Introduction 3 15 25 6 12 8 9 16 19 18 1 2 15 11 In these health service use studies, a variety of potential predictors, such as psychopathology, physical diseases, physical, and mental well-being, have been included. But disability and quality of life were not included. Nor is there a study that compared groups from the same country of origin, that differ in length of stay in a host country. n 12 14 The aim of this paper is to examine patterns and predictors of health service use and their relationship with length of stay. The research questions are: (a) what is the prevalence of service use of Iraqi asylum seekers in the Netherlands, (b) is a long asylum procedure associated with a higher prevalence of service use, (c) what is the relationship between psychopathology and service use, and (d) which predisposing and other need variables predict service use. We hypothesize that a long asylum procedure is associated with a higher prevalence of service use and that higher levels of psychopathology are related to higher levels of service use. Methods 12 From the entire population of adult Iraqi asylum seekers, two groups were selected based on their length of stay in the Netherlands. Personal data on these groups was obtained from the Agency for the Reception of Asylum Seekers (COA). Group 1 was selected on the criterion that persons had been living in the Netherlands for less than 6 months (between September 2000 and November 2001). From the randomly selected 362 respondents, data could be used from 143 interviews. Group 2 was selected on the criterion that they were living in the Netherlands for at least 2 years. On the chosen date of May 31st, 1999, the COA found that 2,352 Iraqi asylum seekers fulfilled this criterion. From the randomly selected 474 respondents, data could be used from 151 interviews. 7 28 22 26 21 13 4 5 Statistics 2 P n P P 20 Results Socio-demographics, health and health related variables 1 12 1 Table 1 Socio-demographic, health characteristics and post-migration living problems in at random samples of Iraqi asylum seekers arrived <6 months (Group 1) versus >2 years (Group 2) in the Netherlands, 2000–2001 Variables n n n P Stay in months (mean, SD) 2.51 (1.16) 36.77 (6.30) 20.12 (17.76) P t Sex (%)    P 2     Male 49.7 78.8 64.6      Female 50.3 21.2 35.4  Age (%)    P 2     18–24 years 21.7 9.3 15.3      25–34 years 42.0 49.0 45.6      35–44 years 14.7 25.8 20.4      >45 years 21.7 15.8 18.7  One or more psychiatric disorder (%) 42.0 66.2 54.4 P 2 a 2.88 (0.99) 2.23 (1.14) 2.55 (1.11) P Z b 3.06 (1.15) 2.74 (1.27) 2.89 (1.22) P Z c 17.31 (7.43) 19.25 (6.77) 18.30 (7.15) P t d 5.37 (8.24) 7.68 (9.17) 6.56 (8.80) P t e 0.85 (1.18) 0.84 (0.98) 0.85 (1.08) n.s. e 0.83 (1.38) 1.62 (1.58) 1.23 (1.54) P t Post-migration living problems f 36.54 (26.55) 52.81 (24.24) 44.90 (26.62) P t f 2.05 (7.92) 11.17 (21.01) 6.74 (16.65) P t f 48.58 (25.35) 60.13 (23.23) 54.51 (24.97) P t f 22.35 (19.16) 32.48 (21.08) 27.55 (20.76) P t f 12.96 (17.46) 14.48 (17.19) 13.74 (17.31) n.s. P a b c d e f Health service use 2 Table 2 Health service use and other help seeking behavior in at random samples of Iraqi asylum seekers arrived <6 months (Group 1) and >2 years (Group 2) in the Netherlands, 2000–2001 Use of services last 2 months n n n P a 76.9 66.2 71.4 P 2 b Use of any out-patient (o-p) service 74.1 52.3 62.9 P 2 b Use of any o-p curative service 38.5 36.4 37.4 n.s. Use of preventive o-p service     Nurse/doctor in center 72.0 39.7 55.4 P 2 b Use of o-p curative service     General practitioner 32.9 25.8 29.3 n.s.     Medical specialist in hospital 12.6 17.9 15.3 n.s.     Social worker 5.6 6.6 6.1 n.s.     Mental health worker 1.4 9.3 5.4 P 2 Use of in-patient service     Hospital admission physical health 1.4 4.0 2.7 n.s     Hospital admission mental health 0.0 0.7 0.3 n.s Use of any drugs 32.2 45.7 39.1 P 2     Use of anxiolytics 10.5 22.5 16.7 P 2     Use of hypnotics 11.9 21.2 16.7 P 2     Use of analgetics 23.8 37.7 31.0 P 2 P a b Relationship between psychopathology and service use 3 P Table 3 Use of services in respondents with and without one or more psychiatric disorder in Iraqi asylum seekers arrived <6 months (Group 1), and >2 years (Group 2) in the Netherlands, 2000–2001 One or more psychiatric disorder n n n n n n n n n Use of services last 2 months a 88.3 68.7* 76.0 47.1* 80.6 60.4*     Use of any out patient (o-p) service 86.7 65.1* 60.0 37.3* 70.0 54.5*     Use of any o-p curative service 53.3 27.7* 43.0 23.5* 46.9 26.1* Use of preventive o-p service     Nurse/doctor in center 83.3 63.9* 47.0 25.5* 60.6 49.3 Use of o-p curative service     General practitioner 41.7 26.5 29.0 19.6 33.8 23.9     Medical specialist (non-psychiatrist) 26.7 2.4* 21.0 11.8 23.1 6.0*     Social worker 8.3 3.6 10.0 0.0* 9.4 2.2*     Mental health worker 1.7 1.2 13.0 2.0* 8.8 1.5* Use of any drugs 45.0 22.9* 58.0 21.6* 53.1 22.4*     Anxiolytics 18.3 4.8* 31.0 5.9* 26.3 5.2*     Hypnotics 18.3 7.2* 29.0 5.9* 25.0 6.7*     Analgetics 31.7 18.1 48.0 17.6* 41.9 17.9* P a The use of drugs in respondents with psychopathology was higher in both groups, compared to those without psychopathology. Almost 60% of the respondents in Group 2 with psychopathology used drugs, versus 21.6% of those without psychopathology. Also the use of analgetics was higher, especially in Group 2 (48% vs. 17.6%). Predictors of service use 4 Table 4 N Service Nurse/Doctor center General practitioner Medical spec. (non-psychiatry) Social worker Mental health worker Use of any drugs a CI (95%) a CI (95%) a CI (95%) a CI (95%) a CI (95%) a CI (95%) Predisposing factors b 0.18 0.08–0.37       5.56 1.08–28.69       Age (older age)   1.03 1.00–1.05       1.05 1.02–1.08 Need factors     One or more psychiatric disorder     1.34 1.18–2.76           Overall Quality of life     1.80 1.18–2.76           Perceived quality of general health 0.44 0.30–0.64 0.51 0.36–0.73 0.54 0.35–0.84   0.35 0.17–0.77 0.49 0.33–0.71 c       0.89 0.80–0.99     d   1.04 1.001–1.08   1.07 1.01–1.15         Physical diseases 1.48 1.01–2.16   1.06 1.02–1.11     2.07 1.41–3.05 PMLP             a b c d 5 6 5 6 Table 5 N Service Nurse/doctor center General practitioner Medical spec. (non-psychiatry) Mental health worker Use of any drugs a CI (95%) a CI (95%) a CI (95%) a CI (95%) Predisposing factors     Age (older age)         1.06 1.01–1.10 Need factors     One or more psychiatric disorder     1.93 1.18–3.16         Overall quality of life     2.49 1.05–3.16   3.16 1.29–7.75     Perceived quality of general health 0.25 0.11–0.56 0.55 0.31–0.97 0.41 0.18–0.96   0.29 0.12–0.74 b   1.08 1.01–1.15           Physical diseases     2.65 1.33–5.28   2.71 1.33–5.54 PLMP           a b Table 6 N Service Nurse/doctor center General practitioner Medical spec. (non-psychiatry) Mental health worker Use of any drugs a CI (95%) a CI (95%) a CI (95%) a CI (95%) a CI (95%) Predisposing factors     Age (older age)   1.04 1.00–1.09       Need factors     Perceived quality of general health 0.54 034–0.87 0.43 0.25–0.72 0.54 0.31–0.96 0.41 0.18–0.88 0.58 0.37–0.93 b 0.92 0.86–0.99         c     1.07 1.01–1.13         Physical diseases   0.56 0.32–0.99     2.16 1.26–3.79 PMLP     Asylum procedure   1.38 1.04–1.83 0.68 0.51–0.92         Socio-economic l.c. 1.19 1.02–1.38   1.23 1.00–1.50     a b c Discussion The main findings of this study are: There is a high overall service use among Iraqi asylum seekers in the Netherlands. The hypothesis that a long asylum procedure is associated with higher levels of service use, is not confirmed by the results, except for mental health service use and drug use. Psychopathology is related to a higher level of service use (second hypothesis), but when corrected for the influence of other predisposing and need factors, other factors, such as: high role and functional disability, and low perceived quality of general health, are more important predictors. Moreover having one or more psychiatric disorder(s) predicts the use of a medical specialist (non-psychiatrist), but does not predict mental health service use. The overall use of mental health service use is very low compared to the high prevalence of psychiatric disorder: over 80% of the asylum seekers with a psychiatric disorder used any health service, but only 8.8% visited a mental health service. Next paragraphs will discuss the four research questions. Prevalence of service use, relationship with length of stay 9 27 24 9 Use of alternative services is very low. Maybe Iraqi asylum seekers are not interested in these services, but even in case they would be, these services are probably not easily available and accessible. We found no other studies on this issue among Iraqi refugees/asylum seekers. Relationship psychopathology and service use 3 23 Predictors of service use 8 17 14 24 5 6 10 15 Several post-migration living problems (PMLP) predict health service use in Group 2. Especially worries about socio-economic living conditions increase the need for healthcare. The findings do not support the idea that asylum seekers look for recognition of their health problems in order to get a resident permit: there is no relationship between PMLP and mental health service use and there is a negative relationship with use of a medical specialist. Conclusion This study has shown that Iraqi asylum seekers have a low level of mental health service use, despite the high levels of psychiatric disorders and other health indicators, especially within the group that stayed in the asylum procedure for over 2 years. Moreover, there is a mismatch between the type of health problem and the type of health service use: asylum seekers with a psychiatric disorder make more use of non-mental health service. There is room for improvement of the ‘gate way’ preventive services in detection and referrals of patients with mental health problems. The study results suggest that this service is a barrier rather than a facilitator in the pathway to mental health care. The general practitioner should be more involved and consulted. Mental health institutions are recommended to start and/or improve consultation and (assertive) care programs.