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Evidence from a Controlled Trial of a Healthcare System View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Copenhagen University Research Information System Know where to go Evidence from a controlled trial of a healthcare system information intervention among immigrants Jervelund, Signe Smith; Maltesen, Thomas; Wimmelmann, Camilla Lawaetz; Petersen, Jørgen Holm; Krasnik, Allan Published in: B M C Public Health DOI: 10.1186/s12889-018-5741-x Publication date: 2018 Document version Publisher's PDF, also known as Version of record Document license: CC BY Citation for published version (APA): Jervelund, S. S., Maltesen, T., Wimmelmann, C. L., Petersen, J. H., & Krasnik, A. (2018). Know where to go: Evidence from a controlled trial of a healthcare system information intervention among immigrants. B M C Public Health, 18, [863]. https://doi.org/10.1186/s12889-018-5741-x Download date: 09. apr.. 2020 Jervelund et al. BMC Public Health (2018) 18:863 https://doi.org/10.1186/s12889-018-5741-x RESEARCHARTICLE Open Access Know where to go: evidence from a controlled trial of a healthcare system information intervention among immigrants Signe Smith Jervelund1* , Thomas Maltesen2, Camilla Lawaetz Wimmelmann1, Jørgen Holm Petersen2 and Allan Krasnik1 Abstract Background: Immigrants may face problems with accessing the Danish healthcare system due to, for example, lack of knowledge of how to navigate it, which may cause inappropriate healthcare-seeking. Danish municipalities provide a mandatory introduction and language programme for newly arrived immigrants, but no information on the healthcare system is offered. This study investigated what effects information about the Danish healthcare system may have on the hypothetical healthcare-seeking behaviour of newly arrived immigrants and their actual healthcare use. Methods: A prospective intervention study of 1572 adult immigrants attending two language schools in Copenhagen was carried out. Two intervention groups received either a course or written information on the Danish healthcare system, respectively, while the control group received neither. Survey data included three case vignettes on healthcare- seeking behaviour (flu-like symptoms, chest pain and depression) and were linked to registry data on sociodemographic characteristics and healthcare use in the year to follow. Logistic regression and binomial regression analyses were performed. Results: Appropriate hypothetical healthcare-seeking behaviour was reported by 61.8–78.8% depending on the vignette. Written information showed no effect on immigrants’ hypothetical healthcare-seeking behaviour, while the course showed a positive effect on hypothetical healthcare-seeking behaviour for flu-like symptoms (adjusted odds ratio [AOR] = 1.71, 95% confidence interval [CI] = 1.01–2.91, p-value = 0.0467), but not on chest pain or depression. The interventions did not affect immigrants’ actual healthcare use; all groups made lower use of health care services in the following year compared with the year where the study took place, except for the use of dental care which remained stable. Conclusions: Information on the healthcare system embedded in the language school programme has the potential to facilitate immigrants’ access to healthcare. Yet, the results underscore the need for further refinement and development of educational interventions, as well as ensuring adequate utilisation of healthcare services by other means. Multi-dimensional and multi-sectional efforts are important for integration issues within healthcare in Europe. Trial registration: Health-seeking behaviour among newly arrived immigrants in Denmark ISRCTN24905314, May 1, 2015 (Retrospectively registered). Keywords: Intervention, Migrants, Information, Healthcare system, Healthcare utilisation, Healthcare-seeking behaviour, Innovation, Integration, Health literacy, Health education * Correspondence: [email protected] 1Department of Public Health, Section for Health Services Research, Danish Research Centre for Migration, Ethnicity, and Health, University of Copenhagen, Øster Farimagsgade 5A, DK-1014 Copenhagen K, Denmark Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Jervelund et al. BMC Public Health (2018) 18:863 Page 2 of 16 Background for indicators of health needs [12, 13], but lower utilisa- Equity in access to healthcare is one of the fundamental tion of preventative services such as screening [14], values of the European healthcare systems [1]. Neverthe- dental care [12] and vaccinations [15–17]. less, recently arrived immigrants may face several prob- The Danish healthcare system is tax-based and offers lems with accessing the healthcare system in terms of universal access and free-of-charge services to all 5.8 informal barriers such as language problems and lack of million inhabitants, except for certain services such as knowledge of how to navigate the healthcare system [2]. dental treatment and medicine requiring co-payment As a result, immigrants may show inappropriate and [18]. Denmark has seen a steady increase in immigration suboptimal healthcare-seeking behaviour and utilisation over the past thirty years, with 58% of immigrants of healthcare services, which are likely to impede health originating from non-Western countries. As of 2018, among immigrants and lead to poor(er) and possibly more than 10% of the population of Denmark consists more costly outcomes both for the individual and for so- of immigrants [19] with the majority originating in ciety. Hitherto, in relation to the present study, we in- Poland, Syria, Turkey, Germany, Romania, and Iraq [20]. vestigated how healthcare education was unfolded in the Danish municipalities provide a free Danish language language school, and whether systematic healthcare edu- education (equivalent to 1.2 years full-time) as part of cation affected immigrants’ knowledge of the Danish the introduction programme for all newly arrived immi- healthcare system. An explorative qualitative process grants in order to support them in obtaining the neces- evaluation elucidated how the participants’ understand- sary Danish language skills and gaining knowledge of the ing of health and their risks perception overruled the culture and society in Denmark with a special focus on normative information they learned on the healthcare work, education and democracy. The aim is that immi- education course [3]. Nevertheless, we found that grants are equipped to participate in and contribute to healthcare education improved knowledge of the Danish society on an equal footing with other citizens [21]. The healthcare system in terms of who to contact in the Danish language education is a compulsory part of the event of an accident but not in the event of illness and introduction programme for immigrants from countries further, it positively affected correct answers for 9 out of outside the EU who are granted residence permits in 11 true or false questions on access to and use of the Denmark due to family reunification or asylum [22]. healthcare system [4]. The next step is to investigate However, no introduction to the Danish healthcare whether improved knowledge leads to more optimal system is offered or included in the introduction healthcare-seeking behaviour and healthcare utilisation. programme. This could otherwise be a natural part of Healthcare-seeking behaviour can be understood as a the introduction programme to ensure that immigrants person’s process of engaging (or not) with a particular are equipped to understand and navigate the healthcare health service. This includes aspects such as how symp- system— a sector which everybody comes into contact toms are perceived and acted upon and how, as well as with (several times a year for many people) and for which type of and when, healthcare services are accessed which access is often vital—on an equal footing with [5]. Healthcare utilisation can be seen as an interrelated other citizens. Additionally, good mental and physical result of, as well as a feedback mechanism to, health is a prerequisite to active engagement in society healthcare-seeking behavior [6]. Inappropriate and sub- and for successful integration, including the acquisition optimal healthcare-seeking behaviour among immigrants of a new language and labour market attachment [23]. has been reported previously by both healthcare profes- Better integration may also improve health outcomes, as sionals [7–9] and newly arrived immigrants themselves immigrants increasingly have the ability to seek health- [10]. Danish healthcare professionals reported that emer- care when needed and tend to achieve life conditions gency room (ER) visits by patients of Middle Eastern that are less harmful to their health [23]. origin were often less appropriate in nature as compared Given the high number of new immigrants in with those by ethnic Danes [8], while immigrants them- Denmark [24] and in other European countries [25] selves
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