Introduction

Effective and timely access to quality primary care is a critical resource for the health of immigrants [1]. In this study of healthcare models, we defined immigrants broadly, see “Box 1”. Numerous studies reveal that immigrants, excluding refugees, arrive in better health than the general population [2, 3]. Their health status, however, tends to decline and converge with that of the native population during the integration process [4–6]. Refugees may have unique socio-demographic characteristics and suffer more infectious diseases, but we included them because, like other migrant groups, they also face barriers accessing and using healthcare services [7, 8].

“Health inequities are when inequalities in health are deemed avoidable, remediable, and unfair”[9]. The definition and measurement of health inequity requires a normative decision about social justice and fairness that may vary based on context [10]. Immigrants face barriers accessing health care [11–14]. Factors that may contribute to inequities include forced migration, limited official language proficiency, country of origin and education level, and other social determinants of health [1]. Limited education and health literacy are potential sources of immigrant health inequity [15]. Patient-practitioner interactions can build trust in a new system [16], but many barriers may intercede [17–19].

Globally, two broad models have emerged to provide primary care to immigrant populations (and the population in general); primary medical care (PMC) and primary health care (PHC) [20, 21]. Both incorporate health services and the two models commonly coexist in health systems [22, 23]. We used the framework described by Muldoon et al. [20] to distinguish the two models in providing health care to immigrants’ populations. Muldoon et al. describes primary care (consider as PMC in this study), “a narrower concept of ‘family doctor –type’ services delivered to individuals”; and PHC “describes a model of health policy and service provision that includes both services to individuals and population level public health –type functions” [20] Hence, we defined PMC as the medically-oriented model and PHC as a community-oriented model. (see “Box 2”).

PHC models are more common in developing countries, while developed nations are more focused on the PMC model [24, 25], but these models frequently coexist in both development contexts. In Canada, for example, two models of primary care are recognized: a community-oriented approach, and a professional approach [26], and a set of attributes have been defined to characterize these models [27]. Expanding healthcare models may be helpful in responding to existing access and healthcare inequities among immigrant populations. The goal of this review was to examine how these two primary care models, PMC and PHC, deliver healthcare to address immigrants’ health needs and how it may affect health inequities.

Methods

We used a systematic scoping review [28]. We followed the Arksey and O’Malley’s scoping review framework [29] which includes: (a) identifying the research question; (b) identifying relevant studies (including a quality assessment in this step); (c) selecting studies; (d) charting data; (e) collating, summarizing, and reporting results.

Identifying Relevant Literature

The research question that guided this review was: what are the strengths and limitations of the two primary care models, in delivering healthcare to immigrants to address their health needs? The review focused on the health problems addressed by these models, the types of prevention strategies used, the types of barriers that the models targeted and the interventions used to target them.

To identify relevant publications, the search strategy included terms in three domains: primary care or primary health care, immigrants, and model of care; following the selection criteria defined in “Box 3”. The search terms were: ‘primary care’ OR ‘primary health care’ AND ‘immigrant’ OR ‘migrant’ and ‘model of care’. Medical subject heading (MeSH) terms and key words derived from those domains were used, (see Online Appendix 1).

With the assistance of a librarian, an electronic search was conducted in the following eight databases: CINAHL, Cochrane Library, EBM Reviews, Embase, MEDLINE, PsychINFO, Web of Science and Global Health. The electronic searches included English language articles, published from January 1st, 1990 to November 30th, 2013. In addition, several journals and international resources or organizations relevant to migrants’ health and health care were purposefully hand searched for same time period, using the keywords: ‘primary care’ or ‘primary health care’ and ‘immigrant’ or ‘migrant’ and ‘model of care’. (Online Appendix 1) We screened, assessed full texts, and imported articles into Endnote X7.

Quality Appraisal

We critically appraised the selected documents using validated tools to ensure a minimum quality of the evidence [30, 31]. To that end, the studies were classified in three categories: quantitative, qualitative and systematic review. A fourth category that included other types of publications (conceptual papers, technical or policy reports, and non-peer reviewed) was included and a special quality assessment tool was developed for this, based on other appraisal guidelines [32–34]. We adapted a ten items checklist for each type of study based on key attributes (see Online Appendix 2). If seven or more items met the criteria, then we deemed the study of good quality and considered for further analysis, otherwise, they were excluded.

Data Extraction and Charting

The studies reviewed were classified as either of two models—PMC or PHC—guided by the principle framework outlined by Muldoon et al., based on the differences described in “Box 2”. Briefly, when the study described family doctor—type measures delivered to individuals inside health services, it was classified as PMC; and when the study included interventions beyond the health services to reach out to the community and/or involved other social services (e.g. legal, food or school programs, transportation, etc.), then it was considered as PHC.

Data Analysis

We used a framework synthesis approach [35] to organize and synthesize the data and to discuss the results. For the purpose of describing and discussing the results, we focused on three dimensions of the health services described as follows: (a) type of health service provided, (b) type of barriers addressed; and (c) type of preventive measures applied (see details in Online Appendix 3). For the type of barrier or facilitator to access nine categories were identified [11, 36, 37]: (1) insurance coverage or eligibility to receive service, (2) cultural issues, (3) language or communication issues, (4) organization of services and quality of care, (5) geographic access, (6) economic burden or costs of services, (7) education and health literacy, (8) social networks and support, and (9) patient-provider relationship [38–40]. Finally, we classified each study according to the type of strategies included to provide those services as: (a) health promotion strategy (HP); or (b) primary (PP), (c) secondary (SP) or (d) tertiary (TP) prevention strategy; following the model of stages of prevention [41]. (see “Box 4”). We also used the WHO-CSDH framework of actions on social determinants of health [42], to assess the potential of each model in tackling health inequities.

Results

We identified 1008 citations from the databases and 377 from the manual searches. (see Fig. 1) Out of the 39 studies selected in the review, 17 were categorized as PMC and 22 as PHC. A summary of selected studies is presented in Table 1, and Online Appendix 4.

Fig. 1
figure 1

Flowchart of the selection process

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Table 1 Summary of studies included in the review
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A total of 22 studies (56%) were theoretical or discussion papers and policy or program reports, 15 were empirical studies (7 quantitative, 8 qualitative) and 2 were reviews. 14 studies targeted immigrant populations in general, including refugees; 24 studies focused on specific immigrant groups (Hispanic, Chinese, etc.) and one focused only on refugees. The immigrants groups more represented were Hispanic/Latinos (8) and Asians (Chinese and Koreans) (6). Three studies were dedicated to immigrant women and three to children. The majority of the studies (62%) were conducted in North-America with 24 studies (21 in the US and 3 in Canada); followed by Europe (6), Australia (2) and other countries (2). Only one study from a former low-middle income country was identified (Chile). Five studies involved several countries.

Both health care models have similar distribution on the type of health care problems or service provided. More than 60% of the type of services for both PMC and PHC were classified as primary care measures, including general medical care for acute or chronic conditions, prenatal care, immunization, disease screening, emergency care and other services (Table 2). Provision of preventive services, were reported in about 40% of the studies in both models, using preventive strategies for specific health problems, such as oral health [43], CVD [44], cancer screening [45, 46]; or preventive care for specific subgroups like children [47], or perinatal care [48, 49]. Mental health services (general mental care, or care for specific mental disorders such as depression) were provided in less than 20% of studies (three studies in each model) [50–55].

Table 2 Type of care or services provided, by type of health care approach
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Targeting Barriers to Primary Health Care for Immigrant Populations

For PHC models, the main barriers addressed were those related to socio-cultural issues, as nearly all of those studies (20 out of 22) included strategies to tackle social barriers, such as attention to cultural norms and to religious background, [52, 56–59] the utilization of safety net models [60] and the use of interpreters and cultural brokers [61] (Table 3). Seventeen studies described strategies promoting social networks and support (78%), such as the involvement of ethno-cultural community leaders and organizations, [52, 57, 62] as well as implementing other social programs and services that helped immigrants with their integration [54, 59, 63, 64]. Strategies to address barriers concerning language and communication problems were reported by 14 studies, including the use of language services [52, 57], and a similar number described strategies for organizing services and quality of care issues (e.g. laboratory services, emergency care), as well as those that promote education and improvement of health literacy [65–67].

Table 3 Type of barriers/facilitators addressed and type of preventive actions offered, by type of health care approach
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Among the PMC models, the top strategy was the organization of services and quality of care (71%), such as multidisciplinary and coordination of care [44, 60], integration of services [68], collaborative model of care [55], medical home model [69]. This was followed by strategies to address cultural barriers (53%) (language, health beliefs) patient-provider relationship (41%) [46, 50, 70], plans to improve access to insurance and entitlement to care (six studies) [44, 71, 72]; as well as tactics to tackle economic costs associated with care (five studies) [43, 73]. (Table 3).

Implementing Health Promotion and Disease Prevention Strategies

All of the PHC studies included strategies of health promotion and social determinants, compared to only 71% of the PMC studies. Examples of those strategies were interventions to improve general education levels of the targeted population [52, 63, 74, 75], or their health literacy [65, 66, 76, 77]; as well as wide health promotion programs using community health workers [44, 57–59, 67]. With regard to primary prevention, all the PHC models encompassed typical primary prevention strategies, such as immunization, disease screening, perinatal care, [74] among others (Table 3). In contrast, only 88% of the PMC models employed primary prevention strategies as part of their bundle package of services; and were more consistent providing tertiary prevention strategies.

Discussion

Overall, the organization of primary healthcare in most countries consists of the provision of health and medical services to the general population, usually in health care facilities (public or private), mainly delivered by health care professionals (doctors, nurses, physiotherapists, dieticians, etc.). According to the emphasis of those services, the system can be mainly medical or curative-based, which corresponds to the PMC model; or can be more community-oriented, focusing on strategies outside the health care services, supported by or engaging other social services, which corresponds to a PHC model. In the actual healthcare practice of many countries, both approaches can coexist and an overlapping of strategies can be seen, but in many cases, specific projects or programs can be identified with a PMC or a PHC model.

Our findings reveal that the organization of services or strategies to deliver health care to immigrant populations at the entrance of the health system can be either through a PMC or a PHC model. Both models can address immigrant population health needs, but they differ in the scope of their strategies and the potential impact on immigrants’ health transitions.

Addressing Barriers to Care

Regarding strategies to address barriers to care, PHC models were more consistent than those of PMC in developing strategies to challenge cultural barriers, such as language and communication difficulties, and in providing social support, and educational programs, [52, 56–59] while only half of the PMC models addressed those common newly arriving immigrant barriers [40, 78, 79].

The studies using the PMC model, however, were more consistent than PHC in implementing strategies to improve the organization and quality of clinical medical care and patient-provider relationships. This has been the focus of many primary care reforms [80, 81]. Some PMC models also integrated strategies to address cultural barriers, including measures to improve language and communication, which can make these services more migrant-friendly and culturally appropriate [19, 82].

Focusing on Health Promotion

Regarding the application of preventive interventions, all studies using the PHC model included health promotion and primary prevention strategies as part of their organization and delivery of services, while among the PMC models around 80% included those types of interventions. Consistent with the barriers addressed, the PHC models were also more consistent in implementing health promotion strategies through culturally-oriented health care interventions and educational programs, promoting and fostering social support, as well as developing community networks in organizing primary care to immigrant populations.

Potential to Impact on Health Care Inequities

Using the WHO-CSDH framework of actions on social determinants of health [42], we identified that PHC models were better able to implement strategies to address contextual factors (i.e. socioeconomic and political context) and structural mechanisms (e.g. social position, education, income, occupation, ethno-cultural factors); that may contribute in reducing immigrants health inequities. For example, the PHC models more frequently implemented strategies to address and accommodate cultural and social values through comprehensive experiences of social and community health services for immigrants,[52, 54, 57–59, 66, 69] as well as education and health literacy programs, than the PMC models [65, 67, 74]. Those structural factors have also been reinforced by international organizations and global consultations on migrants’ health and health care as part of migrant-sensitive health care systems [83, 84].

The PHC models were also better able to roll out strategies to alter key intermediary factors such as material circumstances (housing, financial capacity for consumption) that can have a meaningful influence on how immigrants deal with the new environment as well as psychosocial circumstances that can act as significant stressors during their settlement process. Also, some health programs based on PHC models have developed strategies of social participation and established partnerships with organizations outside the health sector, such as legal services, food distribution and transportation [63, 69]. Experiences of community health centers (CHC) have also provided evidence on the value of intersectoral collaboration to improve health outcomes [57, 58]. Research in Canada and United States has acknowledged that CHCs are serving disadvantaged populations, including a great number of immigrants [87, 88]. For example, a large proportion of immigrants and refugees in urban areas of Ontario are receiving healthcare from CHCs [89, 90]. A recent study in China evaluating CHC models in China, revealed the value of community-based primary care models to improve access, comprehensiveness, and quality of care [91].

Another intermediary factor shaping the health of the population and a potential contributor in reducing health inequities is social capital [92, 93]. Research in the last three decades has explored the influence of social factors and social networks on the health status of individuals and populations [94, 95]. Furthermore some studies also support the importance of social capital in the integration of immigrants into the new society [96]. In line with that, key strategies offered by the PHC models to strengthen social networks and social cohesion to help immigrant families in dealing with integration challenges included access to health services [67, 69, 75, 76, 97]. Finally, another key feature of PHC models is the involvement of community health workers (CHW) or health promoters, [58, 60, 67, 75] who have an essential role as an educator, a health broker, and also as a connector between the community and the health services.

Inequities in health can only be partially tackled by addressing and improving health care, but appropriate health services can have an impact on people’s health status, not only for migrants but also for the population in general [97, 98]. This review reveals that both models have strengths and limitations in providing health care to immigrant populations. Although a mix of strategies from both types of models can be seen in some contexts, the PMC models applied more strategies to enhance the quality of medical services, where the PHC models were more persistent in including strategies to address social and cultural needs of immigrant populations. These results seem to be consistent with growing evidence indicating that health systems grounded on the PHC principles can be effective in tackling health inequities by acting upon the social determinants of health [99–101].

Strengths and Limitations

To the best of our knowledge, no previous research has compared these two models on their capacities to respond to immigrants’ health care needs, neither examined their strategies to address the barriers of access to primary care services nor assessed their potential to tackle health inequities.

However, the analysis has some limitations. None of the studies reported the effectiveness of their interventions or measured the impact on inequities in health care to immigrant populations. Also, these results were limited to the search terms “model of care”, “primary care”, and “primary health care”, which may not have identified all models or bundles of primary care services to. In addition, as these two models can coexist, an overlapping in the use of these services by immigrants can also occur, since health care systems are more and more applying a blend of strategies and interventions to enhance the quality of health care. Finally, we restricted the review to literature published in English.

Conclusions

This systematic scoping review shows that immigrant populations receive a variety of primary health care services in the host country. These services come from a mix of PMC or a PHC approaches. Both models can be helpful in responding to immigrants’ health needs. However, the PHC model was more consistent in applying strategies to address critical factors that affect immigrants in their settlement process. Hence PHC models may be better suited to address social determinants of health and might have more potential capacities to reduce health inequities among immigrants. Despite the differences identified in this study, the two models could act synergistically in responding to immigrants’ healthcare needs. Further research is needed to assess the actual impact and interaction of these models on immigrant health inequities.