Patients’ perception of differences in general practitioners’ attitudes toward immigrants compared to the general population: Qualicopc Slovenia

People leave their home countries for various reasons: either because of war and poor living conditions in their homeland, or due to better job opportunities and socialeconomic status in a new country (1-3). This is why people mostly emigrate from countries with poor medical care to the countries where medical care is considerably better (1). Globally, the number of immigrants is rising every year; between 1990 and 2005, this number increased by 33 million each year. The number of immigrants worldwide is estimated at 200 million (4).

The important issue for this study is that immigrants bring along their cultural differences in relation to health and also their own perspective on the healthcare they need (1). They tend to have a different health behaviour compared to the non-immigrant population: regarding alcohol consumption, smoking, physical activity, among other behaviours. These differences may affect immigrants’ overall health status and lead to chronic health conditions (5, 6). Immigrants are less responsive to various systematic prevention programs, and they have a lower vaccination rate (1, 7). It is also significant that they often do not know the healthcare regulations in their host country, which may lead to difficulties when arranging appointments and following registration procedures (1). In order to ameliorate the situation, general practitioners (henceforth GPs) dealing with recently arrived immigrants are provided with certain guidelines. These guidelines advice caution in the first contact with immigrants and recommend treating high-priority conditions immediately. GPs should pay special attention to abuse or domestic violence, mental illnesses, diabetes mellitus, dental care, infectious diseases (HIV, hepatitis), and other conditions (4, 8-10).When doctors and their patients come from different cultural environments, their communication is somehow difficult. If patients have to express themselves in a foreign language, problems may arise already at the linguistic level. For example, immigrants may not understand their GPs, but are too embarrassed to admit it. They may also misunderstand the doctor’s instructions. Studies have shown that the greatest difficulties occur with the patients that have limited language proficiency: even if they can articulate their problems and they do understand the doctor’s instructions, they might not be able to talk about their emotions. Too often, the language issues prevent these patients from being treated the same way as the non-immigrant population. Many studies have recommended that doctors should suggest an interpreting service for their patients in such cases (11, 12).

Many studies have highlighted adjustment challenges that immigrants might experience, including (as mentioned above) language differences, as well as homesickness, unfamiliarity with the social-cultural system, unemployment, educational difficulties, and social exclusion. They may also experience difficulties with respect to their religion, family traditions, and values (13-15). All of these differences and difficulties may contribute to immigrants’ social and emotional instability. This is an additional challenge that GPs face when consulting immigrants (13).

The data obtained through the Qualicopc questionnaire provided valuable information regarding patients’ perceptions of GPs’ attitude toward immigrants in Slovenia.

According to the data available from the Statistical Office of the Republic of Slovenia, immigrants represent 4.7% of the population (17). This is a much smaller percentage than in our study, with patients that identified themselves as first-generation immigrants (11.6%). Such a difference is due to different methodologies. The statistical office included only individuals with foreign citizenship in this number. On the other hand, our study did not ask about the citizenship but only about the birth country.

Comparing the groups with respect to the education level showed statistically significant differences between the groups. Immigrants have lower education than the non-immigrant population. This is a possible reason why immigrants appear to be more susceptible to their environment and why they tend to think that they are treated worse than others. It was repeatedly shown that immigrants in general have lower education levels, but studies have also shown that those with lower education levels integrate more easily in their host countries (30, 31). On the other hand, for immigrants with a higher education it is more difficult to get a job, mostly due to the low rate of recognition of their credentials (32).

When comparing our three groups (first-generation immigrants, second-generation immigrants, and nonimmigrants), we found no significant differences among them regardless of whether they have a personal GP selected or not. In general, only a very small percentage of the patients answered that they do not have a personal GP or that they had difficulties in making an appointment at their GP’s office. All together could indicate that immigrants in Slovenia do not experience major difficulties accessing GPs and that they do not have to wait longer for an appointment than the general population. It is important to emphasize that these questionnaires were completed by patients in GPs’ waiting rooms. Therefore, this data may only be accurate for our group of patients and cannot be understood in the sense that all immigrants in Slovenia have equal opportunities to get an appointment at a GP’s office. The available data from the literature show that the choice of GP is influenced by several different factors, such as care quality, availability, and practice characteristics (33). Comparable data have been obtained in Canada with respect to the availability of GPs and other specialists for immigrants and for the rest of the population. However, according to the Canadian studies, fewer immigrants benefit from medical treatment. The reasons for such results may lie in better health status of immigrants and cultural differences in attitudes toward medical admission (7, 34). On the other hand, in Norway there is lower utilization of primary healthcare among elderly immigrants compared to the general population. The reasons for this may be the same as above, relying on cultural differences (34, 35). Better health status of immigrants in Europe compared to the non-immigrant population is a bit controversial; it shows a north-south gradient, since immigrants’ health is better in Italy and poorer in France and Belgium (36, 37). Analysing the questions related to the appointment at the GP’s office, we encountered some significant differences between the groups (Table 2). A comparison between the first-generation immigrants and the non-immigrant population shows that GPs are more impolite with immigrants. Several studies have shown that immigrants have a more negative experience with GPs compared to the non-immigrant population due to the language barriers, cultural differences, and the lack of familiarity with the healthcare system in the host country (1, 4, 5, 38, 39). An important cause of GPs’ attitude toward immigrants in Slovenia may also be the additional burden they represent for the GPs’ workload (40). There were 237 GPs per 100,000 people in Slovenia in 2006, which was well below the European average (332 to 338 per 100,000 in 2007) (41). GPs in Slovenia have between 862 and 3,186 registered patients, or an average of 1,771.37 ± 68.8 (42), and immigrant’s unfamiliarity with the country’s healthcare system (e. g., to call for an appointment) may present an additional workload, causing GPs to develop an unfriendly attitude toward the patient. A Canadian study showed that the immigrants’ experiences with GPs significantly improved when these barriers and limitations disappeared (38). Several studies showed that the attitude of GPs is worse toward the people with mental illnesses compared to the healthy population (43, 44). This can lead to the conclusion that, as anybody else, GPs also have their stereotypes, and that these stereotypes influence their attitude toward their patients (45). At this point it is also worth mentioning that, according to some studies, immigrants are more vulnerable to developing a mental illness (46-48), and that they are also less likely to seek professional help in such case (49). Many factors are known to influence immigrants’ mental health. Kirmayer et al. divided these factors into three groups, according to the stage of migration the individuals are in: premigration (e. g., trauma, political involvement, disruption of social norms), migration (e. g., trajectory, exposure to violence, disruption of family or community network), and postmigration (e. g., uncertainty about immigration or refugee status, unemployment, difficulties in language learning). They also presented factors affecting mental health distributed by age (children, adults, and the elderly) and by gender, arising from their different social roles and responsibilities. Immigrant women have a two- to threetimes greater risk of developing depression compared to non-immigrant women (46). It is also interesting that different subgroups of an ethnic group vary according to incidence and type of mental illness. This shows the utmost importance of psychosocial and cultural factors related to migration and mental health (47). Therefore, in dealing with immigrants, GPs should pay special attention to evaluating risk factors for specific subgroups to develop a mental illness.

An important difference between the first-generation immigrants and the non-immigrant population is also that significantly more immigrants answered that their GP did not take enough time for their appointment. There may be multiple reasons for this: the GP may indeed have a slightly more negative attitude toward immigrants and wish to end the appointment as soon as possible, or immigrants may need more time than the non-immigrant population. This may be due to cultural differences, language barriers, and so on (13, 14). As already mentioned, the GPs’ large workload may also prevent them from taking as much time as a patient needs (40). On average, in Slovenia, GPs have 45.63 patient encounters per day, which allows them 6.93 minutes per person – and this may not be enough in certain cases (42). In all three groups, a fairly large percentage of patients (from 20 % to 28%) answered that their GP did not help them solve their personal problems. In our opinion, this shows general discontentment with the healthcare system, which can be connected to the economic crisis peaking in Slovenia in the year the Qualicopc questionnaire was administered. Another reason, as mentioned earlier, may be short consultation times (43).

The analysis of questions related to patients’ negative experience in the past 12 months indicates a significant difference between the groups (Table 3). Secondgeneration immigrants had negative experiences with GPs or their staff more often than the non-immigrant population, but unfortunately we do not have information about the type of these experiences. There are significantly more patients among first-generation immigrants that think that other patients receive better treatment than them. Indeed, several studies have shown that access to healthcare for immigrants may be more difficult because they do not understand the system very well, have trouble understanding the language, have difficulties adjusting to certain norms, and so on (13, 25, 50). All this may lead to poorer healthcare and therefore to more negative experiences with a GP or staff.

All of these differences in GPs’ attitudes toward immigrants in comparison with the general population according to patients’ perspectives could also be due to sociological factors. All individuals derive from their own cultural environment with different values, and thus have subjective expectations from their GPs (1, 4, 5, 39, 51, 52). As mentioned above, immigrants may also face different challenges in their host countries, such as language differences, homesickness for relatives still living in their countries of origin, unfamiliarity with the sociocultural system, unemployment, educational difficulties, and social exclusion, which may affect their view of their GPs’ attitudes (13-15). This is why GPs must be aware of all these obstacles and difficulties that immigrants face and should try to remedy them (38, 53).

Among all of the patients, only 2.7% answered that an interpreter is always available at the GP’s practice, and 1.0% answered that an interpreter is usually available. Based on the data available, we do not have clear information on how many practices abroad have an interpreter available if a patient requires one. However, many authors agree that the presence of an official interpreter (if needed) improves the quality of patients’ care (54, 55). On the other hand, studies show that patients that need an interpreter but do not have access to one receive poorer medical care in comparison to the general population; their outcome seems to be worse, and their confidentiality is repeatedly violated (54, 55). An alternative has also been proposed in the literature: if a professional interpreter cannot be physically available at the practice, a telephone access to a professional interpreter should be offered (54). Another possibility is professionally trained volunteers to work as interpreters at GP practice (56). It has turned out that using family members as interpreters is not an optimal alternative, because they often fail to translate patients’ words literally. They can also magnify patients’ problems or minimize them, or even not attach importance to these problems (54, 57). Their mistakes in translation can also be life-threatening for patients (57). Today, GPs are increasingly aware of the importance of having access to interpreters for their patients if needed (58). Another interesting fact is that 18.5% of respondents are not familiar with the information about interpreter availability at their GP practice. These data should encourage GPs to promote interpreter service where it is available and therefore make it easier for their patients to visit a doctor and to talk about their health issues. It is also important for GPs to encourage the presence of an interpreter at their practice. Another important fact is that there is a significant difference in understanding GP’s directions between G1 and the non-immigrant population (Table 2). The reason for this may be that immigrants have problems fully understanding Slovenian (11, 12) and are therefore in need of an interpreter. Another reason may be that they are less educated (Table 1) (1) compared to the non-immigrant population, and experience difficulties understanding technical words used by GPs.

Disadvantages of our study were that the G3 significantly outnumbered the other two groups (G1 and G2). This was of course expected, since the opposite breakdown is normally found in the general population. An important weakness of this study is also that we have lower frequency of positive answers in some questions than in others, in spite of statistically significant difference between selected groups.

It has been shown that there may be some differences when comparing GPs’ attitudes towards first- or second-generation immigrants to the general Slovenian population based on patients’ opinions. The study showed that there are no statistically significant differences with regard to GPs’ availability when comparing immigrants to the non-immigrant population of Slovenia. However, in their own perception, the second-generation immigrants experienced more negative behaviour from GPs or their staff than the non-immigrant population. First-generation immigrants have more difficulties in understanding GPs’ instructions, and claim to be given insufficient appointment-time when compared to the non-immigrants. However, on the basis of the questionnaire that targeted the patients in GPs’ waiting rooms, we cannot conclude that GPs’ attitude towards the immigrants is indeed below the standards that is assured to the non-immigrant population.