Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers and refugees. Results from a cross-sectional survey in Berlin, Germany

BackgroundAsylum-seekers and refugees (ASR) exhibit high prevalence rates of chronic and mental illness, but low utilization of ambulatory specialist healthcare. Forgoing timely healthcare when facing formal and informal access barriers may direct ASR toward emergency care. This paper addresses the interrelations of physical and mental health and the utilization of ambulatory and emergency care, and explicitly addresses the associations between the different types of care. MethodsA structural equation model was applied to a sample of n=136 ASR living in accommodation centers in Berlin, Germany. Patterns of emergency care utilization (outcome) and physical and mental ambulatory care utilization (endogenous predictors) were estimated, while controlling for age, sex, chronic conditions, bodily pain, depression, anxiety and length of stay in Germany (exogenous predictors) and self-rated health (endogenous predictor). ResultsSignificant associations were observed between ambulatory care utilization and poor self-rated health (0.207, 95%-CI: 0.05; 0.364), chronic illness (0.096, 95%-CI: 0.017; 0.175) and bodily pain (0.019, 95%-CI: 0.002; 0.036); between mental healthcare utilization and anxiety (0.202, 95%-CI: 0.051; 0.352); and between emergency care utilization and poor self-rated health (0.621, 95%-CI: 0.059; 1.183), chronic illness (0.287, 95%-CI: 0.012; 0.563), mental healthcare utilization (0.842, 95%-CI: 0.148; 1.535) and anxiety (0.790, 95%-CI: 0.141; 1.438). We found no associations between ambulatory care utilization and emergency care utilization. ConclusionsOur study generates mixed results concerning the associations between healthcare needs and ambulatory and emergency care utilization among ASR. We found no evidence that low utilization of ambulatory healthcare contributes to emergency care utilization among ASR; neither did we find any evidence that obtaining ambulatory treatment obviates the need to seek emergency care. Our results indicate that higher physical healthcare needs as well as anxiety are associated with more utilization of both ambulatory healthcare and emergency healthcare; whereas healthcare needs related to depression tend to remain unmet. Improving health services accessibility and responsiveness, including the expansion of support services, outreach, and the coverage of medical interpretation, may enable ASR to better meet their healthcare needs. Key Messages1. Implications for policy makersO_LIWe examined if low utilization of ambulatory healthcare among asylum-seekers and refugees (ASR) contributes to potentially avoidable and resource-intensive emergency room visits among this group. C_LIO_LIWe did not find evidence that low ambulatory care utilization determines high emergency care utilization among ASR; neither did we find evidence that getting ambulatory treatment obviates the need to seek emergency care. C_LIO_LIOur study results show that some ASR patients use both ambulatory and emergency care, either moving back and forth between the two types of care (which suggests that neither one meets their need) or seeking either type of care "randomly" (which indicates problems navigating the health system). ASR with depression tend to not get any care for this problem. C_LIO_LIOur findings signal the need to improve accessibility and responsiveness of health services, including understandable health information, help with navigating the health system, low-threshold and outreach services, medical interpretation, and sensitization of administrative and medical health staff. C_LIO_LIEnabling ASR and other diverse groups to get specialized healthcare for their physical and mental health problems will contribute to better health system outcomes, including better health and less health inequalities, greater satisfaction among patients and staff, and more efficient healthcare provision, i.e. less preventable costs and burdens for the health system. C_LI 2. Implications for publicRefugees often have difficulties in getting the healthcare they need. We tested if this makes them use more emergency care. This would be problematic for patients and healthcare providers; for example, because emergency services are already strained and costly. Indeed, our study suggests that refugees with anxiety go back and forth between ambulatory and emergency care, maybe because neither service resolves their problems. ASR with a chronic disease also use both ambulatory and emergency care. It is good if people with more health needs use more healthcare; it is even better, though, if we ensure they get specialized services for their particular problems. Refugees with depression tend to not get any help. More outreach, support with accessing the right healthcare provider, interpretation services and intercultural training for staff will help refugees get better care; and it will help healthcare providers offer treatment for refugees and other minorities effectively and efficiently.