Asian migrants navigating New Zealand primary care: a qualitative study

Keywords: Asian, health services accessibility, health system responsiveness, migrant communities, navigation health literacy, New Zealand, primary health care, qualitative document analysis.

Asians are the third largest population group in New Zealand (NZ), currently making up 15%,¹ and they are projected to become the second largest group.² Aggregated health statistics hide disparities in health outcomes, masking heterogeneity in health issues among Asian subgroups.³ Lower primary health organisation (PHO) enrolment and uptake of screening initiatives have also been reported for Asians compared to NZ European, Māori, and Pacific populations.^4,5 Among Asian youth in NZ, access to health care was poorer than NZ European youth, primarily due to lack of knowledge of the healthcare system, cost of care and lack of transport.⁶ Specific strategies and resources targeted towards Asian migrants have been recommended due to the lack of culturally appropriate resources and the importance of cultural competency for optimal patient engagement and use of the health system.^7–10

Access to, and optimum utilisation of, healthcare services is critical to reducing healthcare costs and improving population health outcomes. Poor access to health care may lead to increased unmet health needs, inequities, increased use of the emergency department and specialist visits, preventable hospitalisation, and financial burdens to individuals/families and the health system.^11,12 Access to health services is particularly low among Asian adults who are recent migrants.⁶ Lack of knowledge about the healthcare system has been identified as a barrier to access among Pakistani women in NZ;¹³ however, such information for other Asian groups is currently absent. International studies have shown similar results for other migrant populations.^14,15 This ongoing issue highlights the importance of addressing health literacy to improve access to health care.^5,8,16–19

Health literacy in NZ currently focuses on consumers’ needs and skills, defined as their ‘capacity to obtain, process, and understand basic health information and services to make informed and appropriate health decisions’.²⁰ However, international studies support the need for health systems and health professionals to embrace their role in creating a conducive health literacy environment. This focuses on health systems’ and providers’ needs and abilities to effectively communicate with patients by providing easily understandable and accessible information, and addressing issues such as language barriers.^21,22 Inadequate interpretation and translation services, as well as institutional barriers such as the lack of linguistically appropriate information about services, are key barriers to access.^9,19,23,24

It has been argued that the complexity of healthcare systems hinders patients from becoming health literate; this supports focusing health literacy research towards health systems also becoming health literate and responsive to patient needs.^25–27 This is especially critical to enhancing patients’ navigational health literacy; that is, the health literacy required to navigate the health system efficiently.²⁸ However, although the New Zealand Health Literacy framework aims to ‘Implement policies, pathways, and processes that make it easier for people to access and find their way through the health system,’²⁹ the responsiveness of the NZ health system (NZHSy) to facilitate navigation by Asian migrants has not been well documented.^8,18

As the NZHSy relies on general practices as the primary point of contact for non-emergency medical care,^30–32 and as the primary gateway for referrals into the wider health system (including secondary and tertiary care),^33,34 investigating online resources for optimal navigation of primary health services by NZ Asians is prudent. This is particularly important as the internet has become a crucial source of health systems information,^35,36 and is used by Asian immigrants to find information on various topics, including healthcare systems.^37,38 Furthermore, with the 2022 NZHS reform, information on improving navigational health literacy – especially for migrant groups – would inform health system infrastructure development to achieve ‘Health for All’.³⁹

As a first step towards improving NZ Asians’ health service engagement, the current study aimed to: (1) document and analyse the current health information resources available on the websites of general practices that aid in optimal healthcare navigation for NZ Asians; and (2) explore Asian migrants’ perceived barriers to navigating the NZHSy – particularly primary care.

The aims of the current study were achieved using qualitative methods. Ethics approval for the study was obtained from the Ethics Committee, Department of Medicine, University of Otago, endorsed by the University of Otago Human Ethics Committee (Ref: D21/347 dated 12 November 2021). A document analysis of the websites of selected general practices was completed using qualitative content analysis to achieve the first objective.⁴⁰

Both website contents and information found in documents, such as patient information brochures, were included in the analysis. After reading approximately 20 website contents, an initial coding list by types of health service information was developed, relevant to the study research questions. Next, codes were further refined using literature and the Navigational Health Literacy framework,²⁸ which describes tasks key to achieving the ‘health literacy required for effective navigation of health care systems and services’.^41–52 This framework by Griese et al. (2020)²⁸ was deemed most appropriate as it specifically concerned the health literacy skills required for effective navigation of health systems rather than general health literacy. Tasks 1–2 and 7–10 (Supplementary File S1) from this framework were particularly relevant to this process in the current study. Codes were reviewed in a team meeting involving all authors, and a working coding framework was developed. The coding framework was then used to code website content. Following this, codes were constantly checked against the dataset and refined, with several codes combined into broader categories. Finally, the entire research team reviewed and finalised the final set of themes. An example of this coding process is shown in Fig. 1.

Fig. 1.  Example of code formation (Codes #1–4, 8).

Qualitative interviews were conducted to explore Asian migrants’ perceived barriers and experiences of navigating primary health care (objective 2). The inclusion criteria for the study were: (1) identifying with at least one Asian ethnicity; (2) having resided in NZ for ≤10 years; and (3) holding a residency or work visa. Limited resources restricted participation in the interviews to only those fluent in English. Recruitment was achieved via advertising and word-of-mouth, and was primarily based in Dunedin, but was open to anyone in NZ who met the criteria. Coronavirus disease 2019 (COVID-19)-related challenges restricted the number of interviews (9/10) that were completed within the stipulated project timeline. A semi-structured, open-ended questioning technique was used for the interviews, which were conducted face-to-face (n = 4) or via telephone (n = 3) or Zoom (n = 2). As the interviewer was an Asian medical student, they used the interview schedule and neutral responses wherever possible during interviews to avoid influencing the interviewee with their own opinions or experiences. Conversely, being a second-generation Asian migrant allowed the interviewer to better understand and relate to the cultural context of participants’ health service experiences. Interview questions focused on establishing contact with a healthcare provider, understanding ofand obtaining information about the NZHSy, and experiences with healthcare providers. The interviews were recorded, transcribed verbatim, and analysed thematically using a coding framework informed by both the Griese et al. (2020) framework,²⁸ and results from website analysis. Signed consent was obtained from the interview participants prior to participation, and a NZ$20 grocery voucher was offered as a koha (a token of appreciation).

In total, 372 general practices were selected for the analysis (Table 1). Seventy-nine general practices had no website, bringing the final number of practices analysed to 293. Key information to facilitate navigation of health systems and health services on the websites centred around three major themes: availability of basic information, linguistic accessibility, and culturally appropriate patient support.

Table 1.  Selection process of general practice websites.

This theme encompassed information on: (1) the NZHSy; (2) enrolment/eligibility; and (3) delineated fees. Information on these domains was infrequently provided, but often excellent when present (Table 2). Content considered under this category included explicit, orientating information such as: explaining the primary and secondary levels of care, the referral system, and the private and public sectors. It also included explanations of commonly used terminology such as ‘enrolled patient’, ‘outpatient clinic’, and what a PHO is.

Table 2.  Health navigation information on the websites of general practices (n = 293).

Only four (1.4%) practices provided information on primary and secondary levels of care, the referral system, and the private and public sectors. Most websites providing information on enrolment described the benefits; fewer explained what enrolment was. Only three practices explained the terminology around ‘casual’ and ‘enrolled’ patients, and eight explained the relationships between PHOs and primary care. Eligibility criteria for health services for non-citizens were only available on 10% of websites.

The tables and lists of fee information available on most general practice websites rarely included information for casual patients – let alone patients ineligible for public funding. Additionally, non-residents were seldom mentioned. In several instances, this information was only available in a document containing exhaustive fee information – including the pricing for many specific services.

Linguistic accessibility included information on interpreter services, language(s) spoken by the practitioner, and information available in non-English languages (Table 2). Information on interpreters was severely lacking. Recommendations of non-professional interpreter services were present on three websites. Information on languages spoken by practitioners was inconsistent across practices in both presence and location (if present). This was difficult to find on many practice websites as information was usually contained in varying locations within individual practitioner biographies, and each paragraph had to be scanned in full. In other cases, this information was found as an inconspicuous sentence in sections such as the ‘Home’ page or ‘About the Practice’.

Very few translated resources were available across the websites analysed. The resources present had the potential to be extremely useful in aiding navigation and confident use of healthcare services, but they were not present often enough and were not available in enough languages. For example, only 8/293 practices contained navigation-related material translated into Chinese; two also had this information in Korean. One of the eight practices also offered this information in Arabic, Japanese, Hindi, and Burmese. Five other practices offered discrete resources in Chinese: an enrolment form, enrolment information, COVID-19 updates, translated names of core services, and patient information brochures.

This theme includes the following categories of information available on the websites: resources or information targeted toward migrants, resources or information targeted toward Asian people, patient rights, use of health information, and supporting effective interaction with providers. This analysis found a lack of relevant resources.

Only 1% of resources across all sites were targeted toward Asian peoples and/or migrants. Pages such as ‘Patient Resources’ and ‘Useful Links’ often consisted of lists of links to websites such as QuitLine and Health Navigator, presented without comment. These rarely included relevant satellite services such as Asian Health Services or migrant-specific health information that could be found on ‘Healthinfo’. Only a single practice from those analysed mentioned explicitly that all children are eligible for free vaccinations, regardless of citizenship.

When information on patient rights was available, it was often just a list of the Code of Rights. Only five practices elaborated and explained their impact on patients’ experiences with general practice services. Only one practice translated patient rights into Mandarin and Cantonese.

Regarding information that would support confident interaction with health professionals, the FAQ sections on some practice sites were the main source of information. Although most of these contained practical information (eg the practice’s late payment and cancellation policies: seven included more support-oriented information). This included sections titled ‘How to get the most out of my appointment’, and explanations of rights to support people and interpreters. Two practices also addressed questions that those new to NZ might have due to differing practice styles, such as ‘Why is my GP asking me what is wrong? Don’t they know? I just want a diagnosis.’ However, in the vast majority of cases, FAQs did not address possible concerns of Asian immigrants.

Barriers to effective navigation of the NZHSy were investigated via nine in-depth interviews with Asian migrants. The seven female participants were aged between 25 and 44 years, and the male participants were aged between 32 and 35 years. Participants had lived in NZ for 2–10 years. They represented several of the Asian ethnic groups in NZ (Chinese-2; Indian-1; Malaysian-2; Nepalese-1; Pakistani-3).

Several themes emerged from thematic analysis of the interviews. For example, participants’ overall impressions of the NZHSy were that it was difficult to navigate and understand; many participants also reported difficulty understanding their eligibility for services and finding information on service costs.

…being a migrant over to New Zealand… I’ve always had that pressure of not wanting to get sick because I wouldn’t know what to do. (Participant 9)

Participants expressed difficulty understanding the system due to the lack of information provided. None of the participants received information about health care on arrival, except two participants, who initially arrived on student visas. Their educational institution either directed them to a general helpdesk or told them to utilise Student Health. Overall, 56% of participants relied on friends or word-of-mouth; the remainder learned through experiences within the system or external resources such as their children’s schools.

A few participants had never considered or wanted to use websites to search for information about NZ health care. Several more had tried, but found websites unhelpful, either because they could not find relevant information, or they could not distinguish which ones were reliable and relevant from the overwhelming array of options. However, one participant successfully enrolled in a general practice using the clinic’s website, and another found specific information for a family member at a hospital. Although websites were found to be unhelpful for learning about the health system, they were helpful in other circumstances.

In total, 8/9 participants had tried to find information on costs and found it challenging. Participant 1 had never looked at or thought about cost due to a lack of engagement with health services overall. The remainder expressed difficulty finding relevant information – saying it required some ‘digging around and calling’ (Participant 6), that ‘they wouldn’t know where to look’ (Participant 8), or they would accept the cost when it came as they had ‘no choice’ (Participant 5). Nevertheless, most participants identified cost as an essential factor in their decisions about accessing health care.

Knowledge of the Code of Rights was acquired via either a physical poster in hospitals (n = 2) or being told as part of receiving treatment (n = 1). The remaining participants had never heard about their rights before.

Impressions around communication with practitioners were generally positive; participants expressed that they felt listened to and that practitioners were friendly. For a few participants, the different practice styles took some adjustment; for example, they felt like their concerns were not taken seriously. Participant 4 said, ‘Asians believe that everything they are given for every disease is just a simple Panadol’. There was also some consternation around being asked to give their own opinion.

Sometimes, I’ve seen here in New Zealand what happens is the GP asks you, “So what do you think about it?” And I feel like, why are you asking me this? Because if I knew what I thought about it, I wouldn’t come here. (Participant 8)

Regarding language, none of the participants had experience using interpreters, although two thought it could be useful, especially for jargon. Several participants expressed concerns about being understood correctly. Another participant witnessed an interaction between an interpreter, nurse, and patient, and noted that the interpreter was providing their own opinion while not translating everything the nurse said – this raises a question about the training requirements for interpreters in general practice.

Participants appreciated the friendliness of staff, receiving funded care, and having access to their health information; however, nearly all participants mentioned feeling frustrated at waiting times to receive care and at the costs of services. There was also some trepidation from not understanding the referral system or the public–private model in general.

Enrolment took 3–5 years for six participants; two were enrolled within a year after arrival. The remaining participant was unsure about their enrolment status. Asian and migrant-specific resources were perceived as lacking; only one participant had ever received Asian-specific information. Another participant noted that during an assessment of risk factors, all Asian groups were in a single category – they felt this was not representative of different lifestyles and risks. Several participants also mentioned an underlying assumption of knowledge:

…the dynamics of class and migrancy, that’s not understood. Whenever I am dealt with, I’m dealt with the assumption that you should know this. I was like, how? Is there a course? (Participant 5)

There was an overwhelming request for simplified, summarised information that introduced the NZHSy. Suggestions included providing information during the immigration process or on arrival in NZ; one participant wanted a brochure that could be given at health centres when someone discloses they are a migrant.

Another suggestion was a website for migrants with relevant and translated information that could be a reference point. Several participants mentioned a flowchart to direct migrants through services, similar to those used by Inland Revenue.

The research reported in this paper aimed to document and analyse the current navigational resources available online to Asian migrants, and explore barriers perceived by Asian migrants in navigating the NZHSy, with a particular focus on general practices.

The key findings of this research indicate that information designed to aid the navigation of the NZHSy is generally lacking, especially for Asian migrants. The nature of currently available resources reflects an assumption of baseline knowledge that most migrants will not have. Understanding a health system is crucial in continued and confident engagement; providing more introductory and tailored information is an important and effective way to improve this.^{41,43,49–52} Little information about the implications of different citizenship or residency status was present; non-English resources were similarly lacking. Although website contents were infrequently discussed within literature, linguistic accessibility has been identified as a critical component of systems health literacy for migrant populations.^9,42,43,52

Resources targeted towards either Asian patients or migrants on practice websites were scarce. Within dedicated ‘Support’ and/or ‘Resources’ sections, information was not designed for Asian peoples or migrants, but for general resources such as chaplaincy services. The importance of cultural safety and Asian-specific health resources have previously been highlighted.^8–10

This lack of available, navigation-assisting resources was confirmed via the interview data. Most participants were not confident about navigating the NZHSy. No participants were provided information on arrival in NZ, and relevant information was difficult to find online. Consequently, participants relied on other sources, such as social networks, to learn about health care. Despite the expressed importance of knowing the costs of services, participants described difficulty finding relevant information. The absence of Asian or migrant-specific information was also felt, and there was a profound lack of knowledge about consumers’ rights. These appear to be common barriers to migrants’ healthcare navigation.^{45,48,52–57}

The interview data indicated a desire for simplified and summarised knowledge and migrant-targeted information in different languages. One suggestion was a brochure given to migrants to provide an introduction and guide to the NZHSy. This bears similarities to the Personal Child Health Record (‘red book’) given to new parents in the UK, which is helpful,⁵¹ and the Taiwan Immigration Agency’s newcomer programme, which includes an information toolkit that assists immigrants in applying for medical insurance and the like.⁵⁸ Currently, there are insufficient resources to support interaction and optimal engagement with the NZHSy.

Information on professional interpreter services was rarely available on general practice websites. This finding was reflected in the interview data, as no participants had used this service even when it may have been needed. This need was primarily due to the use of jargon, but also due to concerns about expressing issues adequately in English. Literature has recommended avoiding jargon and discussed mistrust of interpreters, which may be a factor in this lack of access.^47,50,51

One limitation of this research is that selection and analysis of the general practice websites were achieved through manual searches. Thus, errors may be present both in the location and analysis of resources. However, many websites were analysed following a coding framework for consistency, increasing data accuracy. Additionally, the interviews only being conducted in English excluded those who would have had linguistic barriers in seeking health care in NZ; a small sample size further limits the generalisability of this study. Nevertheless, this research has further explored some of the vital navigational barriers to optimal health-seeking behaviours for Asian migrants in NZ. Further, this research was completed prior to 2022 NZ Health reforms taking effect; hence, the findings are reflective of the responsiveness of the NZHSy to NZ Asians prior to this reform. Nonetheless, this study’s findings will contribute towards ongoing, population-specific health service reforms, and pave the way for future research to improve Health NZ’s responsiveness to Asians and other minority groups.

Overall, the current research indicates a lack of navigational resources for Asian communities on general practice websites for improving navigational health literacy and health services engagement.

As a crucial part of primary care, general practice websites do not sufficiently support navigation or understanding of the health system for the Asian population group in NZ. Including an overview of how Health NZ functions in providing health care and professional interpreter services, while increasing accessibility through resources in Asian languages that are culturally appropriate, would be critical to increase engagement with healthcare services and thus contribute to better health outcomes for NZ Asians.

Data from this study are not publicly available.

The authors declare no conflicts of interest.

This study received funding from the Dean’s Scholarship of Otago Medical School, Dunedin, in 2022. The funder played no role in the design of the study.

Supplementary material is available online.