Date Published: January 23, 2018
Publisher: Public Library of Science
Author(s): Patrick Brzoska, Massimo Ciccozzi.
Immigrants often encounter barriers in the health system that may affect their health care outcomes. In order to better cater to the needs of immigrants, many health care institutions have increased their efforts in recent years to provide services which are more sensitive to the needs of an increasingly diverse population. Little is known about whether these efforts are successful. This study examines difference in outcomes of tertiary prevention between immigrants and the autochthonous population in Germany over the period of 2006–2014.
The analysis is based on a 10% random sample of routine data on completed tertiary preventive treatments in Germany during 2006–2014. Four different indicators of treatment effectiveness were compared between patients with a nationality from Germany, Portugal/Spain/Italy/Greece, Turkey and Former Yugoslavia using logistic regression adjusted for demographic/socioeconomic factors. Interaction terms for year were modeled to examine group differences over time.
Depending on the outcome, Turkish and Former Yugoslavian nationals had an 23%-69% higher chance of a poor treatment effectiveness than Germans (OR = 1.23 [95%-CI = 1.15,1.32] and OR = 1.69 [95%-CI = 1.55,1.83], respectively). Fewer differences were observed between nationals from Portugal/Spain/Italy/Greece and Germans. Disparities did not significantly differ between the years in which services were utilized.
Measures implemented by health care institutions did not reduce existing health care disparities between immigrants and the majority population in Germany. One potential reason is that existing approaches are unsystematic and often not properly evaluated. More targeted strategies and a thorough evaluation is needed in order to improve health care for immigrants sustainably.
In many European countries large proportions of the populations are immigrants. In Germany, more than 20% of the population is considered to be of immigrant origin. About half of them are non-German nationals, equaling about 7.6 million individuals. Turkish nationals, nationals from a former Yugoslavian country and from the South European countries Portugal, Spain, Italy and Greece make up the largest share of immigrants in Germany . Immigrants often differ from the majority populations of the countries they reside in terms of health status, health behavior and health care outcomes. Particularly older immigrants tend to have a worse health status than the autochthonous population of the same age [2–4]. Aside from poor working conditions and a lower socioeconomic status, barriers immigrants encounter in the health system contribute to this differential by affecting the access to health care. This results in a lower utilization of preventive services such as screening [5–7], vaccination [8–10] and rehabilitative care [11–14]. These barriers may also contribute to disparities in health care outcomes between both population groups [11;15;16]. For example, a study from Germany found out that while 15.5% of all Germans who underwent rehabilitation in 2006 were reported to have a poor occupational performance after treatment, the respective proportions were considerably larger for non-German nationals, being 23.0% for Turkish nationals, 25.1% for Former Yugoslavian nationals and 19.6% for nationals from Portugal, Spain, Italy or Greece. This difference was independent of demographic and socioeconomic covariates . Similar disparities were observed for other outcomes such as the self-rated treatment effectiveness and the risk for disability retirement after rehabilitation [15;17].
Information on 617,683 subjects was available who were evaluated on their health status and occupational performance after completing their rehabilitative treatment in the years 2006 through 2014. Of these, 1.6% (n = 9,925) were nationals from Turkey, 1.1% (n = 6,943) had a nationality from a former Yugoslavian country, 1.1% (n = 6,851) held a nationality from the South European countries Portugal, Spain, Italy or Greece and 2.2% (n = 13,747) were nationals from other countries. In total, 6.1% (n = 37,466) of all subjects had a non-German nationality.
In many countries, including Germany, immigrants encounter barriers in the health care system that may affect the outcomes of the care they receive. In order to better cater to the needs of immigrants, many health care institutions have increased their efforts in recent years to provide services which are more sensitive to the needs of an increasingly diverse population. Little is known about whether these efforts are successful and whether they contribute to reducing existing disparities in health care. The aim of this study was to examine differences in outcomes of tertiary prevention between immigrants and the autochthonous population in Germany over the period of 2006–2014. The study shows that immigrants experience poorer treatment outcomes than the majority population, with older immigrants being particularly vulnerable for a reduced effectiveness of treatment. Differences in all four outcomes were especially pronounced for nationals from Turkey and Former Yugoslavia. The observed disparities can only be partially explained by a different distribution of demographic and socioeconomic factors. This is in line with previous research that had focused on other indicators of treatment effectiveness. For example, nationals from Portugal/Spain/Italy/Greece, from Turkey and from Former Yugoslavia were reported to have a 24%, 62% and 68% higher chance of a poor self-perceived treatment outcome than Germans, independent of differences in health status as well as their demographic and socioeconomic profile (aOR = 1.24 [95%-CI = 1.12;1.37], aOR = 1.62 [95%-CI = 1.45;1.80] and aOR = 1.68 [95%-CI = 1.52;1.85], respectively) . Similarly, nationals from Turkey and Former Yugoslavia are at a 70% and 41% higher risk of disability retirement despite undergoing rehabilitative treatment (adjusted hazard ratio [aHR] = 1,41 [95%-CI = 1,22; 1,64] and aHR = 1,70 [95%-CI = 1,49;1,95], respectively) . These findings together with the present study suggest that immigrants experience different challenges and obstacles in the health care system that may interfere with an adequate provision of care. They arise from communication problems between patients and health care providers emerging from limited information about rehabilitative services, a reduced health literacy and poor German language proficiency . These barriers make it difficult for health professionals to instruct patients about therapies and necessary exercises or to obtain their medical history, thus affecting the effectiveness of rehabilitative treatments. Aside from these challenges, problems in communication and interaction can also result from cultural needs and health care expectations that are not sufficiently address by health care providers. These, for example, comprise culture-specific illness perceptions or cultural taboos [34;35].
The present study has implications for practice, research and policy making. It shows that current approaches and strategies of the health system to provide health care for immigrants are not sufficiently able to reduce existing disparities in health care between immigrants and the autochthonous population. Efforts therefore need to be strengthened. Systematic approaches such as diversity management can guide future activities. The findings also emphasize the need for the development of migrant-sensitive health reporting to ensure that appropriate data is collected and available in order to identify and monitor disparities in different sectors of the health system. These disparities need to be address by means of appropriate measures which need to be evaluated in terms of their effectiveness. For this purpose, also the transfer of research findings into clinical practice must be enhanced.