Health and Healthcare Access and Utilization Among Syrian Refugees Migrating to Norway : A Longitudinal Study

Background: An unprecedented number of people are on the move today and the health of refugees has become a vital global public health concern. During the migration process, refugees move from one environment to another and can face multiple healthcare challenges along their journey. Yet, how the migration process and the changing risk and protective factors influence refugee health and their use of healthcare services remains poorly understood. Objective: The overarching objective of this thesis is to explore, describe and analyse (a) the changes in health, Quality of Life and use of healthcare services among Syrian refugees migrating to Norway and (b) the association between these changes and sociodemographic and migration-related factors. Methods: This thesis is part of the Changing Health and healthcare needs Along the Syrian Refugees’ Trajectories to Norway (CHART) project. Both quantitative and qualitative methods were used to answer the objective of this thesis. In the quantitative part of the study (papers I and II), a prospective longitudinal design was used. Data were collected among adult Syrian refugees accepted for resettlement to Norway through a self-administered questionnaire repeated at two-time points. The first assessment was conducted pre-arrival in Lebanon in 2017–2018 and the second assessment after one year of resettlement in Norway. Primary outcomes were Selfrated Health (SRH), Quality of Life (QoL) and use of healthcare services (general practitioner [GP], emergency care [EC], outpatient/specialist care and hospitalization). In the qualitative part of the study (paper III), 15 individual interviews were conducted with adult Syrian refugees to capture their experiences in terms of changes in their own health and use of healthcare services after arriving in Norway. Results: In the quantitative part of the study, 506 Syrians participated in Lebanon and 353 in the follow-up one year later in Norway. In paper I, we found that the percentage of participants reporting good SRH showed a non-significant increase from 58% to 63% from Lebanon to Norway, while mean values of QoL increased significantly. Positive effect modifiers for improvement in SRH and QoL over time included male gender, younger age, low level of social support and lack of residence permit in Lebanon. In paper II, we found that the use of GP and EC increased after resettlement while outpatient/specialist care dropped markedly, and hospitalization rates remained the same. Lack of residence permit and poor SRH prior to resettlement were identified as predictors for the use of healthcare after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and QoL were significantly associated with the use of healthcare services. In paper III, we found that the perceived causes of change in health status seem to be related to the resettlement phase with clear gender differences in the resettlement experience and its impact on health. Participants’ perceptions of the caregiver, communication and consultation/interaction time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver. A model was developed - The Migrant Sensitive Access Model - to address some of the challenges that came to light from our participants’ experiences. Conclusion: Stability and improvement in health and QoL are the most prominent findings of this thesis, indicating strong resourcefulness and adaptability among the studied group, a prerequisite for successful integration. Likewise, this study confirms that both pre- and post-migration factors have an impact on the health and health service use of refugees and underscore that a combination of migration and a social determinant of health approach is necessary for addressing inequities in health and healthcare access. Awareness should be raised of the most disadvantaged refugees with low social support, low education and poor health literacy who may be more susceptible to health disparities by poorer access to healthcare. Despite universal health coverage after resettlement, access barriers and unmet health needs were revealed. To enhance healthcare access, efforts should be made to increase trust in the healthcare system and its caregivers. Further, this thesis substantiates that a responsive resettlement process may have important positive health implications and calls for resettlement countries to provide adequate supportive resources upon arrival for all subcategories of forced migrants