Background
Generally, ethnic differences in use of health services are considered to be undesirable, but have been demonstrated repeatedly regarding a wide range of health problems [
1‐
4]. Apart from the influence of socioeconomic status (SES) and health care need - i.e. ethnic minority status tends to correlate negatively with SES and health status [
4,
5] - reasons for ethnic disparities in access and use of health services are complex and often poorly understood [
6]. Even when SES and health care need are taken into account, differences tend to persist, suggesting that other factors should be considered as well [
4,
7,
8]. Identifying these factors for specific ethnic groups may help us to further understand the differences in health care use and so define strategies for preventive policy.
One factor that deserves closer examination is acculturation [
9‐
13]. Acculturation has been associated with significant changes in health behaviour, health, and morbidity for ethnic minority groups [
9,
14‐
17]. Consequently, acculturation is considered to be an important variable in health psychology and behavioural medicine [
9,
14]. Usually, it is defined along two dimensions, expressing the degree of contact and participation in the larger society and maintenance of heritage culture and identity [
18,
19]. As such, the acculturation process is believed to have four outcomes, namely 'assimilation' (in which the old culture is rejected, and participation in the host culture is high), 'separation/traditionalism' (in which the old culture is preserved, and participation in the host culture is low), 'marginalization' (in which both cultures are rejected) and 'integration' (in which the original culture is preserved and participation in the host culture is high) [
18,
19]. Since most differences in health behaviour have been found between the traditional and assimilated conditions, many researchers have constructed one-dimensional acculturation scales, with traditionalism and assimilation as their extremes [
14].
Several studies looking for the correlation between acculturation and services use suggest that increased participation in (or adaptation to) the host culture (i.e. integration and assimilation) is associated with higher service use [
20‐
22]. However, the empirical evidence from Western European health care settings in support of this hypothesis is still rather poor. Differences compared to findings from the U.S. may be expected as a result of (i) variations between studies and countries with respect to the historical background of migration to the U.S. and the Netherlands (e.g. slavery, decolonisation, or labour migration), (ii) the definition of ethnic minority status (e.g. based on self-identification, religion, country of birth, or race), and (iii) health care systems (e.g. with or without general/family practitioners serving as gatekeepers to specialised mental health care, as well as compulsory health insurance in the Netherlands). Moreover, the empirical evidence that supports the notion of higher use of services in case of higher acculturation is in fact more heterogeneous than supposed, suggesting that the effect of acculturation may vary by ethnic and gender background [
14,
20,
23‐
26].
Compared to the general Dutch population, differences in health status and use of health services by Turkish and Moroccan labour migrants - currently two of the most prominent ethnic minority populations in Western Europe - have been shown [
4,
8,
27,
28]. Although these differences tend to vary, depending on which migrant group or health service type is focused upon [
29], the general impression is that both groups are well represented in general practice, whereas specialised health services, like outpatient care and mental health care, are underutilised in comparison to ethnic Dutch [
4]. As far as we are aware, only one study explored the association between acculturation and health care use among Turkish and Moroccan migrants, showing that higher levels of adaptation and lower levels of cultural traditionalism increased the use of mental health services [
9]. The present study seeks to establish if and how acculturation is associated with use of general practitioner, outpatient specialist and mental health care, among first-generation (i.e. foreign-born) Turkish and Moroccan migrants in the Netherlands, while taking into account predisposing and need factors that may confound the association between acculturation and use of health services [
30].
Results
Of 770 first generation Turkish and Moroccan respondents in the AHM, the majority (83.9%) had complete information on all relevant variables, leading to a sample size of 646 subjects for this study (table
1). There were no statistically significant differences between respondents with complete information and those without complete information regarding ethnic background, gender, age, education, general health, the number of chronic health conditions, GP-care, outpatient care, mental health care, ethnic self-identification, or any of the acculturation subscales. Table
1 presents participant information for the total sample, and for Turkish and Moroccan men and women separately. There were statistically significant differences between Turkish and Moroccan men and women regarding age, educational level, self-reported health and chronic conditions, and uptake of mental health services. Concerning acculturation, differences were found with respect to social interaction with ethnic Dutch and cultural orientation. No significant differences were found for communication and emancipation. Finally, table
1 shows that there was insufficient variance with respect to the variable of ethnic self-identification for this variable to have predictive value. As a result this variable was not introduced in the regression analyses.
Table 1
Sociodemographic characteristics of the study population, per ethnic group (N = 646)
Ethnicity
| | | | | | |
Turkish (%) | 55.4 | - | - | - | - | |
Moroccan (%) | 44.6 | - | - | - | - | |
Sex
| | | | | | |
Female (%) | 49.4 | - | - | - | - | |
Age
| 48.6 (13.0) | 49.7 (12.0) | 44.7 (12.9) | 53.3 (12.8) | 46.9 (12.9) | < 0.001 |
Education
| | | | | | |
more than primary (%) | 34.5 | 42.9 | 33.5 | 32.5 | 27.5 | 0.035 |
Self reported health
| | | | | | |
excellent (%) | 3.7 | 5.3 | 3.2 | 3.8 | 2.3 | 0.037 |
very good (%) | 5.3 | 9.4 | 3.2 | 3.2 | 5.3 | |
good (%) | 35.6 | 35.9 | 30.9 | 40.1 | 36.6 | |
moderate (%) | 39.8 | 31.8 | 42.0 | 41.4 | 45.0 | |
bad (%) | 15.6 | 17.6 | 20.7 | 11.5 | 10.7 | |
N chronic conditions
(range = 0-11; mean(sd.)) | 1.8 (1.7) | 1.5 (1.6) | 2.2 (1.8) | 1.6 (1.6) | 1.7 (1.6) | < 0.001 |
Use of health service
| | | | | | |
general practitioner (%) | 60.8 | 55.3 | 62.2 | 61.8 | 64.9 | 0.347 |
outpatient specialist (%) | 25.2 | 25.3 | 23.9 | 23.6 | 29.0 | 0.709 |
mental health care (%) | 10.2 | 15.3 | 13.3 | 6.4 | 3.8 | 0.002 |
Ethnic self-identification
| | | | | | |
Dutch/bi-ethnic (%) | 8.8 | 9.4 | 8.0 | 10.8 | 6.9 | 0.650 |
Turkish or Moroccan (%) | 91.2 | 90.6 | 92.0 | 89.2 | 93.1 | |
Cultural orientation
(range = 5-15; mean(sd.))1
| 10.0 (2.6) | 10.0 (2.3) | 9.5 (2.6) | 10.5 (2.5) | 10.0 (2.8) | 0.004 |
Emancipation
(range = 6-18; mean(sd.))1
| 15.0 (2.8) | 14.8 (2.9) | 15.3 (2.5) | 14.8 (3.0) | 15.1 (2.8) | 0.253 |
Communication in Dutch
(range = 3-9; mean(sd.))1
| 6.0 (2.9) | 6.3 (3.0) | 5.9 (2.9) | 5.9 (2.7) | 5.8 (2.9) | 0.419 |
Social contacts with
ethnic Dutch
(range = 3-9; mean(sd.))1
| 4.3 (1.6) | 4.7 (1.8) | 4.2 (1.5) | 4.4 (1.7) | 4.1 (1.6) | 0.004 |
Table
2 shows the first results from the regression analyses. With respect to GP care there was no interaction between acculturation and ethnic background, nor between acculturation and gender. Therefore stratified analyses were not conducted. The table shows that there was no relation between acculturation and GP care. Instead the main correlates of GP care were worse self reported health and higher number of chronic conditions. In addition, higher age was also related to higher GP care uptake.
Table 2
Association between acculturation and use of general practice care (odds ratios and 95% confidence intervals)§
Moroccan ethnicity1
| 1.18 (0.82-1.70) |
Sex2
| 0.77 (0.53-1.12) |
Age 3
|
1.03 (1.01-1.05)*
|
Education 4
| 1.23 (0.79-1.92) |
Self reported health 5
|
1.90 (1.51-2.40)**
|
Number of chronic conditions 6
|
1.26 (1.09-1.45)*
|
Cultural orientation 7
| 1.04 (0.92-1.19) |
Emancipation 7
| 1.00 (0.94-1.07) |
Communication in Dutch 7
| 0.95 (0.89-1.02) |
Social interaction 7
| 1.08 (0.99-1.19) |
There was statistically significant interaction between acculturation (communication) and ethnicity with respect to specialist care (p = 0.032; table
3). The analyses were therefore stratified according to ethnicity. In the Turkish group higher acculturation regarding communication was associated with less uptake of specialist care. Among Moroccans there was no such relation. In the Moroccan sample there was also interaction between acculturation and gender (p = 0.044); a higher degree of emancipation was associated with less uptake of specialist care among men, but among Moroccans women there was no such association.
Table 3
Association between acculturation and use of outpatient specialist care (odds ratios and 95% confidence intervals)§
Moroccan ethnicity1
| --- | --- | --- |
Sex2
| 1.28 (0.74-2.24) | --- | --- |
Age 3
| 1.01 (0.98-1.03) | 1.03 (0.99-1.08) | 1.00 (0.95-1.04) |
Education 4
| 1.15 (0.60-2.18) | 1.71 (0.55-5.26) |
0.27 (0.08-0.95)*
|
Self reported health 5
|
1.73 (1.23-2.42)*
| 0.85 (0.48-1.51) | 1.19 (0.65-2.17) |
Number of chronic conditions 6
| 1.17 (0.98-1.40) |
1.41 (1.05-1.89)*
| 1.33 (0.97-1.82) |
Cultural orientation 7
| 1.14 (0.95-1.36) | 0.76 (0.54-1.07) | 1.17 (0.84-1.63) |
Emancipation 7
| 1.04 (0.94-1.14) |
0.81 (0.71-0.93)*
| 1.01 (0.86-1.18) |
Communication in Dutch 7
|
0.90 (0.82-0.99)*
| 1.04 (0.87-1.24) | 1.07 (0.92-1.24) |
Social interaction 7
| 1.04 (0.91-1.18) | 0.93 (0.75-1.16) | 1.23 (0.90-1.54) |
With respect to mental health care there was also statistically significant interaction between the communication subscale and ethnic background (p = 0.033; table
4). Among Turkish there was additional interaction between communication and gender (p = 0.003) and between social interaction and gender (p = 0.02). As a result, stratified analyses were done based on ethnic background and gender, the latter only among Turkish. Subgroup analyses showed that higher acculturation regarding communication was associated with higher uptake of mental health services among Turkish men, while the opposite appeared to be the case for Moroccan subjects. Furthermore, higher social interaction was related to higher uptake of mental health services among Turkish women.
Table 4
Association between acculturation and use of mental health care (odds ratios and 95% confidence intervals)§
Moroccan ethnicity1
| --- | --- | --- |
Sex2
| --- | --- | 2.67 (0.75-9.52) |
Age 3
|
0.95 (0.90-0.99)*
| 1.00 (0.95-1.04) |
0.91 (0.85-0.97)*
|
Education 4
| 0.62 (0.20-1.88) | 0.54 (0.16-1.84) | 1.51 (0.36-6.28) |
Self reported health 5
|
2.15 (1.15-4.04)*
| 1.84 (0.94-3.58) |
3.15 (1.14-8.66)*
|
Number of chronic conditions 6
| 1.27 (0.92-1.76) | 1.19 (0.88-1.60) |
1.61 (1.03-2.54)*
|
Cultural orientation 7
| 0.77 (0.56-1.05) | 1.31 (0.92-1.86) | 1.32 (0.86-2.02) |
Emancipation 7
| 0.93 (0.80-1.09) | 1.00 (0.82-1.21) | 0.98 (0.78-1.24) |
Communication in Dutch 7
|
1.26 (1.06-1.49)*
| 0.83 (0.69-1.01) |
0.74 (0.55-0.99)*
|
Social interaction 7
| 0.96 (0.76-1.22) |
1.27 (1.01-1.61)*
| 1.07 (0.80-1.45) |
Discussion
In this study we focused on the association between acculturation and the use of health services within a population-based sample of first generation Turkish and Moroccan migrants in the Netherlands. Generally, there was only a moderate association between acculturation and health care utilisation, in that predominantly the domain communication in Dutch was related to utilisation, and GP care was not related to acculturation at all. Instead, health care utilisation was strongly related to subjective and objective measures of health care need, namely self-reported health status and the number of chronic conditions. If need factors, rather than factors like ethnic background or - as in this case - acculturation, are major determinants of health care utilisation, this is essentially a positive observation, since this can be argued to be an indicator of equity in health care access [
4].
Some positive associations between acculturation and use of health care services were found. Among the Turkish group acculturation was generally associated with the use of mental health care services; more communication in Dutch (within one's private domain) was associated with more use of mental health care amongst Turkish men, while among women this was the case for social interaction. The direction of these associations is in line with the common hypothesis that increasing participation in the host culture is associated with higher service use. It is also in line with findings among other migrant groups in the U.S. [
20], and - more importantly - with recent findings from a study in the Netherlands focussing on the use of mental health services [
9].
However, among Moroccan subjects the association ran opposite while more emancipation was associated with less uptake of outpatient care (males) and more communication in Dutch was associated with less mental health care (males and females). A possible explanation for the association between more communication in Dutch and less uptake of mental health care among Moroccans may be a result of the methodology used in our study. That is, although general health status was accounted for, a specific measure of mental health was lacking. It could be that Moroccans who were better able to communicate in Dutch experienced less psychological stress and consequently a lower mental health care need. For example, in a previous study we found that lacking the skills to live/participate in the Dutch society largely related to mastery of the Dutch language, was associated with more psychological distress [
43]. If this is the case indeed, then the question of course rises why we found a comparable association with outpatient specialist care and the opposite trend among Turkish respondents.
Another explanation for the aforementioned reverse relationship among Moroccans regarding mental health care utilisation may be found in the absence or availability of social support. That is, compared to Turkish migrants, first-generation Moroccans in the Netherlands tend to have smaller social networks, which often do not extend beyond their direct families [
44]. Possibly, Moroccans with better Dutch language skills are less likely to become socially isolated, may be more likely to have alternative sources of (informal) support in case of health care need, and are consequently less likely to apply for mental health care.
Finally, an explanation of this adverse relationship, especially regarding health care from outpatient specialists, may be that higher levels of adaptation concur with a better knowledge of the Dutch health care system and the role of Dutch GPs. GPs in the Netherlands act as gatekeepers to outpatient specialist care, while in Turkey for example it is common practice to visit medical specialists directly. It might be that those who displayed better skills for living in Dutch society were more aware of this than those who did not, and were therefore more likely to remain in care in general practice. One argument against this explanation, however, lies in the observation that we found no association between acculturation and uptake of care in general practice.
The latter observation is important, because in our view it indicates and supports the notion that GP care in the Netherlands has a low threshold and is highly accessible. Recently, Uiters et al. already concluded that the gate keeping role of general practitioners in the Netherlands functions equally effectively among ethnic minority groups compared to the ethnic Dutch population [
8]. The observation that acculturation was associated with outpatient specialist and mental health care utilisation seems to suggest that if services are less accessible, or when culturally defined stigma and taboo come into play (as is the case for mental health problems), acculturation becomes more relevant as a concept in health services research.
This study has limitations. First, due to its cross-sectional design, no conclusions are allowed on the directionality of the results. For example, it is conceivable that ill health (including mental health), indicated by higher use of services, limits the ability of respondents to acculturate. Moreover, ill health may have resulted in a disproportionately negative self-evaluation regarding one's own acculturation skills. A second limitation concerns the generalisability of our results, which may have been compromised by the relatively high non-response. Selective non-response might have occurred, as people who do not use health care services may also be less willing to participate in research. However, the age/sex distribution in the responding sample was reasonable. The non-response also caused a relatively low number of respondents in each analysis. Considering the moderate range of most of the statistical associations observed, one may wonder if the associations are clinically significant. Some of the confidence intervals were extremely wide. Another source of bias might include the fact that measures were self-reported, although self-report measures have been found to be reasonably valid estimators for comparisons between migrant groups in the Netherlands [
45].
Additionally, the acculturation instrument was strongly focused on measuring adaptation, or assimilation. As such, no statements can be made about the role of the second dimension of Berry's model of acculturation (i.e. maintenance of heritage culture and identity), while in previous studies it has been shown that this is also a very important aspect. On the other hand, measures of acculturation traditionally focus on language ability alone. Indeed, it can be derived from the results that, although the associations between acculturation and health care utilisation were limited and heterogeneous, communication in Dutch was one of the most important and central aspects of acculturation. However, other dimensions played a role of significane as well. The finding that increasing social interaction by Turkish women was associated with increasing mental health care, for example, is noteworthy in the light of marginalisation of Muslim migrant groups in Western countries [
46]. That is, if we consider increasing mental health care utilisation by Turkish women a good development, than current political and social developments, by some labelled as "Islamophobia" can be considered a threat in this respect.
Although the factor structure of the acculturation was supported by our data, reliability of the subscales was not strong. According to Nunnaly, Cronbach's alpha coefficients should be 0.70 or higher [
47]. However, lower values - such as in our study - have also been presented as adequate: by citing other studies [
48,
49], Milfont and Gouveia [
50] argue why reliabilities in the range 0.60 and 0.70 can be regarded as adequate as well, and that if samples are sizes larger than 100 (which is the case for all subgroups in our analyses) alpha coefficients greater than 0.40 are acceptable. Furthermore, the Cronbach's alpha we found corresponded with those found in another Dutch study carried out by Hosper et al. [
16] using the same instrument (Cronbach's alpha of 0.64 is presented for the combined scale and a Cronbach's alpha of 0.84 and 0.80 on the social interaction scale).
Finally, and unfortunately, the acculturation scale was applied only in the ethnic minority groups and not among ethnic Dutch. Comparisons between ethnic Dutch, Moroccan and Turkish respondents were thus not feasible. Adjusting and applying acculturation measures for use among original inhabitants of host countries is not common use in health services research, but is a good suggestion for further studies. For example, it would have been very interesting if we could have seen how the ethnic Dutch scored on the emancipation subscale.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
TF and AEH formulated the research question, performed the statistical analyses and drafted the manuscript. APV contributed to the manuscript with his interpretation of results and comments on earlier drafts. All authors read and approved the final version of the manuscript.