University of Copenhagen, Department of Health Services Research Ethnic disparities in the use of health services Research Seminar on Ethnicity 2. June

University of Copenhagen, Department of Health Services Research

Ethnic disparities in the use of health services

Research Seminar on Ethnicity2. June 2006

Allan Krasnik Dept. of Health Services Research

University of Copenhagen


Themes

1. The right to health care2. Migration, ethnicity and indicators of

equity in access3. The Nordic countries4. Examples of studies

1. Primary prevention2. Screening and diagnostics3. Emergency care

5. Conclusions


UN Declaration of Human Rights, Article 25

• ”Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services…”


The constitution of WHO

”The enjoyment of the highest attainable health is one of the fundamental rights of every human being”


Equity in health

• Equity in health implies that idealy everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that none should be disadvantaged from achieving this potiential, if it can be avoided.

Margaret Whitehead


. An equitable distribution of health

care services:

• When illness is the major determinant of the allocation of resources.

• When the amount of health care received correlates highly with indicators of health needs and is independent of “irrelevant “variables.

Aday LA, Andersen R, Fleming GV. Health care in the US: equitable for whom?

Beverly Hills: Sage Publications, 1980.



Access to health care

• A specified set of health care services• A specified level of quality• A specified maximum level of personal

incovenience and costs• A specified amount of information

Goddard M, Smith P. Equity of access to health careservices: theory and evidence from the UK. Soc Sci Med 2001;53:1149-1162


Equity versus equality

• Equity:– A fair distribution of

services

• Equality:– Equal share to

everybody


Unequal distribution of resources

Health care is ultimately aimed at giving people equal opportunities to achieve optimal health, and within a context of continuing inequality resources have to be distributed unequally. This necessitates the assessment of need and the setting of priorities.

Peter Townsend, 1991


Principles of equity in health care

• Universal entitlement• Sharing financial costs• Free on the point of use• Equality of geographical access• Same high standard of care for all• Selection on the basis of need, not ability

to pay• Encouragement of a non-exploitative ethosAneurin Bevans


Themes




5. Conclusions


Ethnicity and migration

Ethnicity: Social affiliation due to common cultural features (MacBeth & Shetty 2001)

Migration:Proces of (social) changes when moving from one (cultural) setting to another in order to stay for a longer period or permanently (Sved et al 2003)


Indicators of inequity of access I

• Determinants of utilization– Legislation– Information– Financial barriers– Distance

• Process indicators– Contact rates– readmissions


Indicators of inequity of access II

• Outcome indicators– Morbidity– Stage of disease when diagnosed– Survival– Satisfaction


Dimensions of inequalities in access

I. Prevention II. Diagnosis III. Treatment IV. Survival/mortality

Compliance Readmissions


Themes



1. Primary prevention2. Screening and diagnostics3. Emergency care 4. Mortality

5. Conclusions


The Nordic countries

• Principles of equity in the access to health care

• National tax based health care systems• Limited social inequalities• Ethnic homogeneous populations untill 1960’s• 40 years of immigration

– Work force, refugees, relatives

• Ethnic minorities = 1. or 2. generation immigrants


Formal barriers to access in the Nordic countries

Immigration status:– Restricted rights to health care for

asylum seekers and undocumented immigrants (prevention, screening, acute and non-acute care)


Informal barriers to health care in the Nordic countries

• Interaction between factors related to migration and ethnicity such as– Language– Knowledge– Sickness behaviour– Social network– Etc


Themes



• Primary prevention• Screening and diagnostics• Emergency care

5. Conclusions


Maternal characteristics associated with vaccination of

young children

Luman et al. Pediatrics 2003;111:1215-1218


Background Vaccination is a simple and effective method for

prevention. All children have the need. Mothers are key persons regarding the access of children to vaccinations.

Objectives To identify social and ethnic characteristics of

mothers whcih could affect vaccination status of preschool children.

Methods Telephone interviews with mothers of 21,212

children aged 19 – 35 months in USA. Analysis of the association of vaccination status with mothers’ etnicity, education, poverty status and number of children.


Maternal characteristics associated with childhood vaccination

Maternal factor (n) Odds ratio (95% CI)

Maternal factor (n) Odds ratio (95% CI)

Race/ethnicityWhite, non-hispanic (14.600)

Black, non-hispanic (3.446)

Hispanic, any race (4.111)

Other (1.233)

1.0 (ref)0.8 (0.7-0.9) 0.9 (0.8-1.1)

0.8 (0.6-1.0)

Education completed<High school (3.157)

High school (7.160)

>High school (4.375)

College graduate (8.698)

0.6 (0.5-0.8)

0.7 (0.6-0.8) 0.8 (0.7-0.9)

1.0 (ref)

Poverty statusAbove poverty (17.330)

Near Poverty (1.431)

Intermediate poverty (2.807)

Severe poverty (1.822)

1.0 (ref)0.9 (0.7-1.2)

0.9 (0.8-1.1)

0.8 (0.7-1.0)

No. of children in household1 (6.502)

2 or 3 (14.053)

4 or more (2.835)

1.0 (ref)0.8 (0.7-0.9) 0.6 (0.5-0.7)


Conclusions• Mothers with low education, many

children and Afroamerican background have a significant greater risk of having undervaccinated children.

• The result can be interpreted as an effect of social and ethnic inequity regarding access to vaccinations.


Access to screening and treatment for breast cancer

among immigrants in Denmark compared to Danish born women

Nørredam, Krasnik & Holm-PetersenUgeskrift for Læger 1999;161:4385-8


Needs:We assumed that immigrants with breast cancer have the same needs for early diagnosis as Danish born women.

Objectives: To identify possible differences in access to

diagnostic activities regarding breast cancer among immigrant- and Danish born women.

Methods: Comparison of tumour size at diagnosis

among 65 immigrant women and 640 Danish born women as indicator of access before time of diagnosis.


Median tumour size stratified for age and programme for breastcancer screening in area of living

Danish born

Odds ratio (95% CI)

Immigrants

Odds ratio (95% CI)

+ Screening ≥50 - Screening ≥50

0.7 (0.6 – 0.9)1.0 (0.9 – 1.2)

1.2 (0.7 – 1.8)1.2 (0.9 – 1.7)

+ Screening <50 - Screening <50

0.8 (0.7 – 1.0)1.0

0.9 (0.6 – 1.5)1.1 (0.9 – 1.4)


Conclusions• Immigrants are diagnosed with bigger

tumours than Danish born women• Screening has only a significant effect

among Danish born women• The result can be interpreted as an

indication of inequity in access to health care – perhaps as a result of different use of breast cancer screening, delayed discovery of symptoms and delayed contact to health care


Emergency room utilization in Copenhagen: a comparison of immigrant groups and

Danish-born residents

Norredam et al. Scandinavian Journal of Public Health 2004;32:53-59.


Objectives: To identify possible differences in the utilization of emergency room services between different migrant groups compared to Danish born citizens.

Methods:On the basis of the Danish Hospital Registre all 22,026 ”adult” emergency room contacts at Bispebjerg Hospital in 1997 were identified. Rates were calcutated based on the composition of the catchment area population according to age, gender and country of birth.


Emergency room contacts by country of birth (controlled for age and gender)

Country of birth Rate ratios (95% CI)

Denmark 1.00 (ref)

Ex-Jugoslavia 1.22 (1.11-1.34)

Iraque 0.95 (0.79-1.14)

Nordic countries, EU, OECD 0.81 (0.75-0.88)

Pakistan 1.01 (0.87-1.16)

Somalia 1.46 (1.17-1.80)

Turkey 1.36 (1.20-1.53)

Rest of Europe 0.87 (0.75-1.00)

Other countries 0.99 (0.93-1.07)


Conclusions• Immigrants from Somali, Ex-jugoslavia and

Turkey had most emergency room contacts.• Low income groups used emergency room

more often.• These differences could be caused by

– Differences in health (needs)– Limited knowledge about health care services– Different tradition regarding use of health care– Barriers in access to alternative health care

providers (GP and doctor-on-call)


Why do patients attend emergency room?Background Immigrants and Danish born citizens have

different utilization patterns regarding emergency room. So do different income groups.

Objectives To analyse reasons for attending emergency room among different ethnic and income groups.

MetodsQuestionnaires (in 9 languages) among 3809 patients (and their care takers) attending 4 emergency rooms in Copenhagen during 3 weeks in 2004/2005.


The most important reason for attending the emergency room (ER) by income?

<100.000kr

100-300.000 kr

>300.000 kr

Income not known

Could not contact own GP 12% 12% 9% 9%

ER is best suited to handle my problem

56% 59% 64% 35%

My GP referred me to the ER 9% 9% 10% 6%

The doctor-on-call referred me to the ER

6% 6% 5% 7%

Other reasons 17% 14% 12% 43%

Total 100% (n=937)

100% (n=1447)

100% (n=790)

100% (n=635)


The most important reason for attending the emergency room (ER) by ethnic group?

DK West EU OECD

Eastern Europe

Middle East Africa Asia

Could not contact own GP

9% 22% 27% 21% 19% 28%

ER is best suited to handle my problem

60% 46% 45% 47% 37% 37%

My GP referred me

9% 7% 7% 8% 7% 6%

The doctor-on-call referred me

6% 4% 4% 5% 3% 7%

Other reasons

16% 21% 17% 19% 34% 22%

Total 100% (n=2960)

100% (n=146)

100% (n=82)

100% (n=211)

100% (n=62)

100% (n=83)


Conclusions

• Reasons for attending are almost equally distributed among different income groups

• Some immigrant groups have problems getting in contact with own GP and therefore instead tend to use emergency room more often


Copyright ©1998 BMJ Publishing Group Ltd.

Stevens, A. et al. BMJ 1998;316:1448-1452

Triangulation of information sources


Themes




5. Conclusions


Conclusions• Ethnicity and migration must be identified as

two separate but interacting dimensions• Needs must be identified and controlled in

order to demonstrate ethnic inequalities • Sensitive indicators regarding access,

utilization and outcomes should be used to demonstrate inequalities related to the process of disease and care

• Both formal and informal barriers are cruical for understanding ethnic inequalities in access to health care

• A combination of study designs and data are needed to identify these barriers

Documents

University of Copenhagen, Department of Health Services Research Ethnic disparities in the use of health services Research Seminar on Ethnicity 2. June