Health Service Use of Migrants in Germany: Investigating the Influence of Migrant Generations, Country of Birth and Language Proficiency

Abstract

Background: Germany has seen a substantial increase in its migrant population over recent decades, with approximately 27% of its population being migrants as of 2022. These migrants come from diverse backgrounds, with variations in their countries of origin, residence status, reasons for migrating, and language skills. Previous research has often overlooked this heterogeneity, treating migrants as a homogeneous group. This can lead to a lack of understanding of their specific patterns of health service use (HSU) and individual needs. Aim: The aim of this thesis was to investigate different measures of HSU and account for the heterogeneity of migrants based on migrant generations, country of birth, and language proficiency. Methods: This thesis leverages data from the German National Cohort (NAKO) and the German Health and Sexuality Survey (GeSiD), two population-based observational studies. HSU was operationalized by measures of utilization, unmet needs, knowledge about preventive services, satisfaction with utilization, and barriers to utilization, while migration background was defined by the nationality and country of birth of the participants and their parents. Statistical analyses were based on multivariable regression models with a theoretical justification of control variables based on theory and implementation through a directed acyclic graph (DAG). Results: We found that first-generation migrants generally had a lower HSU compared to non-migrants, particularly when it comes to preventive services such as the Human papillomaviruses (HPV) vaccination, chlamydia test in the context of a screening program, and colorectal cancer screening. We also found that language proficiency plays a significant role in determining HSU, as those with poor language skills were less likely to utilize health services. Second-generation migrants displayed similar HSU patterns to the non-migrant population, except for a lower uptake of the HPV vaccination. Additionally, migrants reported higher unmet needs for health services in sexual health care. Barriers to access were mainly informal, including language difficulties and shame. Conclusion: The findings underscore the importance of recognizing migrant diversity in health policy and service design. Strategies to improve migrant health access must prioritize overcoming informal barriers and enhancing health literacy, with special attention to the unique needs of first-generation migrants through culturally sensitive and language-inclusive interventions.