Length of stay, acculturation and transnational medical travel among Polish migrants in the Netherlands

Abstract

An important aspect of the transnational lives of Polish migrants in the Netherlands is their frequent use of healthcare services in Poland. Transnational care use may be detrimental for the continuity and the quality of the care migrants receive. The current study aims to shed light on the antecedents of migrants' doctor visits in Poland. Drawing on a representative population-based sample of Polish migrants in the Netherlands (n = 1,082), logistic regression is used to assess whether length of stay in the Netherlands is negatively associated with the likelihood of doctor visits in Poland. The KHB decomposition method is used to determine the extent to which this potential association is mediated by three specific acculturation factors: ethnic identification, trust in the Dutch healthcare system and Dutch language proficiency. The models show that migrants who stayed in the Netherlands longer were less likely to visit doctors in Poland. Mediation analyses indicated that this effect was largely attributable to their greater Dutch language proficiency compared to their counterparts who arrived in the Netherlands more recently. Strong ethnic self-identification as Polish and lower trust in the Dutch healthcare system were also associated with a higher likelihood of visiting doctors in Poland. However, no significant mediation of the effect of length of stay via ethnic self-identification or Dutch language proficiency was found. The findings suggest that voluntary language programs may foster inclusion of Polish migrants in the Dutch healthcare system and reduce the need migrants perceive to seek care in their country of origin.

Full text

       
                  

Length of stay, acculturation and transnational medical travel
among Polish migrants in the Netherlands
Thijs van den Broek
Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, the Netherlands
ARTICLE INFO
Keywords:
Transnationalism
Patient mobility
Medical tourism
Health care seeking behavior
Cross-border healthcare
ABSTRACT
An important aspect of the transnational lives of Polish migrants in the Netherlands is their
frequent use of healthcare services in Poland. Transnational care use may be detrimental for the
continuity and the quality of the care migrants receive. The current study aims to shed light on
the antecedents of migrants’ doctor visits in Poland. Drawing on a representative population-
based sample of Polish migrants in the Netherlands (n =1,082), logistic regression is used to
assess whether length of stay in the Netherlands is negatively associated with the likelihood of
doctor visits in Poland. The KHB decomposition method is used to determine the extent to which
this potential association is mediated by three specic acculturation factors: ethnic identication,
trust in the Dutch healthcare system and Dutch language prociency. The models show that
migrants who stayed in the Netherlands longer were less likely to visit doctors in Poland.
Mediation analyses indicated that this effect was largely attributable to their greater Dutch lan-
guage prociency compared to their counterparts who arrived in the Netherlands more recently.
Strong ethnic self-identication as Polish and lower trust in the Dutch healthcare system were
also associated with a higher likelihood of visiting doctors in Poland. However, no signicant
mediation of the effect of length of stay via ethnic self-identication or Dutch language pro-
ciency was found. The ndings suggest that voluntary language programs may foster inclusion of
Polish migrants in the Dutch healthcare system and reduce the need migrants perceive to seek
care in their country of origin.
Introduction
The number of migrants of Polish origin in the Netherlands has been rising rapidly since Poland became a member of the European
Union. The number of migrants of Polish origin in the Netherlands increased from less than 36,000 in 2004 to almost 200,000 in 2020
(Source: Statistics Netherlands). Luthra, Platt, and Salamo´
nska (2016) noted that relatively many Polish migrants in the Netherlands
can be labelled “committed expats”, as they tend to be committed to an international life from the very onset of their migration. While
actively developing a new life in the Netherlands, they also maintain multiple linkages to their country of origin (cf. Schiller, Basch, &
Blanc, 1995). For instance, they tend to maintain strong bonds and frequent contact with parents and family in Poland (Conkova, 2019;
Karpinska & Dykstra, 2019) and a large majority frequently consumes Polish online and traditional media (Gijsberts, Andriessen,
Nicolaas, & Huijnk, 2018). The current study focuses on a different aspect of the transnational lives that many Polish migrants in the
Netherlands live, namely transnational medical travel.
Polish migrants in the Netherlands are known to frequently visit doctors in their country of origin (Gijsberts et al., 2018). Such
E-mail address: vandenbroek@eshpm.eur.nl.
Contents lists available at ScienceDirect
International ournal of Intercultural Relations
journal homepage: www.elsevier.com/locate/ijintrel
https:doi.org10.1016j.ijintrel.2021.08.002
Received 23 September 2020; Received in revised form 21 uly 2021; Accepted 2 August 2021

       
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transnational medical travel may be detrimental for the continuity of the care they receive (cf. Kemppainen, Kemppainen, Skogberg,
Kuusio, & Koponen, 2018). Haggerty et al. (2003) dened continuity of care as “the degree to which a series of healthcare events is
experienced as coherent and consistent with the patient’s medical needs and personal context” (p. 1221). When migrants use health
care services in the country of origin in addition to the destination country, then this may hamper the exchange of information between
the different care providers who interact with them. It may also be a barrier to the consistency and coherence of the management of the
treatment of health conditions they may have, and to relational continuity between patient and provider (Haggerty et al., 2003).
Together, this may result in suboptimal quality of the care these migrants receive.
Scholars have pointed out the substantial within-group differences in migrants’ use of healthcare services (Leduc & Proulx, 2004;
Osipoviˇ
c, 2013). Research on drivers of transnational medical travel among migrants has been mostly qualitative (illa-Torres et al.,
201). Although ndings from this qualitative work by design cannot be generalied, the thick descriptions provided by these studies
have highlighted various factors that may shape migrants’ tendency to visit doctors in their country of origin. Most notably, the
qualitative work suggest that the likelihood of doctor visits in the country of origin declines with increasing length of stay in the
receiving country. The current study aims to extend this qualitative work by testing in population based sample of Polish migrants
whether length of stay is indeed systematically negatively associated with the likelihood of visiting doctors in the country of origin, and
by exploring the mediating role of acculturation factors in this association.
Theoretical bacround and hothee
Approximately one in four migrants of Polish origin in the Netherlands frequently use health care services in Poland (Gijsberts
et al., 2018). The use of health care services in the country of origin is also high among migrants of Polish origin residing in other
Western-European countries, such as the United Kingdom (Horsfall, 2019; Osipoviˇ
c, 2013) and Norway (Capka, 2010). Osipoviˇ
c
(2013) emphasied the marked differences in healthcare utiliation patterns within the group of Polish migrants in the United
Kingdom, with some subgroups having a strong tendency to seek health care in the country of origin and others not. In particular, she
pointed to differences between migrants who recently arrived in the destination country and migrants who had been in the destination
country for several years, and argued that “it is crucial to include the aspect of change over time in studies of migrant health care
seeking behavior” (p. 111). Capka and Sagbakken (2016) also noted that migrants of Polish origin in Norway tended to adapt their
health care seeking practices over time. Navigating the health care system of the destination country can be especially challenging for
recently arrived migrants (Leduc & Proulx, 2004), which may make the use of health care services in the country of origin particularly
attractive for them. Therefore, it may be expected that length of stay in the Netherlands is negatively associated with the likelihood of
visiting doctors in Poland (Hypothesis 1).
The association between length of stay in the Netherlands and Polish migrants’ likelihood of visiting doctors in the country of origin
may, in part, be expected to run via acculturation factors. Acculturation refers to the extent to which migrants over time may (or may
not) (a) learn behaviors from the new culture and (b) shed features of their original culture (Berry, 1992). Berry’s (1992, 2005) seminal
acculturation model distinguishes four acculturation strategies that vary on these two dimensions. The integration strategy is char-
acteried by high maintenance of the heritage culture in combination with strong participation in the larger society of the destination
country. In the marginalization strategy, maintenance of the heritage culture and participation in the destination society are instead
both weak. Migrants adopting an assimilation strategy aim to establish relations in the larger society of the destination country, while
doing little to maintain their heritage culture and identity. The opposite is the case for migrants adopting a separation strategy.
Acculturation is not just multidimensional in terms of the independence of the orientations towards the heritage culture and to-
wards the culture of the destination country, but also with regard to its various subdomains, whereby identication, values and
practices can be distinguished (Schwart, Unger, amboanga, & Sapocnik, 2010). Ethnic identity refers to the extent to which
persons explored what their ethnic group means to them, and to the extent they feel attached to their ethnic group (Phinney, 1990). It
may be expected that migrants in the Netherlands who identify strongly as Polish have a relatively strong tendency to visit doctors in
Poland. This is illustrated by a migrant of Polish origin in the UK quoted in Goodwin, Polek, and Goodwin’s (2013) study who preferred
a hospital stay in Poland over one in the UK, and expressed that the reason for this was that “when someone is ill, he wants to be .. at
home’’ (p. 164). Given that Polish migrants may identify more strongly with destination country with increased length of stay (Diehl,
Fischer-Neumann, & Mhlau, 2016), it may therefore be hypothesied that the negative association between length of stay and the
likelihood of visiting doctors in Poland is (partly) attributable to differences in ethnic identication (Hypothesis 2).
With increased length of stay in the destination country, migrants’ cultural values and beliefs may also change (Schwart et al.,
2010). Given the focus of the current study on health care services use, values regarding health care provision may be particularly
relevant here. When migrants arrive in the destination country, they bring particular values and beliefs about how health care services
should be provided and they tend to compare local healthcare practices with those in the healthcare practices in the country of origin
(Goodwin et al., 2013; Leduc & Proulx, 2004; Sime, 2014). When aspects of the healthcare system in the destination country do not
correspond with their values and beliefs and what they are used to, this may result in skepticism and distrust towards the destination
country’s healthcare system. Sime (2014) has argued that “distrust towards the effectiveness of care … may lead many migrants to
view health care in transnational terms as a better and safer’ approach, rather than to rely on local provision” (p. 92) (cf. Capka &
Sagbakken, 2016; Goodwin et al., 2013).
Aspects of the Dutch healthcare system that migrants of Polish origin may have reservations about – and that thus may lower Polish
migrants’ trust in the Dutch healthcare system – are the role of the general practitioner (GP), antibiotics prescription practices, and the
style of communication between physicians and patients. In the Dutch healthcare system, the GP serves as a gatekeeper. This means
that a referral from the GP is required for inpatient hospital care (Boerma, an der ee, & Fleming, 199; Kroneman, 2011).
T. van den Broek

       

ualitative studies conducted in Norway (Capka & Sagbakken, 2016) and the United Kingdom (Madden, Harris, Blickem, Harrison, &
Timpson, 201), where the GP also has a gatekeeping role (Kroneman, 2011), suggest that many Polish migrants do not appreciate this
way of organiing the healthcare system. Many migrants of Polish origin reportedly dislike it when GPs treat a broad spectrum of
diseases, because, in their view, a lack of specialiation is likely to negatively affect the quality of the doctors’ work (Capka &
Sagbakken, 2016). Also, migrants sometimes perceive it as a cost-cutting measure and a sign of inefciency when the GP acts as a
gatekeeper restricting access to specialists (Sime, 2014). Madden et al. (201) even noted resentment among several of their
Eastern-European respondents in the United Kingdom about the power held by the GP, and the way this limited their access to the
specialist care they felt they needed.
In addition to the gatekeeping role of the GP, antibiotics prescription practices are much more restrictive in the Netherlands than in
Poland (Goossens, Ferech, ander Stichele, & Elseviers, 2005; Kroneman et al., 2016). A larger reluctance of GPs to prescribe anti-
biotics is sometimes perceived by migrants as unhelpful and dismissive (Madden et al., 201). Capka and Sagbakken (2016) noted
that “some Polish migrants equate serious treatment by a physician with a prescription” (p. 9) and that a reluctance to prescribe can
undermine Polish migrants’ trust and condence in the health care system of the destination country.
Moreover, patient-GP communication in the Netherlands has become notably more egalitarian since the late 20th Century (Butalid,
erhaak, Boeije, & Bensing, 2012). Although qualitative studies suggest that some migrants of Polish origin appreciate the egalitarian
patient-GP communication in Norway and the United Kingdom (Capka & Sagbakken, 2016; Goodwin et al., 2013), a GP commu-
nication style that is less authoritarian than what Polish migrants are used to in their country of origin may also raise a sense of cultural
unease and doubts about the GP’s competence (Osipoviˇ
c, 2013).
alues and beliefs about how health care services should be provided, and therefore the discrepancy between these values and
beliefs and the way the healthcare system of the destination country works, may change with increased length of stay in the destination
country. Madden et al. (201), for instance, noted that some of their respondents said they had become more open to the United
Kingdom’s approach to self-care and medication use after staying in the country for several years, despite having strong reservations
when they rst arrived. Similarly, Capka and Sagbakken (2016) observed that many migrants of Polish origin who had been in
Norway for many years had changed their views about the use of antibiotics among children. Polish migrants may also increasingly
appreciate physicians’ more friendly and egalitarian communication with patients (Capka & Sagbakken, 2016; Goodwin et al., 2013;
Sime, 2014). All this may make Polish migrants who stayed in the Netherlands longer reappreciate the Dutch healthcare system,
resulting in waning distrust. Consequently, it may be expected that the negative association between length of stay and the likelihood
of visiting doctors in Poland is (partly) attributable to differences in trust in the Dutch healthcare system (Hypothesis 3).
Finally, language is a key aspect of the cultural practices subdomain of acculturation (Schwart et al., 2010; Solis, Marks, Garcia, &
Shelton, 1990). Migrants’ Dutch language prociency tends to improve with increasing length of stay (Geurts & Lubbers, 201). Dutch
language prociency improvements may, in turn, result in a declining tendency over time to seek health care in the country of origin,
as qualitative studies suggest that language barriers are a driver for migrants’ transnational medical travel (illa-Torres et al., 201).
Sime (2014) argued, for instance, that limited language prociency harmed migrants’ ability to nd information on health services (cf.
Osipoviˇ
c, 2013) and the quality of their interactions with medical practitioners (cf. Goodwin et al., 2013), and that this made some of
them feel more reassured when they used healthcare services in the country of origin. In a similar vein, Capka and Sagbakken (2016)
described how Polish migrants in Norway preferred to visit doctors in their country of origin, rather than in the destination country,
because they felt “more secure at the doctor’s in terms of linguistic competence” (p. ). These considerations lead to the expectation
that the negative association between length of stay and the likelihood of visiting doctors in Poland can (partly) be explained by
language prociency differences (Hypothesis 4).
ata and ethod
Sample
The data used in the current study are from the Survey Integration Minorities (SIM) (Dutch: Survey Intergratie Minderheden). SIM is a
repeated cross-sectional survey aimed at providing insights on the structural and socio-cultural position of people with a migration
background in the Netherlands (an Thiel, Hooijmans, Schothorst, & Roema, 2015). The study was commissioned by the Dutch
Ministry of Social Affairs and Employment and conducted by the Netherlands Institute for Social Research, with data collection taking
place at intervals of approximately ve years. The third round of SIM (SIM2015) was collected between anuary and une 2015. In
contrast to prior SIM rounds, the third round data was also collected among a subsample of migrants of Polish origin. Other groups
interviewed were people with Turkish, Moroccan, Surinamese, Antillean, Somali and native Dutch backgrounds.
Statistics Netherlands provided a sample of Polish-born adults aged 15 and older who registered in a Dutch municipality after
anuary 2004 to facilitate data collection among the Polish subsample of the SIM2015 survey. It is important to note that, in the
Netherlands, newcomers with the intention of staying longer than four months are required to register in the municipality where they
reside. 1,129 migrants of Polish origin participated in the survey (response rate: 44. ). Two modes of data collection were used: a
web survey (53.2 ) and computer-assisted face-to-face interviews (46.8 ). Regardless of the mode of data collection, respondents
could choose to participate in a Polish language version (84.1 ) or a Dutch language version (15.9 ) of the survey.
The Polish origin subsample contained 4 respondents (4.2 ) with missing values on at least one variable of interest: ethnic self-
identication (n =21), reported experiences of discrimination (n =13), length of stay (n =8), and educational attainment (n =6).
After listwise deletion a nal analytical sample of 1,082 respondents remained. Supplied analytical weights were used to adjust for
systematic non-response.
T. van den Broek

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Measures
Outcome variable
The outcome variable of interest is whether or not respondents had visited a doctor in Poland in the last year. Respondents were
asked whether they had visited Poland in the 12 months prior to the interview. Those who answered afrmatively were subsequently
asked whether they had been to Poland in the last 12 months to visit a doctor. Based on these two questions, a dichotomous variable
was derived. Respondents who reported having visited doctor in Poland in the last 12 months were coded as 1 and their counterparts
who reported not having been to Poland in the last 12 months, or having been to Poland in the last 12 months, but not having visited a
doctor while being there were coded as 0.
Explanatory variables
Length of stay in the Netherlands was included as a continuous variable. It was derived by deducting the year in which respondents
reportedly moved to the Netherlands for the rst time from the year in which the interview took place. A log transformation was
performed to account for the strongly positively skewed distribution of this variable.
Ethnic self-identication was measured with a single question: “Do you more strongly feel Polish or Dutch”. Respondents who
answered that they felt “completely Polish or more Polish than Dutch were coded as self-identifying strongly as Polish. Respondents
who answered that they felt “as much Polish as Dutch”, “more Dutch than Polish” or “completely Dutch” were coded as not self-
identifying strongly as Polish.
Trust in the Dutch healthcare system was measured with a single question “How much trust do you currently have in the healthcare
system in the Netherlands” Respondents were asked to indicate their level of trust on a 10-point scale, with a score of one indicating
“very little trust” and a score of ten indicating “very high trust”.
With regard to language skills, respondents were asked “How often do you have language difculties when having a conversation in
Dutch” Response categories were “often”, “sometimes” and “never”. Respondents could also indicate that they did not speak Dutch at
all. Respondents for whom this was the case – approximately 13 percent of the Polish origin sample – were coded as having difculties
with the Dutch language often.
Control variables
A range of potential confounders were controlled for to reduce the room for bias in the estimates of the effects of interest. These are
variables that are plausibly predictive of healthcare visits to Poland as well as of one or more of the explanatory variables of interest
(length of stay, trust in the Dutch healthcare system, and language prociency). Failure to account for such variables may bias results,
because estimates of effects of interest may be attributable to the confounders.
Health status determines the need for care, which is, in turn, one of the most important antecedents of health care services use
(Andersen & Newman, 193). Although Polish migrants in the Netherlands tend to have relatively good mental and physical health in
comparison to the general Dutch population without a migration background (Dagevos, 2011; Gijsberts et al., 2018), research has
shown that health and psychosocial wellbeing declines with enduring length of stay (Lubbers & Gijsberts, 2019; an den Broek &
Grundy, 201). A dichotomous variable distinguishing respondents who reported having “good” or “very good” health from their
counterparts who reported that their health was “fair”, “bad” or “very bad” was therefore included.
Experiences of discrimination is a known antecedent of healthcare use in the country of origin (Goodwin et al., 2013; Kemppainen
et al., 2018). It also has a complex interrelation with length of residence in the destination country. Migrants in the Netherlands tend to
report more experiences of discrimination with increased length of stay (McGinnity & Gijsberts, 2018). However, there is also evidence
that experiences of discrimination are associated with return migration (ilma Sener, 2019), which may imply out-selection of mi-
grants subjected to experiences of discrimination among those with lengthy residence spells in the destination country. Respondents
were asked how often they had personally experienced discrimination by Dutch persons. Response categories were “never”, “almost
never”, “now and then”, “often” and “very often”. Categories were collapsed, whereby respondents who reported that they “never” or
“almost never” had experienced discrimination by Dutch persons were distinguished from their counterparts who reported having
experienced discrimination at least now and then.
In addition to these potential confounders, a range of basic socio-demographic background characteristics will also be adjusted for.
In addition to a dichotomous variables for sex (women vs men), employment status (currently in paid employment vs not currently in
paid employment) and partner status (partnered vs unpartnered), and categorical variables for age, educational attainment, and level
of urbaniation were included in the models. Age categories were 24 and younger; 25−34 years old; 35−44 years old; and 45 years and
older. Three categories of educational attainment were distinguished: none or low; intermediate; and high. These categories were pre-
coded. The more detailed information on education followed in Poland as well as in the Netherlands on which the pre-coded values
were based was not made available in the public release version of the SIM2015 dataset. Level of urbaniation of the municipality of
registration was originally measured with a ve-category classication: very strongly urbanied; strongly urbanied; moderately
urbanied; weakly urbanied; rural. Given the lower numbers of respondents in the latter three categories these were collapsed into
one category for low level of urbaniation.
Methods
In addition to basic univariate and bivariate descriptive analyses, a series of logistic regression models were estimated. In the rst
model, the likelihood of healthcare visits to Poland was regressed on length of stay in the Netherlands and the aforementioned range of
T. van den Broek

       
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control variables. In subsequent models the proposed mediators (ethnic self-identication, trust in the Dutch healthcare system and
Dutch language prociency) were added. Karlson, Holm and Breen’s KHB decomposition method (Kohler, Karlson, & Holm, 2011) was
used to formally test the extent to which the effect of length of stay on the likelihood of healthcare visits to Poland was mediated by,
respectively, ethnic self-identication, trust in the Dutch healthcare system and Dutch language prociency. The KHB method is
suitable for the analysis of mediation in logistic regression and other non-linear models, because it accounts for attenuation bias that
may occur in such models.
eult
Descriptive results
Sample characteristics are provided in Table 1. One in four respondents reported having visited a doctor in Poland in the year prior
to the interview. The group that had visited a doctor in Poland differed from the group that had not done so in several ways. Compared
to their counterparts who had not visited a doctor in Poland, migrants who had embarked on such doctor visits, on average, had stayed
in the Netherlands for a shorter period and had lower trust in the Dutch health care system. Also, a relatively large share of this group
reported identifying strongly as Polish and having severe difculties with the Dutch language. They also relatively often reported
having had personal experiences of discrimination. Furthermore, migrants who had visited a doctor in Poland were relatively often
female, highly educated and in less than good health.
Results of multivariate analyses
Table 2 presents the results of the logistic regression analyses. In Model 1, the likelihood of healthcare visits to Poland was regressed
on length of stay in the Netherlands and a range of controls. As hypothesied, results indicated that length of stay was associated with a
lower likelihood of having visited a doctor in Poland in the last year. Adjusted predictions are presented in Fig. 1 to facilitate an easier
interpretation of the magnitude of this effect. These were calculated by setting the value of length of stay at distinct values while using
observed values for each case for all other covariates included in Model 1. Based on these xed and observed values of variables, the
predicted probability of healthcare visits to Poland was then derived for each case, and subsequently the predicted values of all cases
Table 
Sample characteristics; Percentages and means.
All respondents visited doctor in Poland did not visit doctor in Poland Group difference
isited doctor in Poland 24.1 
Mean length of stay
a
6.3 5. 6.6 F(1, 1080) =10.6, p <.01
(standard deviation) (3.) (3.0) (3.9)
Self-identies strongly as Polish 8.0  88.5  4.6 
χ
2
(1, n =1082) =19.3, p <.001
Mean trust in Dutch healthcare system 6.8 6.0 .0 F(1, 1080) =36.2, p <.001
(standard deviation) (2.5) (2.) (2.3)
Dutch language prociency
χ
2
(2, n =1082) =15.5, p <.001
Severe language problems 48.3  58.3  44.5 
Moderate language problems 40.4  35.1  42. 
No language problems 11.3  6.  12.8 
Female 51.6  64.8  4.4 
χ
2
(1, n =1082) =18.8, p <.001
Age:
χ
2
(3, n =1082) =20.0, p <.001
<=24 13.2  13.2  13.2 
25−34 48.2  60.0  44.4 
35−44 24.2  1.2  26.4 
>=45 14.4  9.6  15.9 
Has partner 1.3  0.  1.5 
χ
2
(1, n =1082) =0.1, p =.82
In paid employment 6.3  80.4  5.0 
χ
2
(1, n =1082) =2.9, p =.09
Educational attainment:
χ
2
(2, n =1082) =18.2, p <.001
Low 39.0  32.3  41.0 
Mid 3.9  34.0  39.1 
High 23.1  33.6  19.8 
Level of urbaniation
χ
2
(2, n =1082) =3.2, p =.20
Low 44.4  42.9  44.9 
Mid 24.4  21.5  25.4 
High 31.1  35.6  29. 
Poor self-reported health 15.8  20.6  14.3 
χ
2
(1, n =1082) =4.1, p <.05
Experiences of discrimination 46.1  54.4  43.5 
χ
2
(1, n =1082) =8.0, p <.01
Number of cases 1,082 253 829
Notes: Data are from Survey on the Integration of Minorities (SIM) 2015; n =1,082; data are weighted.
a
Before log transformation.
T. van den Broek

       

Table 
Coefcient estimates from logistic regression analyses of medical visits to Poland.
Model 1 Model 2 Model 3 Model 4
Coeff. 95  CI Coeff. 95  CI Coeff. 95  CI Coeff. 95  CI
Length of stay (log) −0.412 −0.1,
−0.10
−0.315 −0.628,
−0.003
−0.362 −0.6,
−0.04
−0.148 −0.494,0.198
Female 0.0 0.359,1.056 0.35 0.384,1.085 0.683 0.330,1.035 0.00 0.345,1.056
Age:
<=24 Ref. Ref. Ref.
25−34 0.225 −0.309,0.58 0.204 −0.334,0.43 0.223 −0.333,0.80 0.083 −0.4,0.643
35−44 −0.368 −0.984,0.24 −0.34 −0.998,0.250 −0.300 −0.940,0.341 −0.448 −1.094,0.199
>=45 −0.361 −1.013,0.291 −0.343 −1.009,0.322 −0.240 −0.923,0.443 −0.450 −1.145,0.244
Has partner −0.15 −0.533,0.219 −0.1 −0.553,0.200 −0.213 −0.592,0.165 −0.259 −0.639,0.121
In paid employment 0.495 0.08,0.903 0.433 0.023,0.844 0.424 0.006,0.842 0.429 0.013,0.846
Educational
attainment:
Low Ref. Ref. Ref.
Mid 0.09 −0.280,0.44 0.111 −0.269,0.490 0.094 −0.292,0.480 0.118 −0.26,0.504
High 0.643 0.234,1.052 0.646 0.232,1.061 0.60 0.19,1.018 0.63 0.253,1.092
Level of urbaniation
Low Ref. Ref. Ref.
Mid −0.140 −0.561,0.281 −0.166 −0.590,0.258 −0.13 −0.59,0.251 −0.14 −0.600,0.253
High 0.286 −0.03,0.644 0.23 −0.088,0.633 0.262 −0.103,0.62 0.25 −0.111,0.625
Poor self-reported
health
0.625 0.205,1.044 0.60 0.24,1.093 0.652 0.215,1.088 0.616 0.1,1.054
Experiences of
discrimination
0.433 0.116,0.49 0.39 0.08,0.16 0.26 −0.059,0.592 0.262 −0.066,0.589
Strongly self-identies
as Polish
0.883 0.450,1.31 0.842 0.401,1.283 0.694 0.245,1.144
Trust in Dutch
healthcare system
−0.118

−0.183,
−0.053
−0.121

−0.18,
−0.055
Dutch language
prociency
Severe lang.
problems
Ref.
Moderate lang.
problems
−0.419 −0.2,
−0.066
No language
problems
−0.854 −1.495,
−0.212
Intercept −1.636

−2.412,
−0.861
−2.41

−3.33,
−1.606
−1.45 −2.484,
−0.466
−1.34 −2.368,
−0.32
Pseudo R
2
(McFadden) .06 .092 .104 .112
BIC 81,683.1 80,351.4 9,305.6 8,550.6
Notes: Data are from Survey on the Integration of Minorities (SIM) 2015; n =1082; data are weighted; coefcient estimates with 95  condence
intervals in brackets.

p <0.05.

p <0.01.

p <0.001.
i  Predicted probability of health care visits to Poland by length of stay.
T. van den Broek

       

were averaged. All this was done using the margins postestimation command in Stata 15.1 (Williams, 2012).
Model 1 furthermore showed that doctor visits in Poland were more likely for women than for men. Polish migrants with high
educational attainment and those in paid employment were furthermore more likely to have visited doctors in Poland than their lower
educated and non-employed counterparts. Finally, poor self-rated health and personal experiences of discrimination were associated
with a higher likelihood of doctor visits in Poland.
Ethnic self-identication was added as an explanatory variable in Model 2. The model showed, as expected, that doctor visits to
Poland were more likely for migrants who identied strongly as Polish than for their counterparts with a weaker self-identication as
Polish. After the addition of ethnic self-identication, the coefcient estimate of length of stay became somewhat smaller in magni-
tude, but the KHB procedure did not show evidence of signicant mediation (Δb = −0.11; 95  CI: −0351, 0.116; p =.324). No
support was thus found for the second hypothesis that the negative association between length of stay and the likelihood of visiting
doctors in Poland could (partly) be attributed to differences in ethnic self-identication. Estimates of the control variables included in
the model did not change substantially either between Model 1 and Model 2.
Model 3 also included trust in the Dutch healthcare system as an additional explanatory variable. Consistent with expectations, the
model showed that Polish migrants with a higher level of trust in the Dutch health care system were less likely to have visited a doctor
in Poland in the last year. However, the addition of trust in the Dutch healthcare system did not attenuate the estimated effect of length
of stay and the KHB procedure did not show evidence of signicant mediation (Δb =0.033; 95  CI: −0.145, 0.211; p =.1). The
hypothesis that the negative association between length of stay and the likelihood of visiting doctors in Poland could (partly) be
attributed to differences in trust in the Dutch healthcare system was thus not supported. No substantial changes in the estimates of
control variables included in the model could be observed between Model 2 and Model 3.
The nal acculturation factor of interest – Dutch language prociency – was added as an explanatory variable in Model 4. The
model showed that Polish migrants who had severe difculties speaking Dutch were more likely to have visited a doctor in Poland in
the last year than their counterparts who only had moderate difculties or no difculties at all with the Dutch language. The coefcient
estimate of length of stay became smaller and was no longer statistically signicant after the addition of Dutch language prociency to
the model. The KHB procedure indicated that the mediation of the effect of length of stay on the likelihood of doctor visits in Poland via
language prociency was statistically signicant (Δb = −0.234; 95  CI: −0.458, −0.010; p <.05). These results provide empirical
support for the fourth hypothesis that the negative association between length of stay and the propensity of visiting doctors in Poland
was partly attributable to language prociency differences. Again, no substantial change between Model 3 and Model 4 could be noted
in the estimates of the control variables included in the model.
To provide a more intuitive insight in the magnitude of the effects of ethnic self-identication, trust in the Dutch healthcare system
and language prociency, adjusted predictions were again calculated based on Model 4 in Table 2 according to the procedure
described above. The adjusted predictions of the likelihood of doctor visits to Poland are presented in Fig. 2. A strong self-identication
as Polish was, on average, associated with a higher predicted probability of doctor visits in Poland by 10.2 percentage points (95  CI:
.042, .161; p <.01). A one-point increase on the ten-point scale of trust in the Dutch health care system was, on average, associated
with a decline of 1.9 percentage points in the predicted probability of a doctor visit in Poland (95  CI: −.030, −.009; p <.01). Having
severe language difculties as opposed to not having such difculties was, on average, associated with a 12.8 percentage points (95 
CI: .045, .211; p <.01) higher predicted probability of a doctor visit in Poland.
icuion
A key aspect of the transnational lives led by Polish migrants in the Netherlands is their frequent use of healthcare services in their
country of origin. ualitative research suggests that migrants of Polish origin who recently arrived in the destination country are less
likely to visit doctors in their country of origin than their counterparts who had been in the destination country for a longer period of
i  Predicted probability of health care visits to Poland by various acculturation factors.
T. van den Broek

       

time (Osipoviˇ
c, 2013). The aim of the current study was to assess whether length of stay in the Netherlands is indeed systematically
associated with a lower likelihood of doctor visits in Poland, and the extent to which this potential negative association is mediated by
three acculturation factors: ethnic self-identication, trust in the Dutch healthcare system and Dutch language prociency.
As hypothesied, results indicated that migrants who stayed in the Netherlands longer were less likely to visit doctors in Poland.
The analyses presented here moreover showed that a strong ethnic self-identication as Polish, low trust in the Dutch healthcare
system and low Dutch language prociency were associated with a higher likelihood of doctor visits in Poland. Moreover, the analyses
provided evidence that the negative association between length of stay and the likelihood of visiting doctors in Poland was to a
substantial extent attributable to improvements in Dutch language prociency. Earlier research has highlighted that acculturation
matters for access to healthcare in the destination country (e.g., Fassaert, Hesselink, & erhoeff, 2009; Solis et al., 1990; an der
Stuyft, De Muynck, Schillemans, & Timmerman, 1989). The current study adds that, at least for Polish migrants in the Netherlands,
acculturation also shapes the disposition towards medical visits in the country of origin.
Although ethnic self-identication and lack of trust in the Dutch healthcare system were identied as important antecedents of
health care visits to Poland, their inclusion in the models did not signicantly attenuate the estimated negative effect of length of stay
on the likelihood of doctor visits in Poland. This implies that ethnic-self-identication did not weaken and that migrants’ trust in the
Dutch healthcare system did not improve substantially with increasing length of stay in the Netherlands. The absence of a substantial
change with increasing length of stay on the identity (ethnic self-identication) and value (trust in the Dutch healthcare system)
domains of acculturation in conjunction with considerable improvements in Dutch language prociency – an aspect of the cultural
practices domain of acculturation – underscore the point emphasied by Schwart et al. (2010) that the various domains of accul-
turation are independent.
Several limitations of the current study should be considered. First of all, causality cannot be inferred from the current observa-
tional study given its cross-sectional design. Moreover, it is unfortunate that detailed information about the type of the healthcare used
in Poland was not available. Given that costs considerations may also lead migrants to use care services in their country of origin
(Capka & Sagbakken, 2016; Migge & Gilmartin, 2011; illa-Torres et al., 201), it would be interesting to explore whether Polish
migrants in the Netherlands are particularly likely to seek care in Poland for services that are not covered in the Netherlands as part of
the basic benets package of the country’s mandatory and universal social health insurance, for instance dental care (Kroneman et al.,
2016). In this light, it is also unfortunate that the role of income in shaping migrants’ disposition towards doctor visits in the country of
origin could not properly be assessed, given that information on income was missing for a very large part of the sample. The current
study’s nding of a positive association between educational attainment and the likelihood of having visited doctors in Poland may
reect that people with higher levels of education typically have a greater nancial ability to travel back to Poland.
The way in which several key concepts were operationalied constitutes another limitation of the current study. Most notably, the
concept of acculturation arguably contains more domains than the three domains considered here (Arends-T´
oth & an de ijver, 2004;
cf. Schwart et al., 2010). Also, the measure of ethnic self-identication was unidirectional, which means that it implicitly assumed
that strong identication with the county of origin and a strong identication with the destination country were mutually exclusive
(Arends-T´
oth & an de ijver, 2004; Rudmin, 2009). This is at odds with Berry’s (1992, 2005) seminal bidimensional acculturation
model. Future research on the links between acculturation and migrants’ transnational medical travel endeavors would be
strengthened if surveys like the Dutch SIM study would collect more comprehensive and bi-lineal measures of acculturation in future
waves (cf. Rudmin, 2009). Trust in the Dutch healthcare system was moreover measured with a single item. Recently, multi-item trust
measures that acknowledge that healthcare trust comprises multiple dimensions – for instance trust in physicians’ competence, trust in
the absence of a hidden agenda, and trust in the absence of discrimination – have been proposed (e.g., Schwei, Kadunc, Nguyen, &
acobs, 2014; Sheppard, Huei-u Wang, Hurtado-de-Mendoa, Sutton, & Laeist, 2019). Future studies using such multidimensional
trust measures could explore whether specic dimensions of trust in the healthcare systems particularly shape migrants’ likelihood of
visiting doctors in the country of origin.
The theoretical framework underlined the potential relevance of the cultural values subdomain of acculturation – and specically
of values and beliefs about how healthcare ought to be provided – for healthcare services use. Information on such values was,
however, unfortunately not available in the data, and therefore trust in the Dutch healthcare system - conceptualied as an indicator of
the concordance of migrants’ values and beliefs regarding healthcare provision with the Dutch healthcare system – was considered
instead. Caution is called for as to whether trust in the Dutch healthcare system can indeed be perceived as a derivative of migrants’
values about how healthcare should be provided. This is because newly arrived migrants compare the healthcare system in the
destination country not just with their values and beliefs, but also with with the system in country of origin (Goodwin et al., 2013,
Leduc & Proulx, 2004; Sime, 2014). When there are aspects about the system in the country of origin that they do not appreciate, they
may already evaluate the healthcare system of the destination country relatively positively upon arrival (R¨
oder & Mhlau, 2012).
Based on Eurobarometer data, Goodwin et al. noted that Poles have quite negative views about the healthcare system in their home
country (Goodwin et al., 2013). This may be related to the perceptions of corruption in the Polish healthcare system and of suboptimal
efciency of the management of healthcare visits (Capka & Sagbakken, 2016; Goodwin et al., 2013). This may translate in a relatively
positive evaluation of the Dutch healthcare system, also by migrants of Polish origin who recently arrived in the Netherlands.
Finally, there are plausible mechanisms underlying an association length of stay and the likelihood of visiting doctors in Poland that
could not be tested due to data limitations. Moreover, qualitative research highlighted the importance of insufcient familiarity with
the destination country’s healthcare system, e.g. knowledge about entitlements, as a driver of doctor visits in the country of origin,
particularly among recently arrived migrants (Capka & Sagbakken, 2016; Glinos, Baeten, Helble, & Maarse, 2010; Migge & Gilmartin,
2011; Osipoviˇ
c, 2013). Unfortunately, it was not feasible to investigate whether increasing familiarity of the Dutch healthcare system
partly mediated the association between length of stay and the likelihood of doctor visits in Poland, because information on knowledge
T. van den Broek

       

of the Dutch healthcare system was not collected. It should be noted, however, that earlier research suggests that familiarity with the
Dutch healthcare system tends to be quite good among Polish migrants in the Netherlands (Dagevos, 2011). Madden et al. (201) also
reported good familiarity with the British healthcare system among Eastern-European migrants in the UK.
The current study showed that Polish migrants, and particularly those who identify strongly as Polish, those with limited trust in
the Dutch healthcare system and those with a poor command of Dutch, often use healthcare services in their country of origin. This
may reect poor inclusion of certain subgroups of Polish migrants in the Netherlands in the Dutch healthcare system, and may result in
the receipt of care of suboptimal quality among these migrants due to fragmentation. In the light of the nding that low Dutch language
prociency is a strong driver for transnational medical travel, it is important to note that the majority of recently arrived Polish
migrants have severe difculties in understanding Dutch (Gijsberts & Lubbers, 2014). Given that Poland is a member of the European
Union, migrants of Polish origin are not legally obliged to learn Dutch. However, many municipalities offer voluntary language ed-
ucation programs (Gijsberts et al., 2018). The current study’s ndings suggest that offering such programs and encouraging migrants of
Polish origin to participate in them may foster inclusion of members of this group in the Dutch healthcare system and reduce the need
they perceive to seek healthcare in the country of origin.
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