Abstract
Background: More than 10% of the population and nearly 20% of all general practitioners (GPs) in Norway have an immigrant background. There are reasons to believe that immigrant GPs have different demographic characteristic and serve different populations than native GPs.
Objectives: To describe the characteristics of the lists and population subscribed to immigrant GPs in Norway and compare them with those of Norwegian-born GPs.
Methods: Immigrant GPs were defined as persons born abroad with both parents from abroad. Two national registers were linked with information about all inhabitants and GPs in Norway in 2008: the GPs Database, and the National Population Register. Logistic regression was used to study the influence of the GP's immigrant background on different characteristics.
Results: Compared to native GPs, immigrant GPs are younger, more often women, and more frequently work alone and in rural areas. GPs with immigrant background have a higher proportion of immigrant patients (OR = 3.2; 95% CI: 2.7–3.8), not only from their own culture, but also from other cultures, and this proportion increases over time. Immigrant GPs have more difficulties recruiting patients compared to their native colleagues (OR = 0.3; 95% CI: 0.3–0. 4 for having closed lists), but this difference seems to diminish over time. There are, however, substantial differences between immigrant GPs from different areas of the world.
Conclusion: The characteristics of the populations assigned to GPs with or without immigrant background are different. This should be taken into account when studying differences between immigrant and native GPs.
KEY MESSAGE:
Immigrant general practitioners (GPs) more often work alone, in rural areas, receive salary (versus fee-for service), have fewer patients, fewer elderly patients, and a higher proportion of immigrant patients in their lists.
Differences in populations should be taken into account when comparing clinical profiles of GPs with and without immigrant background.
INTRODUCTION
Immigration has reshaped the Norwegian society. In 2012, 547 000 immigrants and 108 000 Norwegian-born persons with immigrant parents were living in Norway. Together these two groups account for 13.1% of Norway's population (Citation1). Increased migration also implies a growing influx of immigrant medical graduates into the western countries, and a large number of these work in general practice. Thus, one out of five general practitioners (GPs) in Norway has an immigrant background (Citation2).
Since the implementation of the Regular GP Scheme in 2001, all legal inhabitants in Norway are entitled to choose a ‘regular’ GP. The name ‘regular’ GP is used to emphasize that patients choose their GP, whose list is thus not random but comprised of patients who actively choose her/him. It is the responsibility of each municipality to have enough regular GPs for the population living in the area. In accordance with the local municipality, each regular GP has the right to decide the maximum number of patients allowed on his list (list limit), and patients can choose among regular GPs who have not reached their list limit. Each patient can change regular GP up to twice a year. In this article, for reasons of simplicity, the ‘regular’ GP will be called ‘GP. ’
Several international studies show that immigrants tend to be less satisfied with their GPs compared to native patients (Citation3–8), and immigrants often report negative health care experiences (Citation9,Citation10) as well as a preference for being attended by immigrant GPs from a similar area/culture as their own (Citation11–14). In addition, many Norwegian GPs find it complicated to deal with immigrant patients (Citation15,Citation16). As a result, GPs with immigrant background probably have a relatively high percentage of immigrant patients in their lists (Citation11–13,Citation17). However, no data is available on this issue as the GPs’ immigrant background has not been systematically registered before in Norway. There are no previous studies from Europe on this topic either.
Immigrant GPs may have different cultural and linguistic backgrounds than the national population, and language can be challenging in their integration as health care providers (Citation8). Educational barriers such as lack of communication training and interpersonal barriers such as unfamiliar dialects, different views of authority in the doctor–patient relationship, and different diagnostic or treatment expectations are among the major difficulties perceived by immigrant practitioners in the US (Citation3,Citation18). These challenges may also play a role in the composition of the lists of immigrant GPs, especially at the beginning of their career in the new country.
Immigrant GPs in North America report differences in clinical practice regarding preventive care (Citation19); prescription of some medications (Citation20); use of laboratory tests; and referral rate to specialists, compared to native colleagues (Citation21). However, these studies are based on self-reported data and are not adjusted for case-mix, i.e. potential differences in populations subscribed to immigrant versus native GPs, especially regarding the proportion of immigrant patients.
By using registry data from all legal inhabitants and their GPs in Norway in 2008, the objective is to describe the characteristics of the lists and population subscribed to immigrant GPs in Norway and compare them to those of Norwegian-born GPs.
METHODS
Study design and Selection of study subjects
This study is based on the linkage of two national registers with information about all inhabitants in Norway in 2008: the regular GP Database, and the National Population Register (Statistics Norway). The GP Database is a register with details of all regular GPs in Norway and their lists of patients and is administered by the Norwegian Social Science Data Services. The National Population Register includes details of all registered residents living in Norway and is administered by the Norwegian Tax Administration.
All Norwegian citizens are given a unique personal identification number (ID number) at birth. Foreigners moving legally to Norway to stay for more than six months are also given an ID number. This ID number is necessary to enlist with a GP and is also used in official records. By converting the ID number to a unique pseudonym, the different registers can be linked on an individual level without revealing personal identities to researchers.
The study is part of the project ‘Immigrants’ health in Norway’ located at the Department of Global Public Health and Primary Care, University of Bergen. The Norwegian Data Inspectorate and the Regional committee for medical research ethics approved the project. Linking of records was performed by the Norwegian Prescription Database and the Norwegian Social Science Data Service.
Variables
Following Statistics Norway, an immigrant in this study is defined as a person born abroad with both parents from abroad. Natives are defined as all other inhabitants registered in Norway (including people adopted from other countries, born abroad with one Norwegian parent and born in Norway with both parents from abroad). For some analyses of the patients in the lists, patients born in Norway with both parents from abroad are studied together with immigrants, as indicated. Immigrants were divided according to the following areas of origin: (Citation1) Other Nordic countries; (Citation2) Western Europe; (Citation3) Eastern Europe; (Citation4) Asia (including Turkey), Africa, Latin America; and (Citation5) North America and Oceania. Length of stay was calculated from the time the immigrant is granted a work/residence permit. For logistic analysis, this variable was dichotomized by the median. Other variables from Statistics Norway used were citizenship (Norwegian or not), immigrant category (immigrant versus native, or immigrant and their descendants versus native), country of finalized higher education (Norway or others), annual income (in NOK), and area of residence (centrality). Centrality is defined as a municipality's geographical location in relation to a centre where there are important services (central functions) (Citation22). For the analysis, this variable was dichotomized into peripheral municipality versus all others.
From the regular GP Database, we obtained data regarding GP's and patient's age and gender, and link between each patient and his/her GP. For each GP's practice the mean value for 2008 was calculated for the following variables: maximum number of patients (list limit), actual number of patients in the list, number of patients into and out of the list per three months period, mean salary in NOK for the population in the list (including only those working), proportion of patients with immigrant background (and proportion of their descendants), proportion of immigrant patients from each area of origin as described over, proportion of women, and of patients in age groups 0 to 15 years, 16 to 60 years and older than 60 years. The proportion of immigrant patients and their descendants, as well as the proportion of women and elderly patients in the lists, were dichotomized by the mean values for logistic regression analysis. Also included was whether the GP worked alone or with other colleagues, whether the difference between the desired and the actual number of patients in the list was more or less than 100 patients, the type of payment (salary versus fee for service) and whether the list was open or closed. A list is open until the number of patients reaches the list limit. Whenever the number of patients is 20 under the list limit, the list is automatically opened again. For this study, a list was open or closed as defined per 30 June 2008.
Statistical analysis
Analyses were conducted using SPSS version 20. For the comparison of immigrant and native groups, we used t-test and chi square as required. Statistical significance was set at 5% (P < 0.05). Logistic regression was used to study the influence of the GP's immigrant background on the proportion of patients with immigrant background dichotomized by the mean. Similar analyses were conducted for the proportion of immigrants and their descendants, proportion of women and proportion of elderly patients in the GP's list. Binary logistic regression was also used to study the impact of the GP's immigrant background on the list being closed (versus open); the GP working alone (versus in groups); being paid salary (versus fee for service); and a difference between desired and the actual number of patients more (versus less) than 100 patients. The adjusting variables were GPs’ age, gender and practice centrality.
To study any time trends within the immigrant group, similar analyses as described above were conducted only for immigrant GPs comparing those who had lived up to 12 years (median value) to those who have lived longer in Norway.
RESULTS
All regular GPs in Norway in 2008 and their patients (4 740 904 persons out of approximately 4 800 000 inhabitants) are included in the analyses.
shows the characteristics of the 728 immigrants GPs (18.4%), their lists and the patients on the lists, compared to 3223 native GPs (81.6%). Immigrant GPs as a group were more often women and younger than their non-immigrant colleagues. Although there was no difference in the number of desired patients in the list, immigrants had fewer patients on their lists and larger numbers of patients entering and leaving their lists per three months. Immigrant GPs were nearly twice as likely to be working in rural areas, working alone, receiving salary as opposed to fee-for-service and having open lists compared to native GPs. Immigrant GPs had more immigrants and descendants on their lists, fewer elderly patients and lower mean patient income compared to their native counterparts.
Table 1. Comparison of the characteristics of regular GP's and their lists according to immigrant or native background.
shows the results for the same variables as presented above for immigrant GPs according to their geographical origin. This table reveals great differences between immigrant groups both in gender, personal immigration history and concerning their lists.
Table 2. Characteristic of the immigrant regular GPs working in Norway and their lists in 2008 according to their geographical background.
represents the mean percentage of patients with immigrant background and their descendants according to the GP's immigrant background. The figure shows a greater proportion of immigrant patients among GPs from Asia, Africa, South America and East Europe, not only from patients from the same area, but also from other world regions.
Figure 1. Mean percentage of patients with different immigrant background according to the regular GP's immigrant background (All patients with any immigrant background included).
After adjusting for GP's age, gender and place of work in peripheral (rural) municipalities () immigrant GPs still were three times as likely to have open lists, and twice as likely to be working alone and receiving salary (versus fee-for-service). Immigrants also had fewer elderly patients and more immigrants and descendants of immigrants on their list. However, there was no difference in the percentage of elderly patients between immigrant and native GPs (OR = 1.2; 95% CI: 0.7–1.5), when adjusting in addition for the percentage of patients with immigrant background in the lists.
Table 3. Characteristics of the lists and patients in the lists for immigrant regular GPs compared to native Norwegians. Binary logistic regression. OR and 95% CI.
Among immigrant GPs who had lived in Norway longer than 12 years (median), the difference between the desired and actual number of patients became more similar to that of native GPs and the proportion paid by fee-for service increased, but they still had open lists and worked alone more often than their native colleagues (). The proportion of immigrants and their descendants increased with length of immigrant GPs’ stay in Norway, whereas the proportion of elderly people in the list decreased. When adjusted for the proportion of patients with immigrant background in the lists, however, there was no difference in the proportion of elderly patients in the lists of the immigrant GPs with shorter or longer stay in Norway (OR 0.7; 95% CI: 0.5–1.0).
Table 4. Impact of time living in Norway among immigrant regular GPs (n = 728). Binary logistic regression, OR and 95% CI comparing number of years living in Norway over or under the median (12 years).
DISCUSSION
Main findings
Compared to native GPs, immigrant GPs in Norway are younger, more often women, and more frequently work alone and in rural areas. Even when controlling for these characteristics, our study confirms that regular GPs with immigrant background have a higher proportion of patients with immigrant background and their descendants in their lists, not only from their own culture, but also from other cultures. Immigrant GPs also have difficulties recruiting patients compared to their native colleagues, but his difference seems to become somewhat smaller over time. The fact that some of the case-mix differences between native and immigrant GPs, as age distribution of the patients, disappeared when controlling for the proportion of immigrant patients in the list, suggest that such variables should be taken into account when comparing clinical profiles of GPs with and without immigrant background.
Interpretation of the study
The main strength of this study is that it includes all the GPs and nearly the whole population in the country. There are few studies comparing immigrant and native GPs. In a study conducted in US immigrant GPs were older, and more often practiced in metropolitan areas compared to American GPs (Citation21). A similar study conducted in Canada (Citation23) revealed that immigrant GPs were more likely to be accepting new patients in their practices and to be practicing in rural and isolated communities. Also, in Canada, it has been suggested that immigrant GPs promote health equity by providing care to remote and poor communities that native medical graduates do not find attractive (Citation24). Our results correspond better with the Canadian ones, especially if we understand some groups of immigrants as a population that GPs are not especially fond of (Citation16). However, earlier studies tend to group all immigrant GPs into one group, while our data show great variation among immigrants from the different world regions. Data regarding GPs’ age, gender, Norwegian citizenship, length of stay in Norway, and place of work in rural or metropolitan areas among others, suggest that differences between countries of origin might be as important as differences between immigrant and native GPs.
Immigrants prefer to have GPs from their own culture (Citation12,Citation13,Citation25). A positive impact of common cultural background (cultural concordance) for both the GP and the patient has been described, and seems to be independent of patient-centred communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship (Citation5,Citation25,Citation26). The fact that immigrant GPs in our study not only have more patients from their own world region, but from other parts of the world is, to our knowledge, not described before. Immigrant GPs interviewed in an earlier project considered their own personal experience as immigrants as an advantage to be capable to understand other immigrants wherever they came from (Citation17). Also, the circumstance that immigrant GPs more often have open lists and have fewer patients than they want, might be a reason for immigrant patients who move to Norway to find a place in their lists. Lastly, both increasing proportion of immigrant patients in the lists and lack of patients seem to be related to longer distance to Norway, geographical and cultural, from the GP's country of origin. This may indicate that native Norwegians also prefer to have a cultural-concordant; this is to say Norwegian or Nordic/European born, GP.
Implications
Results found in this study are probably applicable to other European countries with a GP system where the patient can choose her doctor and with high migration rates. As the proportion of patients and GPs with immigrant background increases, these selection mechanisms should be further studied.
Conclusion
Our study confirms that regular GPs in Norway serve different populations depending on their immigrant background and area of origin. Some of the differences become smaller with time, while the proportion of immigrants in their lists seems to increase. There are, however, important differences between immigrant GPs from different areas of the world.
NOTICE OF CORRECTION
The version of this article published online ahead of print on 3 Sep 2013 contained an error on page 4. The heading of was incorrect and also the sub-headings were misplaced. The error has been corrected for this version.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Financial resources
Grant for two months from the Norwegian Medical Association for Ali Raza in 2011. Department of Global Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway for the linking of data.
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