**3.1 Study design**

This study was conducted in 2016 and employed a mixed-study research design. Statistics alone may mask differences in actual health service use and the reason people seek professional care; therefore, it is important to combine both qualitative and quantitative approaches. This approach not only allowed the researcher to collect thoughts on culturally diverse health-seeking behaviors via questionnaires, but helped to integrate further in-depth understanding, feelings, reflections, and clarity on the research questions and the topic during interviews.

## **3.2 Study population and sample**

The target population was identified as refugees who reside in the city of Bowling Green, Kentucky (in the United States), from 2012 to 2016, are registered with the International Center, and fit one or more of the following criteria [2]: (a). Have been forcibly displaced outside their native countries with a history of hardship, including war, famine, and violence, (b). Have spent a part of their lives in refugee camps, (c). Have resettled in Bowling Green over the past 5 years (i.e., 2012 to 2016), (d). Have used a healthcare facility (urgent care clinic, ER, hospital, health department) at least once. Based on these criteria the actual target population was 3,371 refugees. As identified in **Table 1**, refugees meeting this criterion include: Afghans, Burmese, Burundians, Congolese, Cubans, Iraqis, Nepalese (Bhutanese), and Somalians. A convenience sample of 110 refugees was gathered from the target population because of the non-static nature of the refugee population and challenges in assembling individuals within each refugee group [2]. Nations represented in the study sample as exemplified by **Table 1** below were, Burma (which are one of the largest refugee group in Bowling Green), Burundi, Democratic Republic of Congo, Cuba, Iraq, Nepal (Bhutan), Somalia and Others (Bosnia, Pakistan, and Saudi Arabia). A purposeful sample of four individuals fluent in English were selected for the individual audio-recorded interviews. They included one Burmese, two Congolese and one Iraqi who had given prior consent. See **Table 1** *(here).*


#### **Table 1.**

*Population and sample percentages per refugee group, 2010–2015.*

#### **3.3 Study instrument**

A questionnaire was developed after an extensive literature search. The questionnaire was based on the Andersen-Newman theoretical framework and centered on factors that influence health service utilization. Participants completed informed consent forms. The final instrument consisted of 27 Likert-type questions, five open ended, 10 yes or no, and 15 demographic or background questions.

A pilot study was conducted to test the validity and reliability of the survey instrument. The participants for the pilot study were non-targeted refugees from two main refugee groups in southcentral Kentucky: the Burmese and Congolese populations. The participants in the pilot study were precise in their feedback of the instrument [2]. The researcher then reviewed the information provided, conducted an exploratory factor analysis to validate the instrument.

Factor analysis was conducted on the pilot data. Data checks confirmed that the distribution closely met assumptions relevant to factor analysis, i.e., the sample size (N = 158) was sufficient to support the maximum number of items (27 items). Cronbach's alpha for each scale demonstrated adequate to strong reliability. Seven factors emerged with two to five items, which produced a high Cronbach's alpha with values ranging from 0.742 to 0.913. Four items on the initial draft of the survey instrument overlapped other items during factor loading: I live near (within 3 miles/5 km) to a healthcare facility (loading as 0.578); I understand all the instructions given by the medical professional (loading as 0.469); I feel frustrated going to a healthcare facility because nobody understands my language (loading as 0.547); There are interpreters in my language at the healthcare facility (loading as 0.460). As these items were deleted from the final questionnaire, the number of items on the final survey instrument was reduced from an initial 31 to 27 [2]. Descriptive statistics for individual items are provided in **Table 2**.

The questionnaire was translated to various immigrant languages for example, Arabic, French, Spanish and Swahili for those who did not understand English. Questionnaires and informed consent forms were distributed at the International Center, the Community Action of Bowling Green, the Neighborhood Community Services, and the Bowling Green Housing Authority.

#### **3.4 Variables**

The rationale for including four independent variables (Predisposing Factors, Enabling Factors, Need-Related Factors, and Cultural Competency of Services) and the dependent variable (Frequency of Use of Healthcare Services scale) was grounded in theoretical and conceptual considerations derived from the Andersen-Newman framework. Three of the four sets of items under the Predisposing Factors were chosen because of their relevance to the cultural identity of refugees: Native Language, Nationality, and Religion are fundamental to any group [2]. The items within Enabling Factors (Number of Years in the U.S., Have Health Insurance, Educational Level, Available Transportation, Make an Appointment, and Friendly Environment) can be expected to influence refugees' attitudes about using available healthcare services. Need-Related Factors (Gender and Age) affect refugees' health status or their individual perceptions on health. Finally, the level of Cultural Competency of Services (Interpreters and Health professionals understand patient's condition) items are related to whether a given healthcare facility was tailored toward meeting refugee health needs [2].

The dependent variable for this study was the Frequency of Use of Healthcare Services scale as defined by the number of times in the past year participants used available healthcare services, such as the emergency room, family planning

*Health Seeking Behaviors among Displaced Populations/Refugees DOI: http://dx.doi.org/10.5772/intechopen.97403*

services, visiting friends and family that were hospitalized, and urgent care centers [2]. The Frequency of Use of Healthcare Services scale consists of 5 items: (a). In the past year, I have visited the emergency room for a life-threatening medical condition "x" number of times, (b). In the past year, I have received family planning services at a healthcare facility (e.g., Contraceptives) "x" number of times, (c). In the past year when sick, I have visited/scheduled an appointment at a healthcare facility "x" number of times, (d). In the past year, I have visited a sick family member or friend at a healthcare facility "x" number of times and (e). In the past year, I have been sick or injured "x" number of times [2].

#### **3.5 Data collection—interview**

Individual interviews were conducted with a subset of the participants who opted to participate in this format of the study. The informal interview involved the researcher recruiting refugees who were fluent in English to prevent translation errors that could introduce study bias and issues with response delays [2]. Four participants one Burmese, two Congolese and one Iraqi consented to be interviewed via audio recordings lasting on average 50 minutes using a set of 13 semi-structured, open-ended questions to explore the various perspectives on culture and health-seeking behaviors among refugees. These questions were developed to explore the cultural characteristics, barriers, need-related health issues, and level of Cultural Competency of Services used with the aid of the Andersen-Newman conceptual model on healthcare service utilization. Although all participants were asked about general community issues, some participants were asked to describe their personal experiences as follow-up.

#### *3.5.1 Data quality control*

The information culled from the questionnaires were reviewed and checked for completeness. The questionnaire was initially prepared in English and later translated into four different languages. It was also pre-tested prior to the actual data collection. Changes to the interview questions included (1) modification of words and sentences used, and (2) reduction in the number of questions asked to avoid redundancy.

#### *3.5.2 Ethics—institutional review board*

Formal letter of approval was obtained from Western Kentucky University Institutional Review Board committee. The respondents were informed about the objective and purpose of the study. Verbal and written consent were obtained from each respondent during data collection.

#### *3.5.3 Data analysis*

Data was analyzed using the Statistical Package for Social Sciences (SPSS) 23 software. Variables which found to be statistically significant at *p < 0.05* were identified as independent cultural predictors of health care service use. Audiorecordings and notes taken during the interviews were transcribed. After listening to the interviews many times, the transcripts were reduced, coded, and categorized into themes, and finally triangulated with the quantitative results.

#### **4. Results—quantitative findings**

The study participants were predominantly female (65%) and identified as Burmese (34.8%). All of them spoke their native language because none identified English as their spoken language. Majority identified with Christianity (71%) as their form of religion [6]. An average of two years in the U.S. indicated that most of the participants were new arrivals to the U.S. Almost all participants (80.2%) identified as having received some form of health insurance policy on arrival to the U.S. See **Table 2**. In addition, a little over a third (36.7%) reported having at least an elementary school education from their home country. A smaller proportion (31.2%) identified as either fully employed or working part-time. Most respondents were married (70%) with at least one child living in the home (53.6%). A large majority used Medicaid (83.87%), which is provided a few months after arrival in the U.S. The results also show that most respondents (55.4%) receive some form of assistance, e.g., Supplemental Nutrition Assistance Program (SNAP) from the U.S. government until they find sustainable jobs [6].

Regarding frequency of use of healthcare services, most of the refugees (83%) indicated that they had not visited the emergency room (ER) for a life-threatening illness; 11% had visited the ER once in the past year [2]. Nearly all refugees surveyed (96%) indicated they had never received family planning services or contraceptives from their health department. This could indicate that some aspect of the respondents' culture (e.g., belief or religion) does not advocate the use of contraceptives or that respondents were reluctant to disclose this information. Nearly half (42%) had visited or scheduled an appointment with a healthcare facility during the past year. Of these, some (17%) had done so at least twice and a few (5%) at least five times. Concerning visiting sick friends or family members at the hospital in the past year, the majority (74%) of those surveyed indicated they had not done so. For those who claimed to have been sick or injured in the past year (32%), some (2%) had been sick six times and one person (1%) indicated being sick at least 20 times [2]. See **Table 2** *(here).*



#### *Health Seeking Behaviors among Displaced Populations/Refugees DOI: http://dx.doi.org/10.5772/intechopen.97403*

**Table 2.**

*Summary descriptive statistics for predisposing, enabling, and needs-related factors.*

Student t-test, ANOVA, and correlation analyses were used to assess the association between the predisposing factors and frequency of healthcare services use. **Table 3** further explains these results. An *F (5, 98) = 4.29, p < 0.001* finding indicates that nationality/ethnicity plays a role in the use of healthcare services within the refugee population in southcentral Kentucky. Religion was not found to significantly influence the use of healthcare services.

The extent of relationship between Frequency of Use of Healthcare Services and identified barriers were assessed. Number of years in the U.S. were categorized into two distinct groups: those living in the U.S. for two years or less and those living in the U.S. three years or more. A significant association was found between those that have lived in the U.S. for over three years and a visiting or scheduling an appointment with a healthcare facility during the past year: and *t* = −2.03, *p* < 0.04, meaning that acculturation plays an important role in service use [6]. More so, a significant association was also observed between the number of years in the U.S. and visiting a friend or family member at a healthcare facility in the past year: *t* = −2.43, *p* < 0.01. There is a measure of familiarity with the units/services of a health facility because of one's level of acculturation [6]**.** The number of years in the U.S. was also found to be significantly associated with respondents' health status in the past year (whether they have been sick or injured) *t* = −2.22, *p* < 0.03. This result indicate that the longer refugees acculturate with their host country, the more likely they become aware of acceptable ill or health seeking behaviors. Thus, demonstrating an increase in service use, literacy, and awareness of available services due to duration of stay [6].

Health insurance coverage and the use of available healthcare services was examined among refugees. A significant association was observed between health insurance coverage and visits to the emergency room in the past year t = −3.35, p < 0.001*.* Also, a significant relation was found between health insurance coverage and visiting a sick family member or friend at the hospital within the last year

#### *Demographic Analysis - Selected Concepts, Tools, and Applications*

t = −3.00, p < 0.003*.* From these findings it can be deduced that possessing a health insurance card to an extent determines access to a health facility [6]**.**

Student t-test was used to assess the cultural competency of services. A significant relationship was found between interpreters and the frequency of use of healthcare services (visited the emergency room in the past 1 year), *t* = 1.92, *p* < 0.05. This means that refugees were more likely to visit a healthcare facility where interpreters were available. Many respondents indicated the presence of interpreters at their local health facility, hence the frequent visits to the emergency room [6]. See **Table 3** *(here).*


#### **Table 3.**

*Associations between dependent variables (frequency of use of health care services) and independent variables: number of years in the US, health insurance, and interpreters.*

#### **4.1 Results—interview findings**

Demographically, the four interview participants included one Burmese, two Congolese and one Iraqi, ranging in age from 38 to 75 years with an average age of 56.5. This group did not provide an exact representation of refugees in Bowling Green. Educational attainment on the average was at least a high school degree from their respective countries, and all four subjects were married [2]. Three of the four were gainfully employed; the 75-year-old Burmese immigrant was retired. The sample consisted of three Christians and one Muslim. The study research questions constituted the framework for exploring the existence of cultural influence on the use of healthcare services through the lens of the four interviews [2]. Central themes identified include: (a) Importance of taking care of one's health, (b) Refugees' barriers to use of available healthcare services, (c) Perceptions on physical and psychological state of health, and (d) Issues of cultural competency of the healthcare system regarding knowledge about foreign disease conditions or ailments.

#### *4.1.1 Importance of taking care of one's health*

All the respondents believed that good health was important for working effectively and contributing one's quota to the American society (being a taxpayer) and the local community, and for paying domestic bills. Besides, good health provides peace of mind and this, in turn, is necessary to maintain their daily activities [2].
