In this combined survey and registry-based study, we observed higher use of all somatic healthcare services (GPs, specialist doctors, hospitals, and dentists) in a foreign country among Turkish immigrants compared with ethnic Danes, also after adjustment for sociodemographic and socioeconomic factors, as well as health status. Turkish descendants made increased use of specialist doctors and there were tendencies of increased use of hospitals and dentists, while we found no statistically significant differences in use of GPs in a foreign country compared with ethnic Danes, after adjustment for sociodemographic and socioeconomic factors, as well as health status. For medicine received from abroad, we found no statistically significant differences among the men, but immigrant Turkish women and their descendant counterparts made extensively higher use compared with ethnic Danish women. Socioeconomic factors and health status could explain some, but not the full effect on the use made by the different groups.
Strengths and limitations
The strengths of the study include interviews of the population in their preferred languages and the use of survey data linked to high-quality registry data. Additionally, we examined the use of different healthcare providers abroad, taking into account different population groups’ preferences for types of medical care. Several limitations also apply. Firstly, the survey questions on the use of healthcare in a foreign country give insufficient information: we do not have information on the country(ies) from which the healthcare services are obtained, nor do we have information on which types of healthcare (e.g. which types of medicine) are obtained. Different definitions of healthcare or medication between the groups included may also be at stake. Secondly, the low participation rate of the Turkish immigrant and descendant groups may lead to underestimation of the use of healthcare abroad, as non-respondents are likely to have low socioeconomic status and may have more problems with contacts with Danish authorities, including the healthcare system. Nevertheless, it could also lead to overestimation if non-respondents use cross-border healthcare services less due to their poor financial situation. Thirdly, only immigrants who had resided in Denmark for at least three years were included in the study. Information on newly arrived immigrants’ use of healthcare may also be of interest. Fourthly, use of self-reported health symptoms as a measure of health is problematic, leading to potential residual confounding. Cultural differences in the health of one’s reference group, different expectations of one’s health, and differences in response style, or in the connotation of the symptom questions, may play a role, so that it is uncertain whether the symptom scales function equivalently in all three groups. Fifthly, the registry information lacked accuracy in two aspects: a) information on education was obtained from a questionnaire sent annually to all immigrants. Based on this information, Statistics Denmark classifies immigrants’ education according to Danish standards, but this is subject to uncertainty and lack of information; b) unemployment was defined as full unemployment in week 48, which is a weak indicator and does not take the length of unemployment into account.
Reasons for seeking cross-border healthcare
Reasons for seeking healthcare services across borders/in the country of origin by migrants are complex and deeply rooted in the specific cultural background of the migrants, as well as formal and informal access to the healthcare system in the host country. An Irish qualitative study on recently arrived immigrants showed that the immigrants were confused about the Irish healthcare system, including their entitlements, procedures for obtaining them, and the services available. The immigrants sought to fill some, and occasionally most, of their healthcare needs in their home country, e.g. during summer holidays; and not only for specialised procedures, but also for non-specialised routine check-ups and minor treatments
. Other studies indicate other rationales for seeking healthcare services in their country of origin. Korean immigrants in New Zealand, who represent a relatively young and skilled immigrant group, sought effective care, as well as better and faster treatment, in culturally comfortable settings in Korea
. Treatment in Korea was considered to be faster and of higher quality by the Korean immigrants. Combined with feeling comfortable and safe, and overcoming cultural and linguistic barriers, this seemed to outweigh travel expenses
. Mexicans living far from the border in the US sought medical treatment in Mexico due to unsuccessful treatment in the US, lack of (financial) access to care in the US, and a preference for Mexican care
. For Californian Mexicans (living relatively closer to the border), the predictors of cross-border healthcare use by immigrants were found to be: need, lack of health insurance, delay in the seeking of care, more recent immigration and limited English language proficiency
The case of Turkish immigrants seeking healthcare services in Turkey is somewhat similar to the Korean immigrants in New Zealand seeking healthcare in Korea, since the healthcare systems in the two host countries and in the countries of origin, respectively, to a large extent share similar characteristics. New Zealand and Denmark have a GP gatekeeper system, whereas in Korea and Turkey patients go directly to specialists in hospitals
[12, 16, 18]. However, while the Korean immigrants in New Zealand had to pay out-of-pocket for their treatment in Korea, the Turkish immigrants in Denmark had free-of-charge or partly reimbursed medical treatment, including prescription medicine, in Turkey, as this was covered by the Danish national health insurance at the time of the data collection (until 2008). Yet, for additional services such as dentistry, or in the case of chronic diseases, the Turkish immigrants residing in Denmark had to pay for the services in Turkey themselves. There might also be differences in the accessibility of specialist and hospital care between the healthcare system in Denmark and in Turkey. With reference to the Korean immigrants, it is likely that Turkish immigrants would be more likely to use private services in Turkey, and accordingly receive fast and efficient services in a culturally familiar setting with healthcare providers one trust and thereby avoid waiting lists in Denmark. Future research may focus on how and why and which types of cross-border healthcare have been obtained, as this could be useful to improve measures and to make recommendations for the European healthcare systems.
Alternative or supplementary healthcare?
A recent Danish study showed that Turkish immigrants and their descendants made considerably higher use of somatic healthcare services (GPs, specialists in private practice, emergency rooms, hospitals) but less use of dentists in Denmark, compared with ethnic Danes—also after taking sociodemographic and socioeconomic factors and health status into account
. The present study shows that these utilization differences in the Danish healthcare system cannot be explained by differences in the use of cross-border healthcare by Turkish immigrants, their descendants, and ethnic Danes. One exception is the use of dentists by immigrants, and to some extent by descendants. Since this study showed higher use of dentists in a foreign country among Turkish immigrants and borderline higher use among their descendants compared with ethnic Danes, the lower use of dentists by immigrants and their descendants in Denmark may be of less concern. Nonetheless, less than 10% of Turkish immigrants and less than 6% of Turkish descendants consulted a dentist in a foreign country (Table
1). From these two studies, it seems that use of cross-border healthcare among Turkish immigrants residing in Denmark should be considered to be supplementary healthcare, and not as an alternative.
Informal barriers to the host country healthcare system
The observations of different consumption patterns of use of healthcare abroad may be due to informal barriers to the Danish healthcare system, including inadequate doctor-patient communication, provider insecurity, different healthcare-seeking behaviour, and patient preferences and expectations. As Danish studies have shown dissatisfaction with the doctor-patient encounter from healthcare professionals and from non-Western immigrants
[19, 20], this is likely to lead to the increased use of healthcare services in the immigrants’ home countries. Furthermore, immigrants may have longer stays abroad/in their home countries, which naturally add to increased cross-border healthcare consumption. However, the Irish study of recently arrived immigrants found that the main reasons for seeking healthcare in their home countries appeared to be issues of affordability and perception of the quality of care
. Unlike the common idea that seeking healthcare in a more familiar context, such as their country of origin, may in the case of migrants be due to (perceived) social, cultural, religious, and linguistic differences, as was found by the Korean immigrants in New Zealand
[1, 16], the Irish study suggested that this was due to insufficient information about the Irish health system. Even though the immigrants did not report cultural and linguistic difficulties, the types of complaints, including quality of services, made the authors consider that they might be related to feelings of alienation
. Our study differs significantly from the Irish study in that the current study population has resided in Denmark for at least three years, and in that the descendants were born in Denmark. Consequently, complete unfamiliarity with the Danish healthcare system is not likely to be at stake, yet cultural barriers, including communication and affordability, especially in the case of dentists and medicine, are likely to be present.
Generational differences in the use of healthcare
Only few studies have looked into generational differences in the use of healthcare. Utilisation patterns for immigrants’ descendants may be of particular interest for prioritising in the healthcare system, as we may assume that they converge into the pattern for ethnic Danes. This study showed that, compared with ethnic Danes, Turkish descendants made increased use of specialist doctors and borderline increased use of hospitals and dentists, and female descendants made increased use of medicine from abroad. For GP services, we found no statistically significant difference between Turkish descendants and ethnic Danes. One explanation could be that, in important cases, a second opinion from a specialist/hospital in the country of origin is still associated with a feeling of security and quality, while the use of dentist in a foreign country may be due to lower prices. The use of prescription medicine from a foreign country may be due to affordability, the availability of over-the-counter medicine in Turkey that would be prescription medicine in Denmark, as well as the unavailability of specific medical drugs used in Turkey on the Danish market. The descendants of Turkish immigrants in Denmark are likely to be familiar with the Turkish healthcare system, due to regular visits to Turkey and their parents’ use of services in Turkey; so that the descendants know both the Danish and the Turkish healthcare systems and have the skills to navigate in them and between them, in order to get the best and fastest treatment.
Implications for healthcare in countries of residence
Use of cross-border healthcare services may impose additional strains on the healthcare systems in countries of residence, as it may disrupt continuity of care for patients, including giving patients mixed information and diverging treatment, and may create professional obstacles for healthcare providers. Another implication for healthcare in countries of residence is patient safety regarding contact with resistant bacteria or the increase of antibiotic resistance by using antibiotic too easy. Furthermore, healthcare obtained in a foreign country may entail that the patient does not achieve relevant rehabilitation, etc. in the home country, with the risk of poorer health outcomes and even more fragmented care
. For chronic diseases that to a larger extent require continuity of care, cross-border healthcare use may be a complicating factor. However, the use of healthcare abroad can also be looked upon as a supplement and may thus be beneficial for the patient. Questions about the quality of services abroad have been raised, but relatively little is known about readmission, morbidity, and mortality subsequent to medical treatment abroad
. However, intake of medicine from foreign countries may be highly problematic, as in many cases the quality is questionable due to the lack of proper control or the adulteration of such medicine, making it dangerous for the patient
Patient mobility is increasing worldwide and is high on the agendas of national healthcare systems and health authorities
[7, 22]. Immigrants and their descendants have a background from (at least) two countries, and more affluent members of this group in particular may possess greater knowledge and capability of navigating different healthcare systems, making them better able to exploit services that are most beneficial to them. With increasing globalisation, more and more individuals will be in a similar situation.