1. University of Copenhagen, Department of Health Services Research Ethnic disparities in the use of health services Research Seminar on Ethnicity 2. June 2006 Allan Krasnik Dept. of Health Services Research University of Copenhagen

2. University of Copenhagen, Department of Health Services Research Themes 1.The right to health care 2.Migration, ethnicity and indicators of equity in access 3.The Nordic countries 4.Examples of studies 1.Primary prevention 2.Screening and diagnostics 3.Emergency care 5.Conclusions

3. University of Copenhagen, Department of Health Services Research 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…”

4. University of Copenhagen, Department of Health Services Research The constitution of WHO ”The enjoyment of the highest attainable health is one of the fundamental rights of every human being”

5. University of Copenhagen, Department of Health Services Research 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

6. University of Copenhagen, Department of Health Services Research. 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.

7. University of Copenhagen, Department of Health Services Research

8. University of Copenhagen, Department of Health Services Research 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 care services: theory and evidence from the UK. Soc Sci Med 2001;53:1149-1162

9. University of Copenhagen, Department of Health Services Research Equity versus equality Equity: –A fair distribution of services Equality: –Equal share to everybody

10. University of Copenhagen, Department of Health Services Research 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

11. University of Copenhagen, Department of Health Services Research 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 ethos Aneurin Bevans

12. University of Copenhagen, Department of Health Services Research Themes 1.The right to health care 2.Migration, ethnicity and indicators of equity in access 3.The Nordic countries 4.Examples of studies 1.Primary prevention 2.Screening and diagnostics 3.Emergency care 5.Conclusions

13. University of Copenhagen, Department of Health Services Research 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)

14. University of Copenhagen, Department of Health Services Research Indicators of inequity of access I Determinants of utilization –Legislation –Information –Financial barriers –Distance Process indicators –Contact rates –readmissions

15. University of Copenhagen, Department of Health Services Research Indicators of inequity of access II Outcome indicators –Morbidity –Stage of disease when diagnosed –Survival –Satisfaction

16. University of Copenhagen, Department of Health Services Research Dimensions of inequalities in access I. Prevention II. Diagnosis III. Treatment IV. Survival/mortality Compliance Readmissions

17. University of Copenhagen, Department of Health Services Research Themes 1.The right to health care 2.Migration, ethnicity and indicators of equity in access 3.The Nordic countries 4.Examples of studies 1.Primary prevention 2.Screening and diagnostics 3.Emergency care 4.Mortality 5.Conclusions

18. University of Copenhagen, Department of Health Services Research 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

19. University of Copenhagen, Department of Health Services Research 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)

20. University of Copenhagen, Department of Health Services Research 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

21. University of Copenhagen, Department of Health Services Research Themes 1.The right to health care 2.Migration, ethnicity and indicators of equity in access 3.The Nordic countries 4.Examples of studies Primary prevention Screening and diagnostics Emergency care 5.Conclusions

22. University of Copenhagen, Department of Health Services Research Maternal characteristics associated with vaccination of young children Luman et al. Pediatrics 2003;111:1215-1218

23. University of Copenhagen, Department of Health Services Research 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.

24. University of Copenhagen, Department of Health Services Research Maternal characteristics associated with childhood vaccination Maternal factor (n)Odds ratio (95% CI) Maternal factor (n)Odds ratio (95% CI) Race/ethnicity White, 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 status Above 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 household 1 (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)

25. University of Copenhagen, Department of Health Services Research 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.

26. University of Copenhagen, Department of Health Services Research Access to screening and treatment for breast cancer among immigrants in Denmark compared to Danish born women Nørredam, Krasnik & Holm-Petersen Ugeskrift for Læger 1999;161:4385-8

27. University of Copenhagen, Department of Health Services Research 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.

28. University of Copenhagen, Department of Health Services Research 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)

29. University of Copenhagen, Department of Health Services Research 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

30. University of Copenhagen, Department of Health Services Research 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.

31. University of Copenhagen, Department of Health Services Research 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.

32. University of Copenhagen, Department of Health Services Research Emergency room contacts by country of birth (controlled for age and gender) Country of birthRate ratios (95% CI) Denmark1.00 (ref) Ex-Jugoslavia1.22 (1.11-1.34) Iraque0.95 (0.79-1.14) Nordic countries, EU, OECD0.81 (0.75-0.88) Pakistan1.01 (0.87-1.16) Somalia1.46 (1.17-1.80) Turkey1.36 (1.20-1.53) Rest of Europe0.87 (0.75-1.00) Other countries0.99 (0.93-1.07)

33. University of Copenhagen, Department of Health Services Research 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)

34. University of Copenhagen, Department of Health Services Research 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. Metods Questionnaires (in 9 languages) among 3809 patients (and their care takers) attending 4 emergency rooms in Copenhagen during 3 weeks in 2004/2005.

35. University of Copenhagen, Department of Health Services Research The most important reason for attending the emergency room (ER) by income? <100.000kr100-300.000 kr>300.000 krIncome not known Could not contact own GP 12% 9% ER is best suited to handle my problem 56%59%64%35% My GP referred me to the ER 9% 10%6% The doctor-on-call referred me to the ER 6% 5%7% Other reasons17%14%12%43% Total100% (n=937)100% (n=1447)100% (n=790)100% (n=635)

36. University of Copenhagen, Department of Health Services Research The most important reason for attending the emergency room (ER) by ethnic group? DKWest EU OECD Eastern Europe Middle EastAfricaAsia Could not contact own GP 9%22%27%21%19%28% ER is best suited to handle my problem 60%46%45%47%37% My GP referred me 9%7% 8%7%6% The doctor- on-call referred me 6%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)

37. University of Copenhagen, Department of Health Services Research 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

38. University of Copenhagen, Department of Health Services Research Copyright ©1998 BMJ Publishing Group Ltd. Stevens, A. et al. BMJ 1998;316:1448-1452 Triangulation of information sources

39. University of Copenhagen, Department of Health Services Research Themes 1.The right to health care 2.Migration, ethnicity and indicators of equity in access 3.The Nordic countries 4.Examples of studies 1.Primary prevention 2.Screening and diagnostics 3.Emergency care 5.Conclusions

40. University of Copenhagen, Department of Health Services Research 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