Factors associated with self-rated health among North Korean defectors residing in South Korea

Since the 1945 intervention of the United States and the Soviet Union in the Korean War, the ideologically disparate governments of South and North Korea have remained mutually hostile. The number of North Korean refugees has increased since the mid-1990s due to the worsening economic crisis, food shortages caused by natural disasters, and poor living conditions in North Korea [1]. The number of North Koreans fleeing to South Korea increased from 1,400 in 2000 to 10,000 in 2006, reaching 23,000 in 2012 [2, 3].

Post-arrival health assessment has revealed that many North Korean defectors suffer from various physical/mental illnesses and that diseases they are suffering from remain dormant due to stress until they arrive in South Korea [4]. It is assumed that they had experienced poor living conditions in North Korea, as well as numerous life-threatening events during their illegal stay in a tertiary country, such as China and Russia, before entering South Korea [1, 4]. Moreover, the stress from socio-cultural and economic assimilation in South Korean society increases the risk of psychological and physical disorders [4‐6]. These health vulnerabilities often result in passivity among North Korean defectors with regards to finding employment and participating in government social adjustment programs [4, 7, 8].

The health status of refugees is one of many significant factors that determine the success of their resettlement [9]. Previous studies have shown that newly arrived refugees frequently require immediate care for physical and psychological traumas and illnesses [10‐12] because they are exposed to various forms of harm during migration [13]. Furthermore, a high level of stress due to assimilation into a new society may increase the risk of developing chronic diseases [10, 13]. For these reasons, host countries examine the health of refugees upon arrival and provide a variety of medical support services [14‐18]. The South Korean government has given North Korean defectors refugee status and provides them with medical services under the Medical Aid Act [19]. In 2004, Hanawon, the government resettlement center for North Korean refugees that provides a variety of services like education and mentorship programs, also founded the Hana Clinic to improve the health and well-being of refugees [4].

The health status of North Korean defectors is a significant indicator of their success in settling into South Korean society. Several studies have investigated North Korean refugee health in South Korea; however, most have focused solely on mental health related to trauma exposure [1, 20, 21]. A limited number of studies have investigated the physical health of refugees. Also these studies were restricted in scope because they only used a univariable analysis [4] or lacked follow-up health assessments after initial data was obtained upon their arrival thereby precluding any assumptions regarding their health conditions during the assimilation process [22, 23]. This study investigated the self-rated health status of North Korean defectors who have lived in South Korea for a specific period of time, and it identified the factors related to their self-rated health status.

This study evaluated the self-rated health of 498 North Korean defectors who entered South Korea in 2007; it also analyzed the factors associated with their self-rated health. This study assessed their overall health conditions due to the difficulty involved in determining the appropriate objective health status measurements that would provide a comprehensive picture of their physical and mental health status. The mean value of self-rated health status score among these refugees was relatively low: 2.78 out of 5. This result is consistent with previous findings that reported 11.8-28.4% of North Korean refugees who considered their health condition to be good, as opposed to 40.8% of South Koreans; this shows a significantly lower level of self-rated health among North Korean refugees [4, 29, 30].

With regards to the demographic characteristics of participants, female and elderly respondents tended to have a lower health status, which is a trend observed not only among refugees but also in the general population [31, 32]. It is well-known that individuals with a higher level of education tend to have better health status and longer life expectancy [32‐34]. It has been reported that a lower level of education results in income inequality, particularly among males, which in turn results in a lower health status [35]. However, in this study, the level of education received in North Korea had no association with the self-rated health score. It is assumed that diplomas obtained in North Korea have no relationship with resettlement in South Korea. The socio-economic status of most North Korean defectors declines in South Korean society, and many of them do not have any opportunities to use their previously-acquired abilities and experiences [8].

Individuals with a lower annual household income had lower self-rated health scores. A previous study showed that a refugee’s perceived economic hardship is related to greater decrease in physical health status [9]. In 2008, the average annual family income among North Korean defectors was 8,780,000 Korean won (KRW), which is significantly lower than the income of South Koreans (30,790,000 KRW) surveyed between 2007 and 2009 [36]. Only a small portion of North Korean refugees have stable employment, while most are unemployed or are engaged in entry-level work [8]. According to a survey conducted in 2001, the income of North Korean defectors was only 57% of the average income of South Koreans [8], which could be explained by unstable employment and the unemployment crisis in South Korea [37]. The relationship between individual economic status and health is not limited to refugees; South Koreans with low socioeconomic status are also likely to have low self-rated health [33]. Most North Korean refugees belong to the low socio-economic stratum in South Korea, and so their household income level is likely associated with their health status.

Higher levels of satisfaction with government support, as well as greater life satisfaction, were associated with an increase in self-rated health. This may be explained by the fact that government assistance is linked to the economic status of refugees in South Korea, and therefore it may also be related to life satisfaction. The South Korean government provides various types of support for North Korean refugees, spanning from their arrival until gaining stable residence, in order to provide the necessary conditions for initial assimilation [37]. The South Korean government has also designated refugees as Medical Aid beneficiaries in order to provide them with basic medical health care services [4]. It is most likely that defectors who actively utilize and are satisfied with this government support have higher self-rated health. Considering that self-rated health status of defectors increased with higher satisfaction with government supports, it is necessary to seek a way of improving satisfaction with government support programs. Although the South Korean government provides Medical Aid to refugees to ensure access to basic medical services, this access is limited due to high out-of-pocket costs for those services not covered by NHI. All Medical Aid beneficiaries in South Korea are economically vulnerable and therefore face difficulties paying for medical services outside NHI coverage [38]. The economic status of North Korean defectors is particularly low; therefore, their lack of access to necessary health care services may be more serious. Although the insurance type was not a significant factor associated with self-rated health in the multivariable model, participants receiving Medical Aid reported lower self-rated health. Therefore, the development of alternatives may assist in increasing refugee access to health care services. Further research is necessary in order to identify associations between health insurance type and medical utilization of defectors. Individuals with longer length of stay (>18 months) in South Korea tended to have better self-rated health. This result may be indicative of the fact that North Korean defectors escaped from poor living conditions, such as malnutrition [1] and have since been able to access better health care services [9], thereby increasing self-rated health. Another interpretation suggests improvement in emotional and physical stability after resettlement in South Korea; a previous study reported that immigrants and refugees with longer residency in a new country experience greater assimilation into a new society and culture [39]. However, several studies have reported that a longer length of stay in the United States is actually associated with an increased prevalence of obesity and cardiovascular diseases in immigrants due to the adoption of unhealthy eating habits and lifestyle [40‐42]. North Korean defectors with chronic diseases reported lower self-rated health; although this study was unable to identify the exact onset of such diseases, their prevalence does increase among refugees in the process of resettlement [4]. This result likely suggests that preventive care, early detection and intervention are essential during the early phase of resettlement for the prevention and control of chronic diseases.

The health status of refugees is a key factor affecting resettlement in host countries [9], and many countries provide refugees with various health care services upon arrival to improve their health status. The Australian government provides refugees with a Medicare program and additional services including dental and mental health care [16]. Other countries, such as Canada, United Kingdom, Netherlands, and the United States also provide comprehensive healthcare services to refugees upon arrival [14, 15, 17, 18]. It is recommended that the South Korean government provide newly-arrived refugees with prompt integrated treatment and continuous healthcare services to improve their health status, which is a key determinant of their success in resettlement.

North Korean defectors have undergone numerous traumatic experiences, both in North Korea and during their defection, which can hinder their successful settlement in South Korea [43] and this may be related to their self-rated health. The results from this study showed that higher levels of traumatic exposure in North Korea were associated with higher levels of self-rated health. This may be explained by posttraumatic growth and resilience. Posttraumatic growth is defined as the experience of positive changes resulting from a struggle with previous psychological trauma and stress [44]. Although the negative effects of traumatic experiences cannot completely disappear, individuals who experience posttraumatic growth may expand their understanding of life and develop new coping skills, resulting in personal growth and recovery from previous traumas [45‐47]. Resilience also functions as a buffer against the negative effects of traumatic experiences that affect positive adaption [43]. Previous studies revealed that resilience has a positive effect on one’s physical and mental adaption caused by trauma or high levels of stress [48, 49]. North Korean defectors who experienced traumatic incidents may have undergone positive personal development and may have increased their resilience through struggles with previous trauma. It is assumed that individuals with a high degree of exposure to traumatic events tend to have better self-rated health once they overcome the trauma.

This study attempted to utilize random sampling, however, it was practically impossible since the total number of participants was very low; North Korean defectors tend to avoid identity exposure, and they are passive in face-to-face interviews. Despite attempts to include as many refugees as possible in the interviews, the results may not be generalizable to all North Korean defectors residing in South Korea. Also, this study analyzed data collected from a cross-sectional study, and so it has limitations in detecting causal relations between independent variables and self-rated health.

This study analyzed the factors associated with self-rated health among North Korean defectors living in South Korea. The results showed that the length of stay in South Korea, satisfaction with South Korean government support, traumatic experiences in North Korea, and life satisfaction are significant factors in the self-rated health of defectors when other variables such as demographic, socio-economic, and health-related factors are controlled. These findings should be considered and reflected in government policies and refugee support programs in order to improve the health status of refugees.