Background
North and South Korea separated due to variations in their politico-social environments during the Cold War. Since the 1980s, South Korea has experienced great improvement in its standard of living through rapid economic growth and modernization, whereas North Korea has suffered consecutive natural disasters and great economic hardship as a result of the collapse of the Communist bloc [
1]. Since the mid-1990s, there has been a growing number of North Koreans escaping to China, Russia [
1,
2] and South Korea [
1]. The cumulative number of North Korean defectors entering South Korea has grown from 10,000 in 2007 to 20,000 in 2010, and exceeded 24,000 in 2013 [
3].
Newly arrived refugees, including North Korean defectors, tend to require urgent care for somatic and mental diseases [
4-
8]; thus, host countries examine refugees’ health status upon their arrival and offer various healthcare support services [
5,
8-
11]. Immigrants and refugees in their initial settlement stage suffer numerous health problems, and therefore healthcare systems are critical in supporting social adaptation into their new society [
12]. North Korean defectors residing in South Korea also experience various health problems when adapting to their new society and culture [
7,
13]; the South Korean Medical Aid Act covers them in order to lower economic barriers to medical services utilization [
14].
Generally, refugees have difficulty in accessing healthcare services in host countries due to cultural and language differences [
6,
15]. Refugees’ health-seeking behaviors and attitudes, which are consistent with the norms or culture of their country of origin, often become barriers to medical services utilization in their host country [
6]. North and South Koreans lived under a unified culture and language [
16] but since the national division, the two countries have situated under the disparate ideology without mutual interchange. Thus, North Korean defectors may experience cultural and language gaps and experience lack of understanding of the South Korean health systems, variations in treatment-seeking behaviors, and difficulties in communication with medical staff [
10].
Also, the financial burden of medical care is a significant hindering factor in their use of medical services [
6]. Although most refugees are financially supported by host country governments, refugees often are unable to receive required treatments as they are restricted to those medical services or institutions covered by their healthcare support systems [
17]. These barriers to medical services among refugees are similarly applicable to North Korean defectors living in South Korea. North Korean defectors experience the financial burden of medical care, such as co-payment, in spite of the Medical Aid Act because most are economically vulnerable [
10,
18].
The health status of North Korean defectors is a key predictor of their social adaptation level in South Korea [
7]. Defectors with health problems face difficulties in the initial settlement process. Therefore, it is important to lower the barriers to utilization of healthcare services and to promote the health of defectors from the beginning of their resettlement. There are several studies related to health of North Korean defectors in South Korea; however, most focus on mental health and trauma experiences in North Korea and during their migration [
19-
21]. Some studies investigated the use of healthcare services among North Korean defectors, but most focused on current utilization status [
18,
22-
25]; therefore no previous study has examined the factors associated with their healthcare services utilization. Considering that refugees enter host countries with various health problems, the early North Korean defectors in South Korea would likely have high physical health needs. Therefore, this study is aimed to investigate the frequency of physician visits and factors related to these visits among North Korean defectors living in South Korea.
Discussion
This study evaluated the frequency of physician visits among 498 North Korean defectors who entered South Korea in 2007; it also analyzed the factors associated with this frequency. The average number of physician visits utilized during 2008 was 15.3, which is similar to the number of physician visits among the general South Korean population (15.4) during the same period [
31]. Even though this study did not survey unmet medical needs, as North Korean defectors have relatively greater health needs than the general South Korean population [
4,
6,
12,
13], it may be assumed that their unmet medical needs would be more serious than those of South Koreans [
19,
32]. Therefore, further researches should focus on unmet medical needs and impediments of medical utilization of North Korean defectors residing in South Korea in order to improve their health.
Health-related variables had the greatest association with the frequency of physician visits among North Korean defectors. Previous studies have also found that health-related factors, such as perceived quality of general health and number of somatic symptoms, were significant factors affecting refugees’ use of healthcare services [
15,
33]. This study showed that the number of physician visits was higher among individuals with disabilities, chronic diseases, or lower self-rated health scores. It is generally known that physically disabled people have impeded mobility; therefore their access to healthcare services tends to be low [
34,
35]. This study data only specified whether or not participants had disabilities, and did not distinguish whether their level of disability interfered with their access to healthcare services. More research is needed to identify the relation of disability level on the utilization of healthcare services among North Korean defectors through assessment of the severity of their disabilities. Participants with chronic diseases and low self-rated health scores made more physician visits. Although this study did not investigate the onset timing of chronic diseases, the increased prevalence of chronic diseases among North Korean defectors during the resettlement process suggests that governmental support is essential to prevent such diseases during early resettlement [
7]. The results showed that the frequency of physician visits increased with low self-rated health score. In general, unmet medical needs escalate alongside a lower self-rated health status [
36]. Although there was no data available related to unmet medical needs, it is forecasted that unmet medical needs are likely more serious among North Korean defectors since their self-rated health status is remarkably low compared to that of South Koreans [
7,
15,
33]. Future studies needs to focus on the unmet medical needs of North Korean defectors.
Previous studies on utilization of healthcare services among refugees have shown that their particular characteristics, such as language barriers and cultural differences, are obstacles to medical care [
5,
15,
37]. However, this study presented different results: the frequency of physician visits by North Korean defectors was associated with their residence period in South Korea and traumatic experiences during migration, rather than cultural or language gaps. It is assumed that the differences in findings are caused by that North Korean defectors living in South Korea are different from refugees or immigrants in host countries with a completely different language or culture. North and South Korea were one nation before their division; therefore North Korean defectors likely experience relatively fewer language or cultural challenges, which may explain why these variables had no association with healthcare utilization. This study found that participants had undergone various traumatic experiences, both in North Korea and during their defection. According to Lawrence and Kearns, refugees are easily exposed to traumatic experiences, which can cause intense physiological distress [
6]. Because the traumatic experiences of North Korean defectors may pose a threat to their physical and mental health, their general health status is poorer than that of the general population in South Korea [
7,
21]. The number of physician visits increased among participants who experienced more traumas during their defection, because a greater number of traumatic experiences are linked to exposure to unhealthy environments and risky behavior [
22]. This may have led to an escalation in disease outbreak or disability among participants.
Female participants made more physician visits than males, and this trend is also observed among the general population [
38,
39]. The number of female North Korea defectors entering South Korea from the early 2000s was greater than that of males, and females comprised 78% of defectors entering the country in 2008 [
40]. Since the collapse of the North Korean healthcare system in the 1990s, North Korean women were unable to receive proper care during pregnancy and childbirth, and their postpartum health deteriorated [
41]. Female defectors are also frequently exposed to human trafficking and sexual abuse during their migration from North Korea, and thus many of them arrived in South Korea with obstetric disorders [
39]. However, due to a lack of awareness with regard to prevention and management of such disorders, most female defectors do not receive screening exams or proper medical treatment [
42]. Previous studies determined that many female refugees were unable to receive screening or medical treatment for diseases related to female health [
5,
43]. It is recommended that the South Korean government pay greater attention to female defectors and provide them with education in order to ensure proper utilization of healthcare services.
In general, low-income groups utilize healthcare services less frequently than high-income groups because financial burden prohibit their access of medical care [
44,
45]. Also the study regarding medical utilization of general South Korean population found same result as well [
34]. In this study, however, the frequency of physician visits decreased with increasing annual household income. It is assumed that conflicting results are the result of income disparities between North Korean defectors and the general public of South Korea. The 2008 average annual household income of North Korean defectors was 8,780,000 Korean won (KRW) (approximately 7,803 USD), which is considerably low compared with the 30,790,000 KRW (approximately 27,365 USD) income of South Koreans surveyed between 2007 and 2009 [
46]. Considering previous study results, which indicate that the unemployment rate of North Korean defectors reaches 3-40% and the beneficiary rate for the National Basic Livelihood Security Program is greater than 80% [
47,
48], socio-economic classification is not distinct among North Korean defectors [
7]. Therefore, it is difficult to apply the perspective of equity in healthcare services according to the economic level of the general public to North Korean defectors.
Although insurance type had no significant relation to multivariable analysis, the Medical Aid beneficiary group made more physician visits than the NHI group. It is assumed that North Korean defectors with NHI had greater co-payment expenditures than Medical Aid beneficiaries. The ratio of North Korean defectors giving up medical treatment due to the burden of medical expense was 23.9%, more than twice that of South Koreans at 11.4% [
7]. When North Korean defectors obtain employment in South Korea, they are mandatorily covered by the four major public insurance systems including workmen’s compensation, labor, health, and employment insurance; employed defectors are uniformly excluded from Medical Aid program, and thus their financial burden of medical expense is greater. Since the average income of North Korean defectors is only 57% of the average income of the general public in South Korea [
2], some defectors intentionally avoid finding employment in order to receive Medical Aid benefits [
18]. It is important that the South Korean government differentiates the scope and targeting of its healthcare coverage for North Korean defectors from that of South Koreans by considering their economic and health vulnerabilities.
The results of this study are not generalizable to all North Korean defectors living in South Korea, since random selection was not used for sampling. However, this limitation was inevitable because the total number of subject was very low and defectors tend to concern identity exposure and to avoid external contact. In addition, this study analyzed data collected through cross-sectional study; therefore, it cannot detect a causal relationship between independent variables and frequency of physician visits. Recall bias might have influenced the data collection of the frequency of physician visits.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BRW, JWN and YDK participated in the design of the study. WJ has made substantial contributions to collection of data. BRW and YDK performed the statistical analysis. All authors have been involved in the interpretation of data and drafting the manuscript. All authors read and approved the final manuscript.