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Equity and access: understanding emergency health service use by newly arrived refugees

Mohamud Sheikh, Peter I Nugus, Zhanhai Gao, Anna Holdgate, Alison E Short, Ayman Al Haboub and C Raina MacIntyre
Med J Aust 2011; 195 (2): 74-76.
Published online: 18 July 2011

Health inequities and provision of health care to resettled refugees are complex and critical issues worldwide. Many refugees arrive with significant levels of poor health,1-5 exacerbated by trauma and resettlement difficulties,6,7 which may lead to acute conditions requiring emergency medical attention. Prior patterns of emergency services use can influence the way refugees use them in their country of resettlement.8-11

There is limited information on the way newly resettled refugees engage with emergency department (ED) care in Australia. The role of the ED in categorising patients for potential inpatient admission emphasises the need for such research.12,13 Understanding the way newly arrived refugees engage with EDs can help with education and policy making in relation to emergency care and the treatment of these refugees. We define emergency services as rescue facilities, such as the ambulance service and the ED. Our study aims to identify specific community needs and beliefs about use of the emergency health care service in the south-western Sydney area.

Methods

We administered a descriptive, community-based, semistructured telephone questionnaire over a 4-month period (December 2008 – April 2009). Patient information and contact details were obtained from the Liverpool Hospital ED database of patients who accessed the ED in the 6 months before our survey, indicating attendances at the Liverpool ED, located in metropolitan south-western Sydney. We profiled potential participants by country of birth and asked them if they had a refugee background. Human research ethics committee approval was obtained from the Sydney South West Area Health Service (SSWAHS).

Questionnaire

The questionnaire was developed by community consultation through a cross-cultural adaptation process. Advice was taken from ethnic community health care workers and community leaders, on the clarity and cultural sensitivity of the questions, during our first meeting with them. Trained multilingual community health workers who were qualified interpreters administered the questionnaires.

Data analysis

Descriptive analysis was performed, and 95% confidence intervals and P values were obtained. Differences in proportions of African and Middle Eastern participants were tested by calculation of Pearson’s χ2 test. To examine the potential confounding effects of socioeconomic factors, multivariate logistic regression analysis was performed to show the difference between the African and Middle Eastern groups in terms of access to emergency services. Results were calculated using SPSS version 17 (SPSS Inc, Chicago, Ill, USA).

Results
Characteristics of sample

Overall, 155 out of 172 potential participants completed the survey (90%) response rate). Sixty-eight per cent were from sub-Saharan Africa and 32% were from the Middle East. Box 1 shows the demographic characteristics of the survey participants, Box 2 describes their socioeconomic details, and Box 3 shows the remaining results of the questionnaires. Respondents had lived in Australia for a mean of 4 years (SD, 2.9 years).

Access to EDs and other health services

The survey showed that 144/155 respondents (93%) perceived a need for a general practitioner from their ethnic group who spoke the same language. Half the African refugees (53/106) 50% preferred the ED for an urgent medical condition rather than other services, compared with only 15/49 (31%) of the Middle Eastern refugees (P = 0.024). The preferred way of accessing urgent medical help was substantially divided between the ED and the family GP. Qualitative data showed that most respondents explained their preference for a GP because they thought he or she would explain their health conditions more easily in their own language and in a culturally relevant manner.

A large majority of the participants (142/155 [92%]) knew how to call for emergency medical help. However, a considerable proportion of newly resettled refugees were afraid to call an ambulance, even when they required it (33/155 [21%]; 95% CI, 15%–29%).

Some respondents reported that they were afraid to call an ambulance because, in their countries, when the police heard the ambulance sirens, they sometimes came as well as, or instead of, an ambulance. This was a more frequent theme among sub-Saharan African refugees than among Middle Eastern refugees. Some respondents reported that they would not call an ambulance because they feared they would not understand or be understood by emergency staff. This was more commonly the case with refugees from Middle Eastern backgrounds than the African refugees, and may explain their greater reluctance to use emergency services in preference to GP services.

Logistic analysis shows that there were significant differences between the African and Middle Eastern newly arrived refugee groups in seven issues of access to the emergency department, after adjusting for the potential confounding of four socioeconomic indicators (Box 4). Other variables that we tested but found not to be significant include: participants’ access to Liverpool Hospital ED; participants had used an ED service in other countries; participants used ethnic communities as a source of information about medical care; and participants had access to a GP.

Overall, 87/155 (56%) of those who accessed Liverpool Hospital ED rated the service received at the ED as excellent, good or average. Qualitative data, however, revealed that the refugees believed they accessed a health professional more quickly at a GP service. Box 4 shows some of the sentiments reflecting the refugees’ variable experiences of care.

There was no significant disparity between refugee groups in relation to knowledge, beliefs and attitudes about use of emergency health services. Box 3 presents their beliefs about emergency health care.

Respondents regarded communication, convenience and efficiency as important elements in distinguishing whether to use GP or ED services.

There were no significant differences between the two refugee groups in access to information about the ED service, as shown in Box 4. There were notable differences between preferred ways of accessing urgent medical help, as described in Box 4.

Discussion

Our study shows that the need for improvement in health service delivery to recently resettled refugees7 also applies to emergency services, and there are two major implications for policy and training that emerge. The first is the need for a well trained and diverse health care workforce in Australia to understand patient needs, and to explain assessments, diagnoses and procedures in ways the patients will understand.14,15 This may involve community outreach and enhanced information technology systems for integrated care across health sectors. The second implication from our study is that policymakers need to identify and act on differences between ethnic groups, which are often mistakenly regarded as homogeneous.

Our study has some limitations which point to topics for further research. Generalisation to other ethnic groups is limited because the sample was not representative of the Australian refugee population. Future researchers might, for example, investigate individual emergency services, enabling comparison of use of EDs and ambulance services. A community-based survey might identify a segment of the refugee community (that was not identified by our hospital-based sample) who have less access to health care. Further research might subdivide refugee participants by country of origin, and elaborate on and control for socioeconomic indicators and other potentially influential factors, such as English language competency and length of time in Australia.

Further research is also needed to explore the reasons why many of the respondents were afraid of calling an ambulance, despite their ability to do so and their conviction that such a call was needed. ED use by refugees needs to be compared with ED use by the general population, and the reasons that refugees accessed particular emergency services on a particular occasion. Enhancing access, equity and quality health care delivery will enhance the socioeconomic situation of newly resettled refugees. It will develop a more holistic health care service that will cater for this growing group of marginalised people.

1 Demographic background of survey participants (n = 155)

Demographic factor

African origin (n = 106)

Middle Eastern origin (n = 49)

P


Sex (male)

57.5%

34.7%

0.008

Interpreter required

60.4%

53.1%

0.391

Lived in another country as well as Australia and country of birth

87.7%

83.7%

0.492

2 Selected socioeconomic indicators (n = 155)

Socioeconomic indicators

Number


Has home telephone for emergency call

150 (97%)

Owns a car

98 (63%)

Has had some education

150 (97%)

Can easily read English

67 (43%)

Reads native language

146 (94%)

Unemployed

118 (76%)

Receives a social security payment

130 (84%)

Does not own a house

152 (98%)

Has a Medicare card

153 (99%)

Has a health care card

125 (81%)

3 Beliefs about emergency health care

African country of origin (n = 106)


Middle Eastern country of origin (n = 49)


Survey statement

No

Unsure

Yes

No

Unsure

Yes

P


It is better to get traditional healing than use the ED

56.6%

12.3%

31.1%

61.2%

24.5%

14.3%

0.032

Emergency health services save lives

2.8%

29.2%

67.9%

10.2%

14.3%

75.5%

0.032

In my country of origin, emergency health services were well established

77.4%

18.9%

3.8%

28.6%

24.5%

46.9%

< 0.001

Urgent medical attention can save lives

0%

20.8%

79.2%

4.1%

14.3%

81.6%

0.078


ED = emergency department. .

4 Logistic analysis examining differences between African and Middle Eastern groups in perceived access to emergency services

Access to emergency services

Variable

Odds ratio (95% CI)

P


Afraid to call for an ambulance when required

African*

0.38 (0.16–0.90)

0.028

Owns a car

1.62 (0.63–4.18)

0.317

Can easily read English

0.16 (0.05–0.49)

0.001

Unemployed

1.29 (0.41–4.05)

0.659

Has a health care card

0.53 (0.17–1.61)

0.260

Prefers an emergency health care service for getting urgent medical help

African

2.27 (1.09–4.73)

0.028

Owns a car

1.03 (0.50–2.14)

0.935

Can easily read English

1.16 (0.59–2.31)

0.666

Unemployed

0.45 (0.18–1.18)

0.104

Has a health care card

1.42 (0.52–3.86)

0.496

Prefers family general practitioner for getting urgent medical help

African

0.43 (0.21–0.87)

0.020

Owns a car

1.16 (0.56–2.42)

0.685

Can easily read English

1.00 (0.50–2.00)

0.995

Unemployed

1.72 (0.66–4.52)

0.269

Has a health care card

1.61 (0.58–4.50)

0.363

Ever felt critically ill or been seriously injured enough to require an ambulance or emergency medical attention

African

2.76 (1.27–6.01)

0.010

Owns a car

1.03 (0.49–2.18)

0.940

Can easily read English

1.12 (0.56–2.26)

0.751

Unemployed

0.76 (0.28–2.05)

0.590

Has a health care card

3.11 (1.02–9.52)

0.046

Ever called for an ambulance

African

3.77 (1.60–8.85)

0.002

Owns a car

1.35 (0.61–3.00)

0.459

Can easily read English

0.52 (0.24–1.10)

0.088

Unemployed

0.66 (0.23–1.88)

0.437

Has a health care card

5.91 (1.68–20.80)

0.006

Been treated by ambulance or paramedic staff at home

African

2.40 (1.03–5.61)

0.044

Owns a car

0.94 (0.42–2.08)

0.877

Can easily read English

0.77 (0.36–1.66)

0.512

Unemployed

0.99 (0.34–2.91)

0.985

Has a health care card

5.08 (1.24–20.77)

0.024

Use health professionals (eg, doctors, nurses) as source of information about health and emergency medical care

African

3.57 (1.31–9.73)

0.013

Owns a car

0.36 (0.10–1.24)

0.106

Can easily read English

0.95 (0.35–2.61)

0.921

Unemployed

1.05 (0.30–3.66)

0.944

Has a health care card

2.18 (0.61–7.84)

0.231


* Group variable of African (n = 1) and Middle Eastern (n = 0).


Provenance: Not commissioned; externally peer reviewed.

Received 21 August 2010, accepted 14 April 2011

  • Mohamud Sheikh1
  • Peter I Nugus2
  • Zhanhai Gao1
  • Anna Holdgate3
  • Alison E Short2
  • Ayman Al Haboub4
  • C Raina MacIntyre1

  • 1 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW.
  • 2 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW.
  • 3 Liverpool Hospital, Sydney, NSW.
  • 4 Liverpool Multicultural Health Service, Sydney South West Area Health Service, Sydney, NSW.

Correspondence: m.sheikh@unsw.edu.au

Acknowledgements: 

We thank the study participants and the Liverpool Hospital emergency department for their assistance.

Competing interests:

None relevant to this article declared (ICMJE disclosure forms completed).

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