REFUGEE HEALTHCARE IN BRITISH COLUMBIA: HEALTH STATUS AND BARRIERS FOR GORVERNMENT ASSSISED REFUGEES IN ACCESSING HEALTHCARE by SETAREH ROUHANI B.HSc., University of Ottawa, 2009 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (Health Care and Epidemiology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2011 © Setareh Rouhani, 2011 Abstract Background: Government-Assisted Refugees (GARs) have greater health needs than other immigrants due to their pre-migration and Canadian resettlement experiences. There is a lack of detailed research into their health status and access to healthcare services. This thesis investigated factors associated with reported health, mental health problems, number of annual physician visits and difficulties obtaining healthcare from a sample of GARs. Methods: Secondary data analysis was conducted on data from a study of GARs in BC who attended the Bridge Refugee Clinic during the 26 month period from April 2005 to May 2007. Multivariate logistic regression was used to model the factors associated with excellent health, mental health problems, physician visits and difficulties obtaining healthcare. Results: There were 177 participants in the study. Excellent health was inversely associated with being female, having financial burden, having no English proficiency and having a diagnosed health condition. Factors associated with mental health problems were being female, west Asian, and having financial burden. Attending refugee clinics was inversely associated with reporting mental health problems. Factors associated with physician visits were unemployment, while not having English proficiency and no access to a regular doctor were inversely associated with the number of visits. Young Age, no access to a regular doctor and health region were associated with difficulties obtaining healthcare, while not being married had an inverse relationship with reporting difficulties. Conclusion: Findings highlight sex and English proficiency as important factors associated with GARs‟ health and utilization of services. It is recommended that specialized health literacy classes, health programs and support groups for GARs, especially women, be developed. These interventions would benefit from active participation of ethnic communities. ii Preface The research presented in this thesis was approved by the UBC Behavioural Research Ethics Board (ID # H11-00069). This thesis consisted of secondary data analysis from the “Refugee Health Care in BC: What Facilitates Access to General Practitioner Care” study conducted by Mayhew and colleagues (2010). Setareh Rouhani wrote the thesis, conducted the literature review, contributed to the methodologies, conducted all analyses and interpreted findings with guidance from Dr. Jane Buxton (Supervisor), Dr. Arminée Kazanjian and Dr. Maureen Mayhew (thesis committee members). iii Table of Contents Abstract ........................................................................................................................................... ii Preface............................................................................................................................................ iii Table of Contents…………………………………………………………………………………iv List of Tables ............................................................................................................................... viii List of Figures ................................................................................................................................. x List of Abbreviations ..................................................................................................................... xi Acknowledgements ....................................................................................................................... xii Dedication .................................................................................................................................... xiii 1 INTRODUCTION ................................................................................................................... 1 1.1 Purpose ............................................................................................................................. 1 1.2 Reasons for Current Thesis .............................................................................................. 2 1.3 Research Objectives ......................................................................................................... 2 1.4 Thesis Overview ............................................................................................................... 3 2 BACKGROUND AND LITERATURE REVIEW ................................................................. 4 2.1 Background ...................................................................................................................... 4 2.1.1 Historical Overview of Migration and Resettlement ................................................ 4 2.1.2 Legislation and Policies on Immigration ................................................................ 10 2.2 Methods for the Literature Search .................................................................................. 12 2.3 Rates of Health Service Utilization of Immigrants and Refugees ................................. 13 2.4 Research Paradigms on Immigrant Health ..................................................................... 14 2.5 Health Status of Government Assisted Refugees ........................................................... 16 2.5.1 Mental Health Problems ......................................................................................... 17 2.5.2 Infectious Diseases.................................................................................................. 19 2.5.3 Chronic Diseases ..................................................................................................... 19 iv 2.6 Access to Health Services .............................................................................................. 20 2.6.1 Definition and Measures of Access to Health Services .......................................... 20 2.6.2 Access to Care: Defining „Needs‟ within the Context of Healthcare ..................... 21 2.6.3 Concerns on Difficulties Accessing Care ............................................................... 23 2.6.4 Barriers to Care for Newcomers ............................................................................. 24 2.7 Conceptual Framework: The Andersen Model of Health Care Utilization ................... 25 2.7.1 Initial Model............................................................................................................ 25 2.8 Determinants of Access to Health Care: Predisposing, Enabling and Need Factors ..... 28 2.8.1 Predisposing Factors ............................................................................................... 28 2.8.2 Enabling Factors ..................................................................................................... 34 2.8.3 Need Factors ........................................................................................................... 36 2.9 Determinants Examined in the Thesis ............................................................................ 37 3 METHODOLOGIES ............................................................................................................. 39 3.1 Primary Data Source ...................................................................................................... 39 3.1.1 Subjects ................................................................................................................... 39 3.1.2 Setting ..................................................................................................................... 39 3.1.3 Sampling Design ..................................................................................................... 40 3.1.4 Data Collection ....................................................................................................... 41 3.2 Secondary Data Analysis ............................................................................................... 42 3.2.1 Data Management ................................................................................................... 42 3.3 Measurement .................................................................................................................. 43 3.3.1 Outcome Measures.................................................................................................. 43 3.3.2 Independent Variables ............................................................................................ 45 3.3.3 Derived Independent Variables ............................................................................... 50 3.4 Data Exploration ............................................................................................................ 55 v 3.4.1 Data Exploration: Phase I ....................................................................................... 55 3.4.2 Data Exploration: Phase II ...................................................................................... 55 3.5 Statistical Analysis ......................................................................................................... 55 3.5.1 Research Objective 1 .............................................................................................. 56 3.5.2 Research