Quality of primary care for resettled refugees in the Netherlands with chronic mental and physical health problems: a cross-sectional analysis of medical records and interview data
Marije A van Melle
Martijn M Stuiver
Annette AM Gerritsen
Walter LJM Devill
Department of Public Health, Academic Medical Center, University of Amsterdam
Background: A high prevalence of mental and physical ill health among refugees resettled in the Netherlands has been reported. With this study we aim to assess the quality of primary healthcare for resettled refugees in the Netherlands with chronic mental and non-communicable health problems, we examined: a) general practitioners' (GP) recognition of common mental disorders (CMD) (depression and anxiety, and post-traumatic stress disorder (PTSD) symptoms); b) patients' awareness of diabetes type II (DMII) and hypertension (HT); and c) GPs' adherence to guidelines for CMD, DMII and HT. Methods: From 172 refugees resettled in the Netherlands, interview data (2010-2011) and medical records (n = 106), were examined. Inclusion was based on medical record diagnoses for DMII and HT, and on questionnaire-based CMD measures (Hopkins Symptom Checklist for depression and anxiety; Harvard Trauma Questionnaire for PTSD). GP recognition of CMD was calculated as the number of CMD cases registered in the medical record compared with those found in interviews. Patient awareness of HT and DMII was scored as the percentage of subjects diagnosed by the GP who reported their condition during the interview. GPs' adherence to guidelines for CMD, DMII and HT was measured using established indicators. Results: We identified 37 resettled refugees with CMD of which 18 (49%) had been recognised by the GP. We identified 16 refugees with DMII and 14 with HT from the medical record; 24 (80%) were aware of their condition. Thirty-five out of these 53 (66%) resettled refugees with chronic mental and non-communicable disorders received guideline-adherent treatment. Conclusion: This study shows that awareness in resettled refugees of GP diagnosed DMII and HT is high, whereas GP recognition of CMD and overall guideline adherence are moderate.
According to the United Nations Refugee Agency there
are approximately 75,000 refugees (defined as persons
granted a complementary form of protection and those
granted temporary protection) living in the Netherlands
. When granted a residence permit, asylum seekers
become permit holders and full resettlement is made
possible. Then, resettled refugees are entitled to the
same health care as any other Dutch citizen. Prior to
becoming a permit holder, asylum seekers reside mainly in
reception centres located throughout the Netherlands.
Access to health care is broad but regulated in a different
way: i.e. the first contact point with health services is the
telephone line of the Asylum seekers Healthcare Centre
(GCA), instead of the general practitioner (GP). The GCA
is in charge of directing the health matter to a GP or
another primary healthcare provider. With a (temporary or
definitive) residence permit, resettled refugees (or permit
holders) can make direct contact with their GP (as do the
general Dutch population). In this transition information
from the medical file is transferred to the GP. Generally,
the GP plays a central role as a first contact point in
the organisation and access to healthcare services in
the Netherlands. Access to most specialist health
services can be gained through referral from the GP.
In 20032004, the first wave of this study (T1) on
health and healthcare utilisation of asylum seekers and
permit holders in the Netherlands was conducted among
410 respondents from Afghanistan, Iran and Somalia .
The second wave (T2) evolved subsequently and was
conducted in 20102011 among 172 of those latter
respondents, all of whom had meanwhile obtained a
permit. The data collection used in the second wave was an
exact copy of the first.
Results of the first assessment (T1) showed a high
prevalence of psychiatric disorders, including depression
(68.1%), general anxiety (39.4%) and post-traumatic stress
disorder (PTSD; 28.1%). These numbers far exceeded
worldwide prevalence data (depression 5% , anxiety
10% and PTSD 6.8% ), which is comparable to the
current prevalence in the Dutch population
(depression: 6.1% (5), anxiety 10.1%, and PTSD 1.3%) . This
earlier study confirmed results from international studies
on refugees in Western countries [6-9].
Guideline adherence for CMD the Netherlands is 27
58% , however previous research showed that
refugees with a mental disorder are less likely to receive
adequate care and/or a referral to mental health care
services than the general population, even when
controlled for socioeconomic factors .
Chronic non-communicable conditions are prevalent
among refugees resettled in Western countries [12-14].
Depending on the populations and definitions,
prevalence as high as 15.5% has been reported for diabetes
type II (DMII) and 42% for hypertension (HT) ,
whereas in the native Dutch population this is 4.1% and
51%, respectively . Among Dutch populations of
African descent prevalences of DMII and HT are 46% and
38% respectively . Guideline adherence for DMII and
HT in the Netherlands is 4159% and 60% respectively
; however previous studies found low diabetes control
and low hypertension control in migrant populations,
suggesting inadequate quality of care in these groups [18,19].
In addition, one study found low control rates for diabetes
among refugee populations, suggesting inadequate
quality of care for members of this group . However,
this topic has not yet been thoroughly investigated.
Based on the relatively high disease burden of resettled
refugees in the Netherlands, and the sparse evidence on
primary healthcare for resettled refugees, this study aims
to examine the quality of GP care for resettled refugees
in the Netherlands. We focused on patients with DMII,
HT and symptoms of a common mental disorder (CMD)
because of the relatively high prevalence of these health
problems in our research sample. Only data from the
second wave of the study (T2) were used. We examined
both interview data and GP medical records. Quality of
care can be assessed in several ways. We chose to limit
the assessment of quality of care to the performance of
the practitioner  through guideline adherence.
Rather than limiting the present study to the investigation
of guideline adherence by GPs, we also addressed the
extent to which the GP recognised or diagnosed the three
health complaints (GP-recognition) that are the focus of
this study and the extent to which resettled refugees were
aware of their own chronic disease (patient awareness).
General study design
This study is a cross-sectional analysis of healthcare
medical records and interview data, embedded in a
prospective two-wave longitudinal cohort study on health
and healthcare use by refugees in the Netherlands.
Setting and study population
All 410 respondents of the first wave of the study (T1;
20032004) (for details on recruitment and methods see
[21,22]) were considered eligible for the second wave of
this study (T2). Figure 1 presents an overview of the data
collection process. Of those 410 original respondents,
7 years later, 282 had a valid address in the Netherlands.
Of those 282 respondents, 172 participated in the second
wave of the study (response = 61%, retention rate = 42%).
All respondents in the second wave had meanwhile
become permit holders (Figure 1).
The 172 participants at T2 were also asked for their
permission to collect data from their GP medical records
on the year preceding the interview date. 130
participants signed the informed consent (130/172, 81%).
Finally, 106 (106/130, 82%) complete medical records were
made available from several GP practices.
This study focused on CMD, DMII and HT because of
the widely accepted quality indicators for treatment and
because of the high prevalence of these conditions among
the present study population. Figure 2 shows the process
of patient identification, data extraction and analysis for
CMD, DMII and HT.
Only interviews conducted at T2 were used for the present
study. All interviews were questionnaire based and
conducted in the language of choice of the participants (Dutch,
Dari, Pashto, Farsi or Somali). Interviewers were matched
on gender and ethnic background. The questionnaire
Figure 1 Flowchart of respondents throughout the two waves of the study. T1 had a total of N = 410 respondents, at T2 (the time of this
study) 172 respondents participated in the interviews. 106 medical records were collected. PH = residence permit holders.
was pre-tested in a panel with key-figures from several
ethnical groups, and a random sample of respondents
in this study. In the interview respondents were
questioned about their health and healthcare utilisation.
This included a list of common conditions in medical
and common language.
Socio-demographic variables included in the presented
analyses are: age; gender; country of birth; and educational
level (none; religious school or primary school; secondary
school; higher education; and vocational training and
university). Length of time in the Netherlands since
receiving the permit was also recorded.
GPs medical records
Recognition of common mental disorders The
presence of a CMD was established during the
interview using the Hopkins Symptom Check List
for depression and anxiety (HSCL-25) and the
Harvard Trauma Questionnaire for PTSD (HTQ);
Figure 2 Patient identification and measurement of cases. For Common Mental Disorders, cases are selected in the interview and compared
to the medical record (GP-recognition). Diabetes type II (DMII) and Hypertension (HT) cases are selected in the medical record and compared to
the interview (patient-awareness).
both questionnaires are validated for use in family
practice and within several refugee groups [23-26].
However, the validity and reliability of the translations
of these instruments (Dari, Pashto, Farsi and Somali)
has not been tested in the population included in this
study. We applied widely used cut-off points of
1.75 for the HSCL-25 or 2.5 for the HTQ.
Chronic non-communicable diseases We reviewed
medical records to identify patients with DMII and
HT. A respondent was considered to have DMII
when DMII was found in the problem list and/or
the consultations, and/or when an anti-diabetic
agent was prescribed.
Quality of healthcare
GP recognition of CMD GP recognition was calculated
as the number of CMD cases registered in the medical
record compared to those found in the interviews.
Patient awareness of DMII and HT Patient
awareness of DMII and HT was scored as the
percentage of subjects with DMII or HT diagnosed
by the GP who reported their conditions in the
interview. Participants were explicitly asked to indicate
if they had a chronic condition using a list of chronic
conditions which included DMII and HT. Patient
awareness of DMII and HT were recorded separately.
GPs guideline adherence To evaluate GPs guideline
adherence, we used existing quality indicators based
on the guidelines of the Dutch College of General
Practitioners . Table 1 shows a summary of these
Assessment of guideline adherence in CMD used
a set of indicators used in previous studies on
guideline adherence in treatment of CMD [28-30]
and was defined as: 1) at least five additional GP
consultations within the same illness episode, 2)
and/or short/long-term prescription of
antidepressants, 3) and/or a referral to a mental
Guideline adherence in DMII care was defined as
compliance with at least four of the following eight
rules , including testing in the past year of: 1)
HbA1c; 2) serum LDL cholesterol; 3) plasma
creatinine level; 4) proteinuria; 5) blood pressure
measurement; 6) weight; 7) a foot examination;
and 8) registration of a smoking habit. We used a
strict scoring system of quality indicators (e.g.
when lab done was noted in the record without
specification, the quality indicators HbA1c, serum
LDL cholesterol and plasma creatinine were scored
as negative). To avoid an underestimation of
guideline adherence, we chose a lenient cut-off
value of 4 out of 8 criteria.
Guideline adherence in HT care was defined as
compliance with at least three of the following
five rules  based on the GPs attention paid in
the past year to: 1) (compliance with) therapy; 2)
smoking behaviour (in case of current smoking
or history of smoking); 3) blood pressure
measurement; 4) weight; and 5) lifestyle or
modification thereof (e.g. physical activity advice,
low salt intake, alcohol reduction).
Descriptive statistics were used to present characteristics
of the study groups, compared to characteristics of
nonresponders, and to evaluate GP recognition of CMD,
patient awareness of chronic health problems (DMII and
HT) and guideline adherence in all disorders. Group
differences were tested using Fishers exact test for
categorical data and an independent t-test for continuous data. All
statistical tests were performed as two-tailed and p < 0.05
was considered statistically significant.
Statistical analyses were performed using SPSS 19.0 for
Our project was sponsored by the GGD Nederland
(Association of Community Health Services in the Netherlands).
According to Dutch law, this study was exempt of formal
medical-ethical approval but because of the vulnerable
legal position of asylum seekers [and refugees] formal
approval was obtained before the first wave. Before the
interview at T2 informed consent was obtained from
Table 2 shows the characteristics of these 172 refugees,
divided into groups for which we did and did not
acquire a medical record. There were no significant
differences between these groups, except that Somali
refugees were underrepresented in the group with a
medical record, i.e. 35% of the Somali patients did not
give permission to collect their medical records,
compared to 18% of the Afghan and 13% of the Iranian
Of all the 172 refugees participating in the interviews, the
prevalence of CMD (anxiety, depression and PTSD), DMII
and HT identified in the interview was 34.9% (60/172), 17%
(29/172) and 18% (31/172), respectively.
GP recognition of CMD
Of the 106 respondents for whom we had medical
records, 37 (35%) had symptoms of CMD during the
interview. Of these 37 respondents, the GP recognized a
CMD in 18 (49%). Of the remaining 69 respondents, a
further 6 (9%) were identified as having a CMD in the
Table 1 Indicators for guideline adherence used in our study
1) At least five additional GP consultations within the same illness episode
2) And/or short/long-term prescription of antidepressants
3) And/or a referral to a mental healthcare specialist.
Compliance with at least four of the following eight rules, including testing in the past year
2) Serum LDL cholesterol
3) Plasma creatinine level
5) Blood pressure measurement
6) Weight 7) A foot examination
3) Blood pressure measurement
5) Lifestyle or modification thereof
8) Registration of a smoking habit.
Compliance with at least three of the following five rules based on the GPs attention paid in the past year to
1) (Compliance with) therapy
2) Smoking behaviour (in case of current smoking or history of smoking)
medical record, although they were not identified as
having a CMD diagnosis in the interview (Table 3).
Patient awareness of DMII or HT
Of the 106 respondents with an available medical record,
30 patients were documented to by the GP as having
either DMII or HT. Of these 30 patients, 24 (80%)
indicated awareness of their condition (Table 4). Of the 16
patients documented by the GP as having DMII, 15 (94%)
indicated awareness of their condition. All refugees
reporting DMII in the interview had a DMII diagnosis listed in
their medical record. Of the 14 patients documented by
the GP as having HT, 9 (64%) indicated awareness of their
condition. Ninety-two respondents were not documented
by the GP as having HT. Of these, 7 (8%) respondents
reported to have HT during the interview.
Of the 54 refugees with a GP-diagnosed chronic
disorder listed in the medical record, 35 (65%) were treated
according to healthcare guidelines. Of the 24 refugees
with a CMD diagnosed by the GP, 17 (71%) received
guideline recommended care. Of the 30 refugees with
DMII or HT, 18 (60%) received guideline recommended
care: 10/16 (63%) for DMII and 8/14 (57%) for HT,
diseases was 80% (94% for DMII and 64% for HT). The
GPs adherence to guidelines for CMD, DMII and HT
was 65%. All these percentages are similar to those
found in the general Dutch population [10,17,29,33-35].
Strengths and limitations
A strength of this study is the combination of interviews
and medical records as data source. These two sources
together provide a more comprehensive view on the
process of healthcare provision by the GP, from GP
recognition to patient awareness, to guideline adherence.
To our knowledge, this is the first study focusing on
healthcare for refugees living in a Western country for a
longer period of time. Also, our analyses were
conditionspecific rather than analysing general GP care, which
allows a more focussed quality assessment of GP care.
This study also has some limitations. First, the results
may be hampered by the small sample size, which often
occurs in research on refugees. The prevalence of HT in
the respondent group was lower than expected based on
literature; this might be because healthy participants
were more inclined to give permission to collect their
Also, in the present study, the refugees had lived in
the Netherlands for a considerable period of time, had
good command of the Dutch language, and had a
relatively high education level. Patients with higher health
skills may be more inclined to participate in research
[36,37], which may explain these high percentages of
patient awareness. These factors might limit the
generalisability of these results to other, or more recent, groups
Age in years: mean (SD)
Gender (female): n (%)
Time since permit in years:
Country of origin: n (%)
(n = 105)
(n = 64)
Table 2 Characteristics of the participants (n = 172) with
(n = 106) and without (n = 66) an available medical record
Table 4 Patient awareness of diabetes type 2 (DMII) and
hypertension (HT) among resettled refugees (n = 106)
study. This could have possibly resulted in false positive
and/or false negative case findings.
Finally, the set of adherence indicators we used for CMD
was rather loose compared to the adherence indicators for
DMII and HT; they make no distinction between
treatments. Every treatment (therapy or antidepressants) or
more than five GP observations is seen as guideline
adherence. This ignores the (over) prescription of
antidepressants where psychotherapy would be optimal. Also, it is
possible that a patient had over five appointments with the
GP several in which a patient is returning because they do
not feel their needs have been met, rather than pro-active
follow-up or intervention by the GP.
GP recognition rate of common mental disorders
In previous research, the GP recognition rates for CMD
in the general Dutch population are below 50%
depending on the definition used [29,33,35]. Our study shows a
similar recognition rate of 49%.
Patient awareness of chronic diseases
In the present study, the 80% patient awareness rate for
DMII and HT was much higher than reported in other
studies, ranging from 2960% among Dutch patients
, whereas the reported awareness of HT (64%) was
similar to that in other ethnic populations living in the
Netherlands . No other studies were found reporting
on awareness among patients with DMII. While awaiting
confirmation in future studies, these figures are reassuring.
Guideline adherence by GPs
In this study, the GP guideline adherence for refugee
patients was found to be consistent with other reports of
guidelines adherence in the Netherlands. A systematic
review on guideline adherence in the Netherlands
reported guideline concordant care for 2758% of patients
- Anxiety and/or Depression
(HSCL-25 > 1.75)
PTSD = Post-Traumatic Stress Disorder, HTQ = Harvard Trauma Questionnaire,
HSCL = Hopkins Symptom Checklist, CMD = Common Mental Disorder.
1Proportions denominator, unless indicated otherwise.
of refugees. However, CMD-rates in this subgroup of
172 respondents (47% in 2003) were comparable to the
overall rates found in the first wave of the study (48%;
N = 410), so the respondents in the second wave do not
seem to differ from the respondents in the first wave .
In addition, the translations of the survey tools we
used in the diagnoses of CMD were not validated which
may have implications for the diagnosis of CMD in this
Table 3 GPs recognition of chronic mental disorders
(CMD)1; number of cases of CMD identified in the
interview and as registered by the GP in the medical
in medical record
1PTSD, depression or anxiety.
with a CMD, 4159% for those with DMII, and 60% in
the HT group . This latter study suggests that no
specific barriers exist in the use of GP services for
refugees with chronic conditions compared to the Dutch
Unfortunately, we found no international studies on the
quality of primary care for resettled refugees in Western
countries. To our knowledge, ours is the first study
focusing on healthcare for refugees living in a Western
country for a longer period of time. International studies
on quality of care in minorities and refugees show that
these groups are less likely to receive adequate care
[11,18,19]. We can only speculate why our study shows
a comparable quality of care to the native Dutch
population in our population of resettled refugees. Our refugee
population had lived in the Netherlands for a
considerable period of time, had good command of the Dutch
language, and had a relatively high education level.
Patients with higher health skills in general are more inclined
to participate in research. This can create a selection bias
and explain our results. Another possibility is that barriers
experienced by more recently arrived refugees (e.g.
affordability, poor health literacy and understanding of the health
system, medical mistrust, discrimination, and linguistic and
cultural factors)  reduce through time. Refugees learn
the language, culture and get to know the Dutch health
care system. They build a relationship with their GP, which
Our results are of interest for all countries with a
primary care-based healthcare system and we recommend
further research on this resettled population, especially
in view of the constant flow of refugees over time.
The results of this study indicate that GP recognition of
CMD, patient awareness of chronic non-communicable
diseases, and guideline concordant care by the GP for
resettled refugees with chronic health problems, is
neither better nor worse than the care for ethnic Dutch
patients. Nevertheless, GP awareness of the high prevalence
of CMD (and especially PTSD) in this population could
be further improved, together with overall patient
awareness of HT.
Future research should combine assessment of
primary healthcare provision for (resettled) refugees, native
Dutch and other Dutch ethnicities in a matched
controlled study to further explore known barriers and
Our study shows that awareness among resettled
refugees of GP diagnosed DMII and HT is high, whereas GP
recognition of CMD and overall guideline adherence are
Recognition, awareness and guideline adherence were
in concordance with that of the general Dutch
population. However, GP recognition and patient awareness of
CMD and HT are not yet optimal in either the refugee
or the general patient population.
MM, ML, MS, AG, WD and ME conceived the study. MM developed the
protocol. ML and ME closely supervised the protocol development. MS
contributed to the protocol development. MM retrieved the data from
medical records. MM analysed the data, interpreted the results and wrote
the first draft of the manuscript. ML and ME supervised the analysis and
interpretation of the results. All authors participated in reviewing and editing
of various drafts of the manuscript and they all read and approved the final