Humanitarian)

Student

Family, spouse

Length of stay in Australia

Less than 2 years

2–4 years

5 years or more

18 (46.2, 31.6–61.4)

22 (36.1, 25.2–48.6)

12 (31.6, 19.1–47.5)

34 (48.6, 37.3–60.1)

7 (15.6, 07.8–28.8)

18 (40.0, 27.0–54.6)

67 (47.5, 39.5–55.7)

21 (53.8, 38.6–66.4)

39 (63.9, 51.3–74.8)

26 (68.4, 52.5–80.9)

36 (51.4, 40.0–62.8)

38 (84.4, 71.2–92.3)

27 (60.0, 45.5–73.0)

74 (52.5, 44.3–60.1)

39 (16.9, 12.6–22.3)

61 (26.4, 21.1–32.4)

38 (16.5, 12.2–21.8)

70 (30.3, 24.7–36.5)

45 (19.5, 14.9–25.1)

45 (19.5, 12.6–25.1)

141 (61.0, 54.6–67.1)

Values outside the parentheses are the numbers of ED presentations. Values in the parentheses are

proportions and their 95% confidence intervals.


Table 3. Logistic regression model (ORs and 95% CI) for NESB patients’ patients

having considered contacting a GP before attending the ED & main reasons for

attending the ED, adjusted for sex, age, education and income

Reasons for attending the ED OR (95% CI) P

Reference group: ESB

Considered contacting a GP before visiting the ED

0.5 (0.3–0.7)

0.000

I do not have a GP

GPs charge extra fees

My GP’s opening hours are not suitable

It would take a long time to get an appointment with my GP

The ED is closer than my GP

4.0 (2.1–7.4)

1.1 (0.5–2.7)

2.1 (1.0–4.4)

7.1 (3.4–13.3)

0.5 (0.1–1.9)

0.000

0.870

0.055

0.000

0.321

The ED can deal with the problem better than my GP can 0.4 (0.2–0.7) 0.001

I generally prefer the ED to my GP 1.2 (0.4–3.2) 0.288

Table 4. Where patients would seek help if they developed the same problem in their

birth country (Overseas born only)

Hospital ED

(%)

GP (%) Private doctor

(%)

Other (%) Total (%)

ESB 107 (69.5) 42 (27.3) 5 (3.2) 0 (0) 154 (100)

NESB

Total

109 (47.4)

216 (56.3)

45 (19.6)

87 (22.7)

71 (30.9)

76 (19.8)

5 (2.2)

5 (1.3)

230 (100)

384 (100)


Discussion

The study showed that the NESB patients in triage categories 3 to 5 were far less

likely than ESB to consider contacting a GP before attending the ED. Their reported

reasons for not contacting a GP were either that they do not have a GP or that it can

take a long time to obtain an appointment with their GP. However, the ESB patients

were more likely than the NESB patients to perceive the ED as more suitable for

treating their medical condition.

In our sample, over 50% of the NESB patients indicated that they would go to a GP

or private doctor if they were to develop the same condition in their country of

origin. Thus, the study findings suggest that the NESB patients did not choose the

ED according to the urgency of their medical condition nor the belief that the ED

was better equipped than a GP to address their problem.

These results agree with other studies which have indicated that immigrants and

linguistic and ethnic minorities tend to use ED services for non-urgent conditions at

the expense of primary health care.[1, 2, 18]

A Danish study reported immigrants were

more likely to have irrelevant ED visits than the Danish population.[2]

Furthermore,

an American study found that a large number of Somali patients use the ED for care

that a GP normally provides.[1]

Similarly, Cots and colleagues suggested that

immigrants in Spain tend to use the ED in preference to other health services.[19]

Our findings that patients who have had a short length of stay in Australia and

patients on a student visa or under refugee status are less likely to consider

contacting a GP before attending the ED might also support the existence of these

barriers. There may be other reasons for these groups not to have a GP, such as a

short stay in the country which would make it difficult for people to establish a

relationship with any primary health care services. We suggest that educational


intervention regarding the importance of having a regular GP, and availability of

health services and the health system in Australia, especially targeting international

students and refugees who are new to the country, might help these groups access the

most appropriate services to meet their health needs. In addition, such education

might reduce the burden on already overcrowded EDs in Australia.[20]

Despite the insight that it provided on the differences between NESB and ESB

patients’ use of ED services, this study had several limitations. First, the use of a

convenience sample and the cross-sectional nature of the study limit the

generalisability of the findings. Second, the study period was limited to the four-

month data collection period. Finally, we considered NESB patients as one group.

However, people from NESBs are not a homogeneous group; their attitudes towards

ED services might differ according to their ethnicity and cultural needs.

Conclusion

The study showed that NESB patients in our study area might attend the ED for other

reasons besides an urgent medical condition. Patients who are new to Australia and

those on student or refugee visas are less likely to consider contacting a GP before

attending the ED. These groups might be unfamiliar with their options within the

Australian health care system. Therefore, educational interventions might assist them

accessing the most appropriate health care service that meet their needs and thus

reduce the burden on the hospital ED.

Acknowledgements

The authors are grateful to the staff at the Princess Alexandra Hospital Emergency

Department and the study participants.


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7. Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR. The cost and

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8. Rodi SW, Grau MV, Orsini CM. Evaluation of a fast track unit: alignment of


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9. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital

emergency department without being seen by a physician. JAMA. 1991;266(8):1085-

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10. Labour Market Research Unit. Persons of non-English Speaking Background.

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11. Planning Information and Forecasting Unit. Multicultural Communities in

Queensland. Diversicare; 2007 [12/09/2013]; Available from:

http://www.diversicare.com.au/upl_files/file_74.pdf.

12. Forero R, Nugus P. Literature Review on the Australasian Triage Scale

(ATS): University of New South Wales; 2012.

13. Woods SE, Bivins R, Oteng K, Engel A. The influence of ethnicity on patient

satisfaction. Ethnicity and health. 2005;10(3):235-42.

14. Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language

barriers on patient satisfaction in an emergency department. J Gen Intern Med.

1999;14(2):82-7.

15. Australian Bureau Statistics (ABS). 2006 Census of Population and Housing

Canberra: ABS2006 [06/09/2011]; Available from:


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ABS; 2013 [16/04/2013]; Available from:


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17. Garrett PW, Dickson HG, Whelan AK, Whyte L. Representations and

coverage of non-English-speaking immigrants and multicultural issues in three major

Australian health care publications. Aust New Zealand Health Policy. 2010;7(1):1.

18. Bazargan M, Bazargan S, Baker RS. Emergency department utilization,

hospital admissions, and physician visits among elderly African American persons.

The Gerontologist. 1998;38(1):25-36.

19. Cots F, Castells X, García O, Riu M, Felipe A, Vall O. Impact of immigration

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Chapter 5: General Discussion 129

Chapter 5: General Discussion

Utilization Rates

According to the analyses of three years of EDIS data (2008 to 2010), the top

languages spoken by those who visited EDs were English, Chinese, Vietnamese,

Arabic, Spanish, Italian, Hindi and German. The study found an association between

utilization rates and language spoken at home. The crude ED utilization rate was the

highest among patients who speak only English at home, followed by Arabic

speakers, and the lowest among German speakers. The findings concur with the

notion of the healthy immigrant effect, which suggests that immigrants are healthier

than native residents, because of the selectivity of the immigration process (health

screening before migration, education level, language proficiency and age), the

healthier behaviour of the immigrants before migration and immigrant self-selection,

whereby the healthiest and wealthiest individuals are the most likely to migrate

(Baum, 2008; Buron, Cots, Garcia, Vall, & Castells, 2008). On the other hand,

several international studies have shown that language barriers might be the reason

for poor access to health care, including emergency care, and might contribute to

health disparities (Yeo, 2004; Wen, Goel, & Williams, 1996; Ponce, Hays, &

Cunningham, 2006). In addition, the literature has identified other contributing

factors to lower access to health care facilities among immigrants, such as

unfamiliarity with the health system, lack of knowledge and fear of high cost

(Razzak & Kellermann, 2002; Sheikh et al., 2011). However, the limitation of the

secondary data precludes any determination of the reasons for the lower utilization

rates among those who speak other languages at home in QLD.

130 Chapter 5: General Discussion

The study showed lower utilization of ED service among those who speak languages

other than English at home in QLD, and part of that could be due to the healthy

immigrant effect or language barriers. Further research using an in-depth

methodology is needed to explore the role of language in access to ED care in the

Australian context.

Modes of Arrival at the ED

The study showed that, compared with English speakers, there were lower rates of

ambulance use among patients who speak a language other than English at home.

The association between lower ambulance use and speaking a foreign language at

home might also be due to the healthy immigrant effect. However, assuming that the

population in QLD is similar to the population studied in the literature, the

contributing factors may also be similar, including the healthy immigrant effect,

language barriers, unfamiliarity with the health system, lack of knowledge and the

fear of high cost (Razzak & Kellermann, 2002; Sheikh et al., 2011).

The study also found that IRSC patients tend to use ambulance service more than the

Australian born population. This is despite a study from the Liverpool Hospital ED

in Sydney that found that newly arrived refugees do not call an ambulance when

required, despite their ability to make such a call. The Liverpool study revealed that

one of the reasons why these people do not call an ambulance is previous

experiences in their home countries, where the police would also come when they

heard the ambulance (Sheikh et al., 2011). However, their study was a single site

study with a small sample size, which limits its applicability to the whole Australian

refugee population. Due to the secondary data limitation, this study could not reveal

whether the high use of ambulances among IRSC is due to the vulnerability of this


group to illness, and attending EDs with advanced illness requires an ambulance, or

due to a lack of transport. To date, there has been a paucity of empirical studies on

how immigrants in Australia use ambulances. Thus, this topic warrants further

investigation.

ED Length of Stay

LOS is a marker of ED overcrowding and a key component of ED quality assurance

monitoring (Herring et al., 2009; Yoon, Steiner, & Reinhardt, 2003).

The study found that patients who speak other languages at home had statistically

significant, longer LOS in the ED compared to those who speak only English at

home. However, in reality, some of these differences might not be significant, as they

were less than five minutes long.

The study also showed that IRSC patients were more likely to have a longer LOS

(half-hour) in the ED compared to the Australian born population. For example, the

patients who were born in Ethiopia, Eritrea and Sudan stayed in the ED

approximately one hour longer than the Australian born patients.

Public hospital EDs in QLD see patients who have little or no understanding of

English, due to the high proportion of immigrants living in the state. Additional time

is needed to obtain an interpreter, and even when an interpreter is readily available,

the emergency physician requires additional time for this interaction (Bernstein,

Bernstein, Dave, Hardt, James, & Linden, 2002). Thus, if a patient with limited

English proficiency requires an interpreter, this can prolong his or her LOS. This is

supported by the study finding that the IRSC patients had higher usage of interpreter

service compared to the IOC patients.


In the regression models used in the study, the explanation for the variability in LOS

improved significantly when the interpreter use was added to the final model,

suggesting the importance of this factor. However, when the regression models

controlled for interpreter use and triage priority, it explained only about 17% of the

variability in LOS. This indicates that there are other significant factors influencing

LOS in EDs, besides language and the severity of the condition, which were not

captured by our study.

The first possible reason is that some disadvantaged immigrants, such as refugees,

might attend EDs with more advanced illnesses or complex conditions which require

longer assessment and additional diagnostic tests, and prolong treatment times

(Kwok & Sullivan, 2007).

The second possible reason is the clinical situation of these patients, such as the

number of patients in the ED at that time, the laboratory tests ordered, the use of

diagnostic imaging and specialty consultation (Yoon, Steiner, & Reinhardt, 2003).

Cultural barriers may constitute the third possible reason. For example, women from

Islamic or Middle Eastern cultures prefer to be seen by a female doctor, which can

prolong their LOS (Baker, Stevens, & Brook, 1991; Bener, Rafie Alwash, Miller,

Denic, & Dunn, 2001).

Further research is needed to identify the reasons for the longer stay and to provide

scientific evidence for effective future planning and to serve these groups in a timely

manner.


Departure Status

In general, the study showed that patients who speak a language other than English at

home are less likely to be admitted to hospital from the ED. The study also found

that IRSC and IOC patients were less likely to be admitted to hospital than

Australian born and MESC patients. These findings, in addition those regarding

utilization rates and ambulance service, also agree with the healthy immigrant effect.

The study also showed that 10% of Arabic speakers did not wait for their treatment

to be completed at the ED and left the ED against the doctor’s wishes; this figure was

higher than any other language group. This might be due to a cultural barrier, as

some studies have argued that women from Islamic or Middle Eastern cultures prefer

to be seen by a female doctor (Baker, Stevens, & Brook, 1991; Bener et al., 2001).

Further research is needed to confirm this assumption. This is important, as the

immigration data indicate that increasing numbers of immigrants, refugees and

foreign students from Arabic speaking countries are coming to Australia (ABS,

2006).

Reasons for Attending the ED

The study showed that the NESB patients in triage categories 3 to 5 were far less

likely than the ESB patients to consider contacting a GP before attending the ED.

Their reported reasons for not contacting a GP were either that they do not have a GP

or that it can take a long time to obtain an appointment with their GP. However, the

ESB patients were more likely than the NESB patients to perceive the ED as more

suitable for treating their medical condition. The NESB patients in this study

indicated that they would go to a GP or private doctor if they were to develop the

same condition in their country of origin. Thus, the study findings suggest that the

NESB patients did not choose the ED according to the urgency of their medical


condition nor the belief that the ED was better equipped than a GP to address their

problem.

Further, the study found that patients who have had a short LOS in Australia and

patients on a student visa or under refugee status are less likely to consider

contacting a GP before attending the ED.

These results are consistent with a number of other international studies which have

suggested that immigrants might use the ED as their primary source of care for

problems that can be treated by a GP, due to cultural and language barriers and

unfamiliarity (Davidson et al., 2004; DeShaw, 2006; Norredam et al., 2007). The

inappropriate use of ED service has several negative effects on patient care. Hence,

easy access and not needing to make a prior appointment are the most likely reasons

why these patients attended the ED, rather than the urgency of their condition. This

may also result in prolonged LOS and increased wait times in EDs, which together

reduce the quality of the care provided, leading to the increased probability of

complications for urgent conditions (Norredam et al., 2007; Pines et al., 2009;

Ackroyd-Stolarz et al., 2011).

Directing NESB patients to access the appropriate health services for their needs

might eliminate inequity and reduce the burden on already overcrowded EDs in

Australia.

Satisfaction with ED Service

The NESB patients were less satisfied with their ED service than the ESB patients

were in all aspects investigated in the study. The promptness of service received the

lowest satisfaction rates, while courtesy and friendliness received the highest

satisfaction rates. The two groups reported that the most important elements of their


ED service are the promptness of service, quality and professional care, and

communication.

Patient satisfaction has been defined as occurring when the patient’s expectations for

medical treatment and care are met or exceeded (Trout, Magnusson, & Hedges,

2000). In the hospital ED, patient satisfaction is considered an important indicator of

quality care (Woodward et al., 2000; Cleary & McNeil, 1988). These results are

consistent with previous studies that indicated that immigrants belonging to language

and ethnic minorities are less satisfied with their ED service than local populations

and immigrants whose language background is the same as that offered by the ED

service (Carrasquillo et al., 1999; Meredith & Siu, 1995; & Quyen, Phillips, &

Greenfield, 2007 ). Furthermore, our study assessed the satisfaction on site and

immediately after the ED service was completed, where the recall bias was greatly

reduced as compared to those previous studies.

Among the patients who were triaged 3 to 5, there was a possibility that some of

them could have been treated by a GP. In our sample, over 50% of the NESB

patients indicated that they would go to a GP or private doctor if they were to

develop the same condition in their country of origin. Therefore, most probably,

these patients’ expectations were not met when they came to the ED and had a long

wait time, according to their triage category, and this may have affected their level of

satisfaction (Pavlish, Noor, & Brandt, 2010). Several studies have suggested that

cultural and language barriers may cause immigrants to use the ED as their primary

source of care for problems that can be treated by a GP (Davidson et al., 2004;

DeShaw, 2006). The inappropriate use of ED services has several negative effects on

patient care. It may result in prolonged LOS and increased wait times in EDs, which

together reduce the quality of the care provided, leading to an increased probability


of complications for urgent conditions (ABS, 2006; Pines et al., 2009; Ackroyd-

Stolarz et al., 2011). All of these factors may lead to decreased patient satisfaction

and an increase in the number of patients who leave the ED before being seen

(Baker, Stevens, & Brook, 1991). Thus, further investigations are warranted to

determine whether there are barriers which prevent NESB patients from accessing

primary care in Australia.

Limitations

This research had several limitations. The data of the first two studies originated

from routinely collected state-wide data (EDIS). The limitations of the EDIS are

mainly those of large secondary data analyses, such as adequacy, accuracy,

completeness and other measures of the quality of the data. The EDIS also provides

limited information on the characteristics of the patients. For example, the EDIS

dataset does not include information about length of time in Australia. Immigrants

who had been in the country longer would have had more knowledge about the

availability of health services and know how to access them than those who had

recently arrived in the country. Moreover, the dataset did not allow for the inclusion

of all influential factors of ED care utilization identified in the literature, such as

socioeconomic status, refugee status and having a usual source of care. In addition,

due to ethics, the EDIS data were de-identified, which did not allow for analyses of

individual patients. As such, the dataset might have included some patients who had

made multiple visits to the ED.

The third study used a convenience sample and a cross-sectional design, which

limited the generalizability of the findings. In addition, it was a single site study

covering only the catchment area of one hospital, thereby limiting its applicability to

other areas. The study also considered NESB patients as one group. However, people


from NESBs are not a homogenous group; their attitudes towards ED service might

differ due to their ethnicity, cultural needs, LOS in Australia and immigration status.

Moreover, to be consistent with the literature, the study considered a “good”

response as “not satisfied.” However, some cultural groups may consider a certain

level of health care as “good” while other cultural groups may consider the same

level as “very good or excellent” (Osmond, Vranizan, Schillinger, Stewart, &

Bindman, 1996). Therefore, cultural concepts in rating satisfaction need to be

addressed by using multi-lingual questionnaires. Finally, the study period was

limited to the four-month data collection period.

Chapter 6: Conclusions & Recommendations 139

Chapter 6: Conclusions & Recommendations

Conclusion

This study revealed that NESB patients use the ED service differently from ESB

patients. The study found a significant association between the lower utilization of

ED service and speaking a language other than English at home; this association may

be attributed, in part, to the healthy immigrant effect. The study also showed that a

close relationship exists between the language spoken at home and the LOS in the

ED, indicating that language may be an important predictor of prolonged LOS. In

addition, it was found that the NESB patients were significantly less satisfied with

their ED service than were the ESB patients; this may be attributable to differences

in expectations.

This is one of the few studies in Australia to investigate the use of ED service by

immigrants from an NESB and to assess their satisfaction with the services provided.

Future studies on specific ethnic minority groups and disadvantaged immigrants

using representative samples, may provide further information that will be useful for

addressing people’s unique health needs and information on the barriers related to

NESB patients’ low satisfaction with the ED service. This study has provided

valuable new knowledge which may aid in the development of educational

interventions to assist non-English speaking people with accessing the most

appropriate care to suit their needs.

Recommendations Based on the Research Findings

The findings from this research provide valuable new knowledge for professionals

and policy makers when planning emergency services for NESB immigrants in QLD.

The findings provide scientific evidence for developing policies and educational

140 Chapter 6: Conclusions & Recommendations

interventions to ensure equitable use of ED service among vulnerable NESB

immigrants.

The study found that the majority of the NESB patients in QLD live in south

metropolitan Brisbane, consistent with the ABS data. Therefore, these areas can be

targeted for policy interventions, such as those developed to increase the number of

health care providers from NESBs, in ED and GP settings, and allocating more

NESB help resources.

Educational interventions targeting international students and refugees, who are new

to the country, regarding health system in Australia, having a regular GP and where

to seek medical help may help these groups access the most appropriate services to

meet their health needs. Health information should be delivered in culturally

sensitive manner, using familiar and accepted language, images, and examples to

demonstrate key messages.

This is the first study in QLD to investigate NESB immigrants’ access to health care

services including ED service. Additional multisite studies with a large number of

participants and longer periods of data collection are required in order to inform

policy and identify the barriers which NESB populations face in accessing ED and

GP services. The particular areas that warrant more research are the uses of

ambulances, primary care and interpreter services.

The EDIS is a great resource for those studying NESB patients’ access and patterns

of use. However, the EDIS lacks some vital information about NESB patients, such

as LOS in Australia and visa status. Someone who is new to Australia would have

limited information about the availability of health services, as compared to those

who have lived longer in the country. Adding such information to the EDIS database

would assist in studying immigrants’ use of EDs.

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Appendices 151

Appendices

Appendix A Questionnaire & information sheet

Questionnaire

152 Appendices

Appendices 153

154 Appendices

Appendices 155

Information Sheet

156 Appendices

Appendix B Ethics approvals

Study I

Appendices 157

158 Appendices

Study II

Appendices 159

160 Appendices

Study III

Appendices 161

Appendix C Conference participation certificate

162 Appendices

Documents

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