title: Equity in access to health care among asylum seekers in Germany: evidence from an exploratory population-based cross-sectional study.
abstract: BACKGROUND
  Research on inequities in access to health care among asylum-seekers has focused on disparities between asylum-seekers and resident populations, but little attention has been paid to potential inequities in access to care within the group of asylum-seekers. We aimed to analyse the principles of horizontal equity (i.e., equal access for equal need irrespective of socioeconomic status, SES) and vertical equity (higher allocation of resources to those with higher need) among asylum-seekers in Germany.
  
  
  METHODS
  We performed a secondary exploratory analysis on cross-sectional data obtained from a population-based questionnaire survey among all asylum-seekers (aged 18 or above) registered in three administrative districts in Germany during the three-month study period (N = 1017). Data were collected on health care access (health care utilisation of four types of services and unmet medical need), health care need (approximated by sex, age and self-rated health status), and SES (highest educational attainment and subjective social status, SSS). We calculated odds ratios and 95% confidence intervals (CI) in multiple logistic regression models to analyse associations between SES indicators and access to health care under control of need.
  
  
  RESULTS
  We contacted 60.4% (614) of the total asylum-seekers population, of which 25.4% (N = 156) participated in the study. Educational attainment showed no significant effect on health care access in crude models, but was positively associated with utilisation of psychotherapists and hospital admissions in adjusted models. Higher SSS was positively associated with health care utilisation of all types of services. The odds of hospitals admissions for asylum-seekers in the medium and highest SSS category were 3.18 times [1.06, 9.59] and 1.6 times [0.49, 5.23] the odds of those in the lowest SSS category. After controlling for need variables none of the SES indicators were significantly associated with measures of access to care, but a positive association remained, indicating higher utilisation of health care among asylum-seekers with higher SES. Age, sex or general health status were the only significant predictors of health care utilisation in fully adjusted models. The adjusted odds of reporting unmet medical needs among asylum-seekers with "fair/bad/very bad" health status were 2.16 times [0.84, 5.59] the odds of those with "good/very good" health status.
  
  
  CONCLUSIONS
  Our findings revealed that utilisation of health services among asylum-seekers is associated with higher need (vertical equity met). Horizontal equity was met with respect to educational attainment for most outcomes, but a social gradient in health care utilisation was observed across SSS. Further confirmatory research is needed, especially on potential inequities in unmet medical need and on measurements of SES among asylum-seekers.
authors.affiliation: Department of General Practice & Health Services Research, University Hospital Heidelberg, Voßstr.2, Geb. 37, 69115, Heidelberg, Germany. kayvan.bozorgmehr@med.uni-heidelberg.de.
authors.forename: Kayvan
authors.initials: K
authors.lastname: Bozorgmehr
authors.affiliation: Department of General Practice & Health Services Research, University Hospital Heidelberg, Voßstr.2, Geb. 37, 69115, Heidelberg, Germany. Christine.Schneider@stud.uni-heidelberg.de.|Institute of General Practice and Interprofessional Care, University of Tuebingen, Tuebingen, Germany. Christine.Schneider@stud.uni-heidelberg.de.
authors.forename: Christine
authors.initials: C
authors.lastname: Schneider
authors.affiliation: Institute of General Practice and Interprofessional Care, University of Tuebingen, Tuebingen, Germany. stefanie.joos@uni-tuebingen.de.
authors.forename: Stefanie
authors.initials: S
authors.lastname: Joos
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D005858:Germany; D006296:Health Services / Q000706:statistics & numerical data; D006297:Health Services Accessibility; D006304:Health Status; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012036:Refugees / Q000706:statistics & numerical data*; D012923:Social Class; D011795:Surveys and Questionnaires; D055815:Young Adult