Journal of HIV for Clinical and Scientific Research Assessment of Level of Knowledge and Practice of Nursing and Midwifery Students on HIV Post Exposure Prophylaxis in Hawassa University, Ethiopia

Endalew Gemechu Sendo
College of Health Science
School of Nursing and Midwifery
Addis Ababa University
Addis AbabaP.O.Box 1176, P.O.Box 1176Ethiopia, Ethiopia, Ethiopia

Journal of HIV for Clinical and Scientific Research Assessment of Level of Knowledge and Practice of Nursing and Midwifery Students on HIV Post Exposure Prophylaxis in Hawassa University, Ethiopia

Citation ; : Sendo EG (2014) Assessment of Level of Knowledge and Practice of Nursing and Midwifery Students on HIV Post Exposure Prophylaxis in Hawassa University, Ethiopia . J HIV Clin Scientific Res 1(1): 001-006. ; : ; Sendo EG (2014) Assessment of Level of Knowledge and Practice of Nursing and Midwifery Students on HIV Post Exposure Prophylaxis in Hawassa University, Ethiopia . J HIV Clin Scientific Res 1(1): 001-006.
10.17352/2455-3786.000001Dates: Received: 25 March, 2014; Accepted: 19 April, 2014; Published: 21 April, 2014001 Research Article *Corresponding author: Endalew Gemechu Sendo, Addis Ababa University, College of Health Science, School of Nursing and Midwifery, Addis Ababa,Post exposure prophylaxisHuman Immunodeficiency virusnursing/midwife studentsHawassa UniversityEthiopia Citation
Background:Nurses, midwives and other health care workers are at risk from Human Immunodeficiency Virus (HIV) and other blood borne infections in the workplace. Post exposure prophylaxis of HIV is the only way to reduce risk of HIV after potential exposure to needle pricks, blood and body fluids.Objectives:The objective of this study is to assess the level of knowledge and practice of nursing and midwifery students regarding post exposure prophylaxis for HIV in Hawassa University, College of Medicine and Health Science in Ethiopia.Methods: Institution-based cross-sectional descriptive study was conducted from October to December 2013. A total of 185 students (comprising of 136 nursing and 49 midwifery) who were eligible for the survey were involved in the study. Data was collected using pretested self-administered questionnaires. Data was entered and analyzed by Statistical package for Social Science (SPSS) version 20. Associations of selected variables with HIV PEP use were assessed using chi-square test. A p-value of <0.05 has been considered as statistically significant. The results were presented in frequency tables and percentages.Results:A total of all 185 students belonging to 2 rd , 3 rd and 4 th years of nursing / midwifery students participated in the survey. The mean age of respondents was 21.04 ± 1.59 years.Among all of the respondents, 54 (29.2) were exposed to HIV risky conditions and of these exposed respondents, the most 32(59.3%) started PEP. The main reasons reported as a cause of exposure to HIV risk conditions in the work place were; lack of protective barriers 43 (79.7%) followed by lack of knowledge on standard precautions 10 (18.5 %). Students of final year were more likely to Practice PEP (p=0.01) as compared to students studying in 2 nd year and 3 rd year. However, post exposure prophylaxis use was not associated with gender and professional category (P>0.05)Conclusion and Recommendations:The present study revealed that the level of knowledge and practice of Nursing and midwifery students regarding post-exposure prophylaxis against HIV was inadequate. Accessible PEP centre with proper guideline is recommended so that their practice towards utilization of PEP can be enhanced.

The World Health Organization (WHO) estimates that 3 million percutaneous occupational exposures to blood or other body fluids occur in health care settings. CDC estimates 380,000 needle stick injuries in US hospital yearly. Globally 98 confirmed and 194 possible cases of HCWs infected of HIV occupationally. Ninety percent of occupational exposure across the world occurred in developing countries [4]. In developing countries like Ghana, Indonesia and Uganda, 80-90% of patients who visited a health centre received one or more injections per visit [5]. A positive correlation has been Background HIV/AIDS is a serious public health problem costing the lives of many people including health care workers and health science students [1]. It is probably the most serious and causes the highest level of anxiety amongst health care workers (HCWs) and students in many countries [2]. Each day thousands of healthcare workers (HCWs) around the world suffer accidental occupational exposures to blood borne pathogens [3,4].

reported between the frequency of injections and the prevalence of blood-borne infections in the population. In South Africa, 91% of junior doctors reported sustaining a needle stick injuries [NSI] in the previous year [6] . In Ethiopia, there are 800,000 people living with HIV/AIDS and 1.5% of population aged 15-49 is infected with HIV [10]. However, there is no national study concerning risks of accidental blood exposure and PEP use in Health care workers in Ethiopia.

Post exposure prophylaxis (PEP) prevents 81% of sero conversion [1]. The estimated risk of HIV transmission is 0.3% after a needle stick injury and 0.09% after a mucous-membrane exposure [1,5]. Nurses and midwives are probably the most vulnerable of all the health care workers to get exposed to the occupational hazard of HIV infection. In developing countries, the risk of occupational transmission of blood-borne pathogens is increased by excessive handling of contaminated needles that result from unsafe practices like administration of unnecessary injections on demand, the reuse of non-sterile needles, capping needles, and the unregulated disposal of hazardous waste [5,6].

These are largely preventable through strict infection control, universal precautions, use of safe devices, proper waste disposal and prompt management of exposures including the use of post-exposure prophylaxis for HIV [7]. Post exposure prophylaxis is currently the only way to reduce the risk of HIV infection in someone exposed to the virus. It refers to the use of antiretroviral medications to help prevent HIV transmission. The rationale is that ARVs given immediately after exposure can stop the virus from disseminating in the body and establishing infection. The majority of occupational exposures do not lead to HIV infection [6].

Preventing the occurrence of HIV infection resulting from such accidental injuries at work place and the use of HIV Post-exposure prophylaxis (PEP) is recommended by WHO/ILO [1,9]. With regard to this, the Federal Ministry of Health of Ethiopia developed guidelines for infection prevention and PEP use (in the ART guideline) in 2004 and 2005, respectively [7,8].

Nurses are an integral part of the healthcare system and are perceived to be knowledgeable in providing institutional and community health care to the patients [10,11]. They play an important role in providing healthcare to patients, especially in rural areas of the country as there is less number of doctors. The role of nurses is even becomes more critical in a society that is battling to control and prevent HIV/ AIDS infection and related super infections [12,14].

According to the World Health Organization, the exact scale of occupational risk in the health sector is unclear, partly because of the stigma and blame attached to the reporting of sharps injuries and the lack of available post-exposure prophylaxis [4,5]. Nursing students are also at risk of such infections and injuries due to accidental contamination during their practical occupational exposure.

Nurses are usually at the forefront of patient care [13]. So when they are students they need to have an adequate knowledge and a positive attitude towards healthcare problems including HIV/ AIDS which has recently become a major public health concern in the country [15,16]. In contrary to their roles, studies from different countries have reported a poor knowledge among the nurses regarding HIV/AIDS [17]. However, at a national level the number of health professionals and students that suffer from sharp injuries remains unknown in Ethiopia. Thus, identifying the knowledge of nursing students may provide baseline data which may then be a useful source for intervention. Providing pertinent information on PEP for the health care professionals including students would help to prevent the transmission of HIV, provide epidemiological data, identify unsafe practices, and reduce anxiety, and/or productivity.

This study, therefore, assessed the level of knowledge and practice of nursing and midwifery students on HIV post exposure prophylaxis in Hawassa Univesrsity, College of Medicine and Health Sciences in Ethiopia.

Hawassa University [HU] is 275 km away from Addis Ababa to the South of Ethiopia. It was established at heart of Hawassa City in April 2000. Since 1976, the different colleges of HU had been operational starting with the College of Agriculture. Today, HU is a comprehensive university engaged in the provision of all-round education, research, training, and community service through its diversified areas of academic programs. Currently, the university has an undergraduate student population of 22,000 consisting of 18,203 males (82.7%) and 3797 females (17.3%). Most of the students come from the rural areas of Ethiopia.

Methods

Study design, sample size and sampling technique

Institution-based cross-sectional descriptive study was conducted from October to December 2013. The study participants were all regular undergraduate nursing/midwives students of Hawassa University who registered for the academic year of 2013. Census sampling method was used. All second year and above nursing/midwives students were eligible to participate in the study. However, students of pre-clinical years (1st year) were excluded from the survey. A total of 185 students (comprising of 136 nursing and 49 midwifery) who were eligible for the survey were involved in the study

Data collection

Data was collected using pretested self-administered questionnaires. The questionnaire was adopted from reviewed literatures [2,3]. The questionnaire was translated into the Amharic (local language) by linguistic professionals. The respondents were approached in their respective departments and after taking an informed verbal consent, the questionnaires were distributed. Then the completely filled questionnaires were collected on the same day

Data analysis

Data was entered and analyzed by Statistical package for Social Science (SPSS) version 20. In descriptive analysis, the mean and standard deviation of continuous variables and percentages of categorical variables were computed. Associations of selected variables with HIV PEP use were assessed using chi-square test. A p-value of <0.05 has been considered as statistically significant. The results were presented in frequency tables and percentages

Ethical consideration

The ethical clearance was obtained from the institutional review board of Hawassa University. All study participants were adequately informed about the purpose, method and anticipated benefit of the study by the data collectors. They were given clear options regarding voluntary participation. Verbal consent was obtained from each participant and confidentiality of the study subjects was maintained.

Operational definitions and terms used in this study:

Adequate Knowledge-when respondents correctly answer > 75 % of the seven knowledge questions.

Inadequate knowledge-when the correct answer of respondents is < 75 % of the seven knowledge questions.

Post-exposure prophylaxis (PEP) is short term antiretroviral treatment given to reduce the likelihood of HIV infection after potential exposure occupationally.

PEP use /practice-reported as respondents have practiced using Post-exposure prophylaxis of HIV following occupational exposure to HIV risky conditions.

HIV risky conditions-when they are exposed to occupational hazards through per cutaneous injury such as needle stick or cut with sharps, contact with the mucus membrane of eyes or mouth of HIV infected person, contact with non intact skin exposed with blood or other potentially infectious body fluids in the workplace.

Results

Socio demographic characteristics

A total of all 185 students belonging to 2 rd , 3 rd and 4 th years of nursing /midwifery students participated in the survey. Therefore, the response rate in our study was 100%. One hundred thirty Six students (73.5%) were from nursing and while 49 students (26.5 %) were from midwifery categories. Ninety seven (52.4%) were female while eighty eight (47.6 %) students were male. The mean age of respondents was 21.04 ± 1.59 years. Majority 105 (56.7 %) were Christians. Regarding the marital status of the respondents, most 181 (97.8 %) of them were single.

Respondents' Knowledge of HIV post exposure prophylaxis

Respondents' knowledge of post exposure prophylaxis is as presented in Table 1 below. When asked to state if they were familiar with the concept of post exposure prophylaxis, the most 124 (67.1%)

Characteristics Number (%) Total (%)

Ever heard about Post exposure prophylaxis ( N=185) With regards to the source of information about PEP, out of 124 respondents who ever heard about PEP, most of the students responded that it was taught as a part of the curriculum (61.3%). Other important sources of information mentioned by the students included personal studies (17.7%), seminars (15.4%) and posters (5.6%). One hundred twenty one (65.4 %) respondents correctly answered that cerebrospinal fluid is considered as high risk body fluids for transmission of HIV, followed by semen 120(64.8%), blood 118(63.8%) and vaginal discharge 84(45.4 %) respectively. Only 60(48.4%) respondents knew that PEP initiation is best within 2 hours of needle prick injuries and 88(71%) knew that PEP is given for 28 days.

Yes No

Professional category

Twenty six (21%) of the respondents reported that they don't know PEP guidelines. Eighty six (46.5%) of nurses and 46(24.9%) of midwives answered correctly that PEP is indicated for person who is exposed to HIV risk by needle sticks or cuts, followed by person who is exposed to HIV with blood or body fluids in eyes and mouth 55(29.7%) nurses versus 84(45.4%) midwives and person who is exposed to HIV with blood or body fluids in broken skin only 24.2% nurses versus 30.8% midwives.

Respondents' level of knowledge was measured by calculating the total possible score in PEP of HIV questions & classified into 2 categories: Adequate knowledge (above 75 percentile), and inadequate knowledge (below 75 percentile). The majority (63 %) of the respondents had inadequate knowledge on PEP of HIV.

Respondents' exposure to HIV risk conditions and practice of PEP

Respondents' exposure to HIV risk conditions and practice of PEP was shown in Table 2. Among all of the respondents, 54 (29.2) were exposed to HIV risky conditions and of these exposed respondents, 32(59.3%) took PEP. However, 22 (40.7%) of the exposed respondent did not take PEP. Also worth mentioning is the fact that even out of those 32 respondents that agreed to use PEP, only 24 respondents completed the recommended duration for the use of PEP.

Among the respondents who ever exposed to HIV risky conditions, 28 (51.9%) of the respondents have sustained needle stick injury during their clinical practice, 18 (33.3 %) exposed to blood and 8(14.8%) exposed to body fluids. The main reasons reported as a cause of exposure to HIV risk conditions in the work place were; lack of protective barriers 43 (79.7%) followed by lack of knowledge on standard precautions 10 (18.5 %). Of the 22 participants who didn't initiate PEP, the major reasons reported for not using PEP of HIV after exposure were lack of awareness of the existence of PEP service/ protocols by 19 (86.4%), worried about side effect of drugs by 10 (45.5%), lack of support and encouragement to report by 8 (36.4%), and the patient was at low risk for HIV by 4(18.2%). Table 3 details the association between selected variables and HIV PEP Practice. Using Chi square test, the year of study emerged as an independent predictor for receiving PEP for HIV. Students of final year were more likely to Practice PEP (p=0.01) as compared to students studying in 2 nd year and 3 rd year. However, post exposure prophylaxis use was not associated with gender and professional category (P>0.05).

Discussion

This study assessed the level of knowledge and practice of nursing and midwifery students on HIV post exposure prophylaxis in Hawassa Univesrsity, College of Medicine and Health Sciences in Ethiopia.

Characteristics Number (%) Total (%)

Ever been exposed to HIV risky conditions (N=185)  Health care workers and students on training who are directly involved in treating and nursing patients face a great risk of acquiring blood-borne infections from the workplace [19]. In health care settings there is an increased risk of HIV transmission to HCWs because of occupational exposure to blood borne infection from needle sticks [20]. Evidence suggests that treatment with antiretroviral drugs soon after occupational exposure to HIV decreases the risk of infection.

Typically regimens are prescribed for a four week period; PEP should be started within hours of the potential exposure not days. The sooner PEP is started the better, and it should be started within the first 72 hours after exposure [21].

In the present study, among all study participants 67.1 % have heard about PEP for HIV. This finding is lower compared to other study which was conducted in a tertiary hospital in Nigeria (97%) and Gonder in Ethiopia (92.8%) [15,16], respectively. Considerably high proportions (63 %) of nursing and midwifery students were knowledgeable about PEP of HIV in this study area. The findings of this study are higher than the results of the study done in Malaysia Hospital where 56% of nurses and 25% of midwives were aware of correct risk of transmission of HIV at work place [1,17].

The proportion of respondents who heard about PEP of HIV from formal class room lectures was 61.3%. In this study, it was evident that the theoretical aspects of training of trainees emphasized the importance of incorporating the concept of PEP into classroom activities as the majority of the respondents claimed to have the information about PEP during their classroom sessions. However, some students seemed to be making use of the opportunity for personal studies through the reading of books and journals to make up for whatever deficiency they had in the class as a total of 17.7 % got information about the concept of PEP from the literature.

However, the role played by display of posters and similar IEC materials was extremely low among the respondents (5.6%). Generally, the posting of such materials on strategic locations within the hospital and class rooms was very limited to only a few places.

Considering the importance of such materials in reminding, warning and informing health Science students as regards what they need to know and/or do, it could be more helpful if information is provided on visual aid within each ward or unit and other strategically located places within the hospital or college vicinity.

In the present study, 65.4 % of respondents had knowledge that high risk body fluids for transmission of HIV are cerebrospinal fluid followed by semen (64.8 %), blood (63.8%), and peritoneal fluid (40.5%), respectively. This finding is supported by a study of Foster,Lee, Mcgaw & Frankson which showed that, participants considered the following fluids high risk for HIV transmission: CSF (55%), peritoneal fluid (53%) breast milk (79%), saliva (14%), urine (27%), pleural fluid (53%), synovial fluid (37%), feces (27%), and vomitus (21%) [18].

In this study, almost half (48.4 %) of respondents had knowledge that the best time for initiation of PEP is within 2 hours of exposure. This finding is almost similar with a study of Alenyo, Fualal & Jombwe which showed that 51.8 % of respondents' had knowledge about best time for initiation of PEP [18,19]. However, the current findings is higher than the finding from study conducted in Mulago Hospital in Uganda which showed only 22.3% being sure it should be started within an hour of exposure [11]. The difference might be because of the difference on the level of awareness among the different study populations.

Regarding respondents' exposure to HIV risk condition & practice of PEP, only 29.2% of respondents reported that they had exposed to HIV risk condition in their work place. Among 54 respondents exposed to HIV risk conditions, 51.9 % of them sustained needle prick injury, 33.3% of them exposed to blood and 14.8 % of them exposed to body fluids. This finding is supported by a study of Bosena et al. [1,18] which showed that out of 174 who were exposed to risk of HIV, 60.3% sustained needle prick/cut by sharps, 44.3% to blood and 39.1% exposed to patients' body fluid. This study showed that large number of students reported as they have ever been exposed to HIV risk conditions which is higher than the 2003 Italian study that indicated the overall (HIV, HCV, HBV) occupational exposure to be 11.3, 11, 4.9, and 4.1%, in midwives, nurses, cleaners, and laboratory technicians, respectively [22].

As regards to respondents' opinions on causes of exposure to HIV risk, 79.7% of respondents perceived lack of protective barrier followed by lack of knowledge on standard precautions (18.5%) & others (1.8%). This finding is supported by a study of Bosena et al which showed that the perceived causes of exposure were; high workload 44.3%, lack of protective barriers 33.3% and lack of knowledge on standard precautions 17.8% [1,18].

Nevertheless, 29.2% of the exposed respondents who took PEP for HIV in this study, only 75 % of them were able to complete the regimen of the drug which requires 28 days. However, of those exposed, 25% reported that they did not use PEP. This finding was in agreement with other study conducted in Dares Salaam in which they showed that 40% of the respondents failed to use PEP for the full length of time prescribed [20].

On the other hand, study conducted in Gujarat showed that their respondents had better practice in this regard than our study participants in which more than 94% were able to complete the regimen [21,23]. This fact alerts that the practice of PEP for HIV in the study area needs improvement. This difference might be due to the difference in the study settings. The difference could also be explained by the fact that our study population included only students, while  the other studies have included all health care workers and students. Generally, the need to embark on actions aimed at ensuring protection of health personnel including students thus become very apparent so as to limit chances of HIV infection from the workplace.

One strategy to minimize long-term consequences of occupational hazards including needle stick injuries is to improve medical student awareness about occupational health. Assessing the risk of an exposure, management protocols, and understanding the role and risk of anti-retroviral prophylaxis are important concepts to teach.

Conclusion and Recommendations

The present study revealed that the level of knowledge and practice of Nursing and midwifery students regarding post-exposure prophylaxis against HIV was inadequate.

Prevention of occupational infection with blood-borne pathogens to these young students who are not yet in employment should be a priority to the national program for promotion of infection control. Hence, establishing a system that includes written protocols for prompt reporting of occupational exposure, evaluation, counseling, treatment and follow-up is imperative. Students should have access to clinicians who can provide post exposure care during all working hours, including nights and weekends. Antiretroviral agents for PEP should be readily available for timely administration. . Moreover, formal pre-service training for all students regarding PEP for HIV should be provided to advance their knowledge. Accessible PEP centre with proper guideline is also recommended so that their practice towards utilization of PEP can also be enhanced.

Table 2 :
2Respondents' exposure to HIV risky conditions and Practice of PEP, Hawassa University, December 2013.** Multiple responses

Table 3 :
3Factors associated with HIV PEP Practice. Copyright: © 2014 Sendo EG. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Sendo EG (2014) Assessment of Level of Knowledge and Practice of Nursing and Midwifery Students on HIV Post Exposure Prophylaxis in Hawassa University, Ethiopia . J HIV Clin Scientific Res 1(1): 001-006. DOI: 10.17352/2455-3786.000001
AcknowledgmentsI would like to thank Hawassa University Research and Publication Office for financing this research project. I am indebted to all students who provided me their responses. I also thank data collectors for their support.
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Dutch national scientific research program on land subsidence Living on soft soils -subsidence and society
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ErkensE Stouthamer
Delft University of Technology

G Cohen
Delft University of Technology

HeggerK
Delft University of Technology

Driessen, P., Weikard, H. PD Hefting
Delft University of Technology

M Hanssen
Delft University of Technology

FokkerR
Delft University of Technology

AkkerP A
Delft University of Technology

J V D
Delft University of Technology

Van Rijswick
Delft University of Technology

M
Delft University of Technology

Dutch national scientific research program on land subsidence Living on soft soils -subsidence and society

Proceedings of the IAHS Citation (APA) TISOLS: the Tenth International Symposium On Land Subsidence -living with subsidence
the IAHS Citation (APA) TISOLS: the Tenth International Symposium On Land Subsidence -living with subsidenceIAHS38210.5194/piahs-382-815-2020Publication date 2020 Document Version Final published version Published in (2020). Dutch national scientific research program on land subsidence: Living on soft soils -subsidence and society. In P. A. Fokker, & G. Erkens (Eds.), Proceedings of the IAHS: Important note To cite this publication, please use the final published version (if applicable). Please check the document version above. Takedown policy Please contact us and provide details if you believe this document breaches copyrights. We will remove access to the work immediately and investigate your claim. This work is downloaded from Delft University of Technology. For technical reasons the number of authors shown on this cover page is limited to a maximum of 10.Stouthamer, EstherErkens, GillesCohen, KimHegger, DriesDriessen, PeterWeikard, Hans PeterHefting, MarietHanssen, RamonFokker, Peter AAkker, Jan van den
In the Netherlands land subsidence is a continuously ongoing process. Consequently, an increasing number of people and economic assets are exposed to subsidence, damage costs are soaring, and flood risk and greenhouse gas emissions are increasing. In some areas tipping points have already been reached, where current land-use can no longer be maintained without considerable costs, underlining the urgency to take action.Together with a consortium consisting of universities, research institutes, governmental agencies, public and private partners we have developed a national, multidisciplinary research programme aiming to develop an integrative approach to achieve feasible, legitimate and sustainable solutions for managing the negative societal effects of land subsidence, connecting fundamental research on subsidence processes to socio-economic impact of subsidence and to governance and legal framework design.The program is designed to co-create insights that help to effectively mitigate and adapt to subsidence within the Netherlands by making major improvements in measuring and modeling the processes and consequences of subsidence, identifying, developing and critically evaluating control measures and designing governance and legal approaches that facilitate their implementation. Hereto we will develop (a) new satellite-based technology to measure, attribute and monitor subsidence, (b) solid understanding of the interacting multiple processes contributing to total subsidence, (c) sophisticated physical and economic numerical models to predict humaninduced subsidence rates and impacts, and (d) implementation strategies that go beyond technical measures, to strengthen governance and financing capacities as well as legal frameworks. This fully integrated approach deals with all impacts of land subsidence on society and the economy.Published by Copernicus Publications on behalf of the International Association of Hydrological Sciences.

Land subsidence in the Netherlands

In the Netherlands land subsidence is a continuously ongoing process due to (1) drainage of peatlands and areas reclaimed from the sea, (2) expansion of built-up areas and the infrastructural network on soft soil, (3) salt mining and gas extraction (Fig. 1). These human-induced drivers result in relatively high rates of subsidence ( ∼ 0.5-10 cm yr −1 . An increasing number of people and economic assets are exposed to subsidence and damage costs are soaring, accumulating to over EUR 5 billion for infrastructure alone till 2050 ( Van den Born et al., 2016). Moreover it gives rise to serious safety issues due to increased flood risks and in case of subsidence as a result of peat oxidation -causes considerable greenhouse gas (GHG)emissions which will further contribute to climate change. Because the shallow subsurface of ∼ 50 % of the Netherlands and ∼ 80 % of the low lying western and northern part contains organic material (peat and organic clay) (Koster et al., 2018), subsidence rates will increase further due to climate change (> oxidation and GHG emission). In some areas (e.g. parts of polder Groot-Mijdrecht, Zuidplaspolder) tipping points have already been reached, where current land use can no longer be maintained without considerable costs, underlining the urgency to take action.

During the last decades a range of mitigation and adaptation measures have been developed, however these are mostly ad-hoc applied local measures in response to incidents. This is caused by the fact that there is still little understanding of the exact rates and processes causing subsidence. That makes that timeliness of implementing measures and their effectiveness are hard to assess by land owners and responsible authorities, stalling implementation of measures at the large scale on which the problem is occurring. The implementation of measures for mitigating or adapting to land subsidence poses governance, economic and legal challenges. Mitigating measures may to some extent enable the continuation and reconciliation of certain land-use functions such as agriculture and nature conservation, but this is not without limits. At some point political choices might need to be made that deviate drastically from existing and historical policies and impact numerous interests and stakeholders.

Subsidence and GHG emissions can be mitigated by smart and efficient management strategies regarding e.g. spatial planning, extraction of hydrocarbons and groundwater, groundwater tables, and land use. However, this requires thorough knowledge on the (interacting) processes causing subsidence, its impacts and possible integrated solutions.

National scientific research program

The threat of land subsidence, the knowledge hiatus on process-interplays causing it, and lacking mid-to long-term coping strategies, ask for an integrated research program that addresses the issue of land subsidence in a holistic way, whereby insights about physical-chemical-biological system functioning, development, evaluation and implementation of measures as well as an assessment of their governance and legal implications co-evolve.

Therefore, together with a consortium consisting of 3 universities (Utrecht University, Delft University of Technology, Wageningen University), research institutes (Deltares, TNO-Geological Survey of The Netherlands, Wageningen Environmental Research), governmental agencies, public and private partners we have developed a national, multidisciplinary research programme (runtime: 2020-2024) aiming to develop an integrative approach to achieve feasible, legitimate and sustainable solutions for managing the negative societal effects of land subsidence, connecting fundamental research on subsidence processes to socio-economic impact of subsidence and to governance and legal framework design. The program is to contribute significantly to the ability to mitigate and adapt to subsidence in populated, governed deltas in the short and in the long term and via management of subsidence, lower GHG emissions and decrease risks and looming damage for low-lying delta plains under climate change.

Program objectives

The underlying scientific challenges and objectives of this program are to:

1. tailor latest satellite-based radar technology to measure and monitor ground movement at high spatio-temporal resolutions, integrate this with inverse-modelling techniques to disentangle total shallow and deep subsidence, anthropogenic and natural contributions, and offer conscious choices when recombining the geophysically separated components in subsidence projections (spatial forecasts);

2. understand and quantify all mechanisms causing subsidence and associated GHG emission currently at play in the Netherlands, with attention to interrelationships and process-separation uncertainties, offering models of the processes affecting the aerated topsoil and actively consolidating subsoil, which are calibrated at experiment plot scale and recalibrated to coarser cell-scales of the spatial forecasts;

3. develop a set of reliable, alternative-scenario-sensitive spatial forecasts for actual and projected subsidence rates, including modules that convert subsidence rates (mm yr −1 ) to costs (EUR yr −1 ) and use these as operational tools to develop strategies to convey results of cost-benefit analyses to decision makers. The step to costs (pricing) requires to develop algorithms to (i) account for risk of structure-failure under differentiated subsidence, (ii) assessing impacts on agriculture and, (iii) integration of costs and benefits per potential mea- sure (implementation costs, damage, social/health risks, GHG emissions); 4. develop effective and legitimate subsidence mitigation strategies, making use of the findings on drivers of subsidence and its socio-economic impact, supported by governance approaches and the necessary financial and legal frameworks to enable successful selection and implementation of these future-proof, context-sensitive management strategies for intensively used agro-urban delta plains.

Program set-up

The program consists of four scientific work packages and a fifth one on knowledge utilization. To enable direct use of results in policy making, the program covers the 6M approach in dealing with subsidence (Erkens and Stouthamer, 2020): subsidence measuring and analysis of mechanisms, quantifying impacts, deliberating measures and evaluating performance (Figs. 2-3). Each work package delivers knowledge of direct use to activities of the linked step in the policy cycle.

Work packages

WP1 -Measuring and monitoring of subsidence rates at local and regional scales: will utilize InSAR satellite- based radar technology at high spatio-temporal resolutions and integrate this with geophysical modelling techniques, to disentangle total ground movement into shallow and deep and anthropogenic and natural contributions, including sea-level rise related subsidence Figure 3. Program structure. We will follow an iterative approach whereby insights from the different work packages feed into one another and enrich the knowledge needs addressed by other WPs.

components. InSAR techniques will be developed to monitor soft soil subsidence in agricultural and urban areas, with disentangled signals of groundwater, salt and hydrocarbon extractions (inverse modelling) and glacioand hydro-isostasy (GIA modelling, gravimetry, background regional relative sea-level rise).

WP2 -Mechanisms and GHG emissions: aims to unravel, better understand and quantify the interacting subsidence processes such as peat oxidation with associated GHG emissions, compaction, shrinkage, creep, and examine the environmental impact of subsidence mitigation measures. It includes parameterization and calibration of process models used to analyze and forecast subsidence.

WP3 -Impact analysis: focusses on predictive modelling by integration of process models in one numerical framework to predict subsidence under different management scenarios, and the development of new methods to estimate subsidence-related damage to infrastructure, buildings and agriculture, besides GHG emissions, as input for an socio-economic cost-benefit analysis (SCBA, converting mm yr −1 to EUR yr −1 ). This work package has a focus on numerical model development and (big) data analyses and includes geomod-elling, material science research and economic modeling.

WP4 -Measures and governance approaches: aims to (i) identify suitable mitigation, adaptation and compensation measures, (ii) develop economic and financial tools aiming at supporting parties to carry the costs of damage and/or implementation of measures, (iii) provide recommendations for strengthening governance capacities for dealing with existing and new challenges (e.g. drought, salinization due to sea-level rise) in water management and spatial planning, (iv) develop equitable and legitimate legal frameworks to effectively implement new strategies of dealing with subsidence.

WP5 -Knowledge utilization and entrepreneurship: will translate the scientific results to practice in close cooperation with knowledge-users and entrepreneurs; design and development of innovative mitigation and management strategies under different scenarios of socioeconomic and climatic circumstances.

Knowledge utilization is an integral part of this research program. Knowledge-users are part of the consortium and stakeholders in case study areas will be actively involved.

Expected deliverables

As results, the program is expected to deliver:

1. Technology for satellite-based subsidence monitoring, interpretation and use in forecasting (WP1); 2. Improved empirical understanding and knowledge integration on individual processes and their interactions and feedbacks driving soft soil subsidence, including upscaled calibration allowing to implement it in spatial models (WP2), and operationalize it for damage quantifications and cost-benefit analysis (WP3);

3. Open-source spatial subsidence models and forecast maps (scenarios), that will support decision-making and policy-design (WP3-4), developed aligned with existing (TNO-GSN) and newly launched (NIB) national data infrastructure, to feed, host and reiterate such modelling.

4. Technical and economic measures to mitigate and adapt to subsidence.

5. Governance and legal strategies that facilitate the implementation of proposed measures: policy and decision support tools to manage subsidence.

Data availability.

No data sets were used in this article.

Author contributions. ES wrote the paper. GE commented on an earlier draft of this paper. This paper is based on the research proposal "Living on Soft Soils: Subsidence and Society" (NWO-NWA) that was initiated and coordinated by ES. All authors of this paper contributed to the design and writing of the research proposal.

Competing interests. The authors declare that Gilles Erkens is member of the editorial board of this special issue but has not reviewed this paper, nor has he influenced the publication decision process.

Special issue statement.

This article is part of the special issue "TISOLS: the Tenth International Symposium On Land Subsidence -living with subsidence". It is a result of the Tenth International Symposium on Land Subsidence, Delft, the Netherlands, 17-21 May 2021.

Financial support. The Dutch National Scientific Research Program on Land Subsidence: Living on Soft Soils -Subsidence and Society will be primarily funded by the Dutch scientific organization (NWO-NWA, grant: NWA.1160.18.259), and will be cofunded and supported by 17 consortium partners (see above).

Figure 1 .
1(a) Land subsidence over the last 1000 years in the coastal peat lands of the Netherlands due to drainage, loading and peat mining(Erkens et al., 2016). (b) Prediction of the amount of land subsidence for the coming decades, showing land subsidence of soft soils, salt mining and gas extraction(Erkens et al., 2017).

Figure 2 .
2The program framework and approach link up with the policy cycle to ensure uptake of the research results in policy and to facilitate implementation of effective measures (after:Erkens and Stouthamer, 2020).
Proc. IAHS, 382, 815-819, 2020 proc-iahs.net/382/815/2020/
proc-iahs.net/382/815/2020/ Proc. IAHS, 382, 815-819, 2020

The 6M approach to land subsidence. G Erkens, E Stouthamer, Proc. IAHS, this volume. IAHS, this volumeErkens, G. and Stouthamer, E.: The 6M approach to land subsi- dence, Proc. IAHS, this volume, 2020.

Double trouble: Subsidence and CO 2 respiration due to 1,000 years of Dutch coastal peatland cultivation. G Erkens, M J Van Der Meulen, H Middelkoop, Hydrogeol. J. 24Erkens, G., Van der Meulen, M. J., and Middelkoop, H.: Double trouble: Subsidence and CO 2 respiration due to 1,000 years of Dutch coastal peatland cultivation, Hydrogeol. J., 24, 551-568, 2016.

G Erkens, J Stafleu, J J H Van Den Akker, Bodemdalingvoorspellingskaarten van Nederland, versie 2017, Deltares rapport klimaateffectatlas. Erkens, G., Stafleu, J., and Van den Akker, J. J. H.: Bodemdal- ingvoorspellingskaarten van Nederland, versie 2017, Deltares rapport klimaateffectatlas, 2017.

3D distribution of organic matter in coastal-deltaic peat: implications for subsidence and CO 2 emissions by human induced peat oxidation. K Koster, J Stafleu, K M Cohen, E Stouthamer, F S Busschers, H ; G J Middelkoop, F Kragt, D Henkens, B Rijken, B Van Bemmel, S Van Der Sluis, 10.1016/j.ancene.2018.03.001Dalende bodems. 22Van den Born,. Stijgende kosten. Report Planning Agency for the Environment (PBL), report nr. 1064, 93 pp.Koster, K., Stafleu, J., Cohen, K. M., Stouthamer, E., Busschers, F. S., and Middelkoop, H.: 3D distribution of organic matter in coastal-deltaic peat: implications for subsidence and CO 2 emis- sions by human induced peat oxidation, Anthropocene 22, 1-9, https://doi.org/10.1016/j.ancene.2018.03.001, 2018. Van den Born, G. J., Kragt, F., Henkens, D., Rijken, B., Van Bem- mel, B., and Van der Sluis, S.: Dalende bodems, Stijgende kosten, Report Planning Agency for the Environment (PBL), report nr. 1064, 93 pp., 2016.


Utilization of somatic specialist services among psychiatric immigrant patients: the Norwegian patient registry study

Shawel Dawit
Abebe
Jon Ivar Elstad
Lars Lien
Utilization of somatic specialist services among psychiatric immigrant patients: the Norwegian patient registry study
10.1186/s12913-018-3672-yR E S E A R C H A R T I C L E Open Access
Background: Amongst psychiatric patients, the leading causes of reduced quality of life and premature death are chronic viral infections and cardiovascular diseases. In spite of this, there are extremely high levels of disparity in somatic healthcare amongst such populations. Little research has explored patterns of healthcare utilisation and, therefore, this study aims to examine the use of somatic specialist healthcare for infectious diseases and diseases of circulatory system among psychiatric patients from different immigrant groups and ethnic Norwegians. Methods: Register data from the Norwegian Patient Registry and Statistics Norway were used. The sample (ages 0-90+) consisted of 276,890 native-born Norwegians and 52,473 immigrants from five world regions -Western countries, East Europe, Africa, Asia, and Latin America, all of whom had contacts with specialist mental healthcare during the period 2008-2011. Statistical analyses were applied using logistic regression models. Results: Rates of outpatient consultation for circulatory system diseases were significantly lower amongst patients from Africa, Asia and Latin America compared with ethnic Norwegian psychiatric patients. Only patients from Eastern Europeans had a higher rate. With regard to hospital admission, all psychiatric patients had a lower rate than ethnic Norwegians with the exception of those from Africa where the finding was non-significant. In terms of infectious diseases, patients from African countries had significantly higher outpatient and admission rates than ethnic Norwegians. Outpatient consultation rates were lower amongst those from Western and Latin America and hospital admission rates were lower amongst those from Eastern Europe and Asia. Conclusions: The findings suggest that the majority of immigrant psychiatric patients have lower hospitalization rates for circulatory system diseases than Norwegian psychiatric patients. This may suggest that poor access for immigrants is a contributing factor, though the findings were less pronounced for infectious diseases.

Background

An alarmingly high proportion of mental disorder patients have a higher risk of morbidity and mortality, particularly patients with severe mental disorders such as schizophrenia, bipolar disorder, or depression [1][2][3][4][5][6]. The high burden of somatic diseases is the main contributor for excess morbidity and mortality, i.e., about 60% of excess mortality is due to somatic problems [7,8]. In particular, cardiovascular diseases (CVD) and infectious diseases (e.g., pneumonia, tuberculosis and chronic viral infections) are identified as major comorbid somatic diseases in patients with mental disorders [9][10][11]. For example, a review of studies reported that people with depression have a 50% greater risk of CVD [12]. The prevalence of hepatitis among people with severe mental illness is approximately 5 to 11 times higher than the estimated population rates of this infection [12,13]. Studies have suggested that such somatic comorbidities may even be greater among immigrant psychiatric patients, particularly among refugees with post-traumatic stress syndrome and depression [14,15].

Despite such a high burden of somatic comorbidities, rates of undiagnosed and untreated somatic illness are greater in mental disorder patients than in the general population [16]. Mental disorder patients are also subject to unacceptably high levels of disparity in healthcare access and utilization, which contribute to poor somatic health outcomes [16]. In particular, such disparities could be much worse among immigrant patients where underutilization of healthcare services is highly prevalent compared with non-immigrant patients [17,18]. For instance, our recent research work found that the majority of immigrant groups in Norway have generally lower utilization rates of specialist mental healthcare compared to ethnic Norwegians [19]. However, there is little research investigating utilization of somatic medical services among psychiatric immigrant patients. This study therefore aims to examine the use of specialist somatic healthcare services among psychiatric patients with and without immigrant backgrounds.

Mental ill individuals in general may face a number of barriers to use and access to healthcare services, which are associated with patient-and illness-related factors as well as factors related to healthcare providers and the healthcare system. Such factors may influence the recognition and management of somatic illness. Particularly, patients with immigrant backgrounds may experience a number of such barriers. For instance, they might lack information regarding the healthcare system, little knowledge about health behaviours, or inconsistencies between their expectations and what healthcare providers are able to offer [20]. Moreover, access to care might not be straightforward, as a result of waiting lists or a tendency for lower medical referral rates amongst immigrants. Such factors can impact upon an already under-utilised system leading to significant unmet needs amongst psychiatric immigrant patients.

In this study, we therefore aimed to examine differences in the utilization of specialist somatic healthcare between immigrant and ethnic Norwegian psychiatric patients. Specifically, the study describes differences in rates of outpatient visits and hospital admission for circulatory system diseases and infectious diseases since psychiatric patients seem to be particularly affected by these disease categories. The rationale of the study is to identify utilization patterns of somatic healthcare which could suggest specific needs among immigrant psychiatric patients compared to ethnic Norwegian psychiatric patients. The empirical knowledge provided by this study will ultimately inform about inequalities in use and access to somatic healthcare, which will be vital in efforts to improve the coordination of care across the somatic and mental healthcare delivery system for vulnerable groups.

Methods

Study design and population

The base data file, comprising all individuals listed in the Norwegian population register per 1 January 2008 (approximately 4.7 millions), was constructed by linking sociodemographic information from Statistics Norway with data from the Norwegian Patient Registry. The analysed sample was restricted to those who had at least one contact, either outpatient or hospital admission or both, with specialist mental healthcare during 2008-2011 and were living in Norway at the start of 2008 (N = 329,363).

Immigrants were defined in this study as "1st generation", i.e., born abroad by non-Norwegian parents. Because of data protection requirements, specific country background information was only available for the larger immigrant groups, while other immigrants had been pooled into broader background categories (e.g., Latin America, West Europe) by the data provider. This background information was used to construct a variable indicating five world region origins among the immigrants, in addition to Norwegians used as the reference category. Western migrants consist of those from Nordic countries, West and Central Europe, and overseas Western countries. Those from Bosnia-Herzegovina, Poland, Serbia, Russia, and other countries in these parts of Europe were classified as East European migrants. Somalia and 'other Africa' were combined into one category. Turkish immigrants and all migrants with an Asian background were pooled into the Asian migrant category, while the Latin America category was kept unchanged.

Variables

The outcome variables were dichotomized and indicated whether the psychiatric patients in the study sample had attended one or more outpatient appointments or had been admitted to a somatic hospital during the four years 2008-2011, either due to infectious diseases or to diseases of the circulatory system, i.e., Chapters I and IX in the International Classification of Diseases (ICD), 10th Revision [21].

Gender was coded 0 for males and 1 for females. Information about age was only available in ten-year bands, due to data protection stipulations; the age variable (per 1 January 2008) was categorized into 0-19 years, 20-59 years, and 60 years and above.

Statistical analysis

After describing the study population, logistic regression models were used to analyse use of specialist somatic healthcare during 2008-2011 among those with a Norwegian background and the immigrants classified according to world regions of origin. Estimates were adjusted for age and gender. The results from these regression models are reported as marginal effects (predicted probabilities with robust standard errors -β (se)). Reporting marginal effects makes interpretation more easy since the marginal effects indicate average change in the probability of the outcome (P (y = 1)) when taking into account the distribution of the other independent variables across all observations. The reported results denote the predicted probability of having had at least one contact with specialist somatic healthcare (either outpatient, or hospital admission) because of conditions of the circulatory system or because of infectious diseases during the study years. Estimates were judged as statistically significant when p-values ≤0.05. The analyses were made by means of Stata SE/14.

Results

Characteristics of the study population Table 1 illustrates that, of the total number of psychiatric patients (N = 329,363) there was a higher proportion of children and adolescents aged 0-19 and a lower proportion of those aged 60 and above in the immigrant sample, compared to the sample of ethnic Norwegians. About half of immigrant psychiatric patients were from Western countries. In total, about 8% of the ethnic Norwegians and 4% of the immigrants had outpatient contact with specialist somatic healthcare for circulatory system diseases at least once during the years 2008-2011. The rates of outpatient contacts for infectious diseases were comparable between Norwegians and immigrants. In both types of disease categories, immigrant psychiatric patients had lower hospital admission rates than ethnic Norwegian psychiatric patients.

Utilization of specialist somatic healthcare services across world regions of origin Table 2 presents utilization rates among Norwegians and immigrants from the five world regions of origin, i.e., the proportions (in %) who made contact at least once during 2008-2011. It indicates that Norwegians and Eastern European psychiatric patients had a higher proportion of outpatient visits for circulatory system diseases, while immigrants with African origins had a higher proportion of hospital admission for circulatory system diseases. For infectious diseases, there were less marked differences as to the outpatient visit, while Norwegians had a higher rate of hospital admissions.

Marginal effects (predicted probabilities) for each world region of origin, age-and gender-adjusted, estimated by logistic regression models, are presented in Tables 3-4.

These predicted values indicate the probability of outpatient visit and admission to specialist somatic hospitals among specific world regions of origin.

In Table 3, for circulatory system diseases, East European psychiatric patients had significantly higher outpatient visits than the ethnic Norwegian psychiatric patients, while those with Africa, Asia and Latin America backgrounds had a significantly lower outpatient visits. As to the rate of admission for circulatory system diseases, all psychiatric immigrant patients had significantly lower rates compared to Norwegian psychiatric patients, except for those from Africa who did not differ significantly from the Norwegian psychiatric patients.

Predicted probabilities in Table 4 indicate that African psychiatric patients had significantly higher outpatient visits and admission rates for infectious diseases than the Norwegian psychiatric patients. Psychiatric patients from western countries and Latin America had also a higher outpatient visit for infectious diseases as compared to the Norwegian psychiatric patients. However, psychiatric patients with East Europe and Asia backgrounds had lower rates of hospital admission for infectious diseases than the Norwegian psychiatric patients.

Discussion

Our study found that the majority of non-Western immigrant patients have lower rates of utilization of somatic healthcare services for diseases of the circulatory system. In particular, the rate of hospitalization was significantly lower in most immigrant groups, except for psychiatric patients with African backgrounds. Prior research findings have revealed that immigrant psychiatric patients, particularly refuges and asylum seekers, have a higher burden of somatic comorbidities, e.g., hypertension, diabetes and cardiovascular diseases [14,15,22,23]. Based on this evidence, we suggest that underutilization is likely among non-Western immigrants, in the sense that comorbidities between mental disorders and circulatory system diseases that would normally trigger specialist healthcare for Norwegians, do not lead to specialist healthcare for many non-Western immigrants. Specifically, it seems that under-utilisation of somatic healthcare services is unlikely to be due to lack of availability or need. This may lead to lack of detection or treatment of circulatory system diseases in immigrant psychiatric patients, or late diagnosis resulting in poor prognosis, treatment responses and outcomes [9,24,25].

In contrast, we found less disparities in the utilization rates of somatic specialist healthcare for infectious diseases,   Statistically significance values showing differences between immigrants and the Norwegians (the reference group): *p < 0.05, **p < 0.01, ***p < 0.001. β (se) = predicted probabilities and robust standard error (in parenthesis) and are adjusted to age and gender. CI = confidence interval especially for the outpatient services. The findings rather reveal that African psychiatric patients had higher outpatient and hospital admission rates for infectious diseases. This could be due to the heightened attention given to screening on arrival and management of infectious diseases among immigrants, especially for those from high burden countries, e.g., African immigrants. Such increased attention from both health personnel and policy makers towards prevention and management of infectious diseases could contribute in reducing inequalities in access and utilization of somatic care for infectious diseases as well as improve coordination of care across the somatic and mental healthcare delivery system. This study indicates that immigrants from non-Western countries are especially faced with a double barrier to health care. As shown in an earlier paper, immigrants have less utilization of mental health services in general [19], and those who access mental health services have a higher barrier to get somatic services. There is an urgent need to inform policy makers and health care workers about these disparities and address them accordingly.

One strength of the present study is that it has investigated use of specialist somatic healthcare among immigrants with high-quality register data which cover the entire population, implying that selection bias is practically absent. Only a very small number of private-practising physicians, psychologists, psychiatrists and hospitals are not obliged to report on their activities to the Norwegian Patient Registry. Thus, the patients analysed here will cover practically all patients in specialist psychiatric care during the study years, and the estimated utilization rates in specialist somatic healthcare are likely to be quite precise. Another strength is that the data provided by Statistics Norway include all registered immigrants in Norway, meaning that each immigrant world origin was represented by a sample of usable size. Further, the registry offers data concerning the origin of patients making it possible to explore based on world regions of origin rather than heterogeneous groups, i.e., western vs. non-western immigrants or immigrants from high vs. low income countries. The study period 2008-2011 coincides with the 'Great Recession' in Europe which was followed by austerity measures in the health care of many countries. However, since the international financial crisis had few effects in Norway, the time period analysed here did hardly differ from previous or later years.

Various limitations may nevertheless have affected the reported results of this study. The outcome variables indicate whether the psychiatric patients had at least one outpatient visit or at least one hospital admission for circulatory conditions or infectious diseases during the observation period, but they do not distinguish between few and many visits and hospital stays. Only registered inhabitants are included on the register, thereby, migrants staying in Norway without being registered, and asylum seekers whose applications have not been decided on, are not part of the analyzed samples, implying that particularly vulnerable migrants are not analysed here. A weakness which affects the present study as well as most other investigations based on administrative registers, is that the information available is often very limited and possibilities for testing hypotheses and detailed explanations will be restricted. Research of the themes addressed in this study will benefit from data more suitable for exploring explanatory mechanisms.

Conclusions

This study has served to highlight significant differences in the uptake of somatic healthcare services for circulatory diseases between psychiatric patients based upon their world regions, though there are less variations for infectious diseases. Underutilisation of hospitalisation is most likely amongst patients from Asia and Latin America. The findings suggest that interventions addressing inequalities in access to and utilization of somatic healthcare should primarily target non-Western psychiatric immigrant patients with diseases of the circulatory system. Policy-makers and Statistically significance values showing differences between immigrants and Norwegians (the reference group): *p < 0.05, **p < 0.01, ***p < 0.001. β (se) = predicted probabilities and robust standard error (in parenthesis) and are adjusted to age and gender. CI = confidence interval service providers should try to implement measures which improve the responsiveness of somatic healthcare services to the needs of psychiatric immigrant patients. Such measures should emphasize a much stronger follow up of somatic disorders in mental health care and an improved cooperation between mental and somatic health care.

0.080 (0.004)*** 0.072-0.087 0.038 (0.003)** 0.032-0.044 Africa 0.053 (0.005)*** 0.043-0.063 0.037 (0.005) 0.028-0.046 Asia 0.066 (0.002)** 0.061-0.071 0.036 (0.002)*** 0.032-0.039 Latin America 0.040 (0.005)*** 0.030-0.050 0.021 (0.004)*** 0.012-0.029

CVD: Cardiovascular diseases; ICD: International classification of diseases occurring addictive and psychiatric disorders: a practice-based handbook from a European perspective. Heidelberg: Springer; 2015. p. 3-12. 25. Merikangas KR, Ames M, Cui L, Stang PE, Ustun TB, Von Korff M, et al. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry. 2007;64(10): 1180-8.

Table 1
1Descriptive summary of the study populationpatients who had contacts with psychiatric specialist healthcare from 2008 to 2011, N = 329,363Variables
Ethnic Norwegians (N = 276,890, 83.3%)
Immigrants (N = 52,473, 12.7%)

N
%
N
%

Age

0-19
91,001
32.87
27,326
52.08

20-59
154,707
55.87
24,587
46.86

60+
31,182
11.26
560
1.07

Gender

Male
129,275
46.69
26,559
50.61

Female
147,615
53.31
25,914
49.39

World regions of origin

Norway
276,890
100
-
-

Western countries
-
-
29,156
55.56

East Europe
-
-
5507
10.49

Africa
-
-
3035
5.78

Asia
-
-
12,065
22.99

Latin America
-
-
2710
5.16

Circulatory system diseases

Outpatient visit rate
21,559
7.79
2241
4.27

Hospital admission rate
14,284
5.16
917
1.75

Infectious diseases

Outpatient rate
7228
2.61
1461
2.78

Admission rate
7411
2.68
997
1.90

Table 2
2Proportion of the use of specialist healthcare for diseases of circulatory and infectious diseases among psychiatric patients from 2008 to 2011Region origin
Circulatory system diseases
Infectious diseases

Outpatient
Admission
Outpatient
Admission

N
%
N
%
N
%
N
%

Norway
21,559
7.79
7228
2.61
7411
2.68
14,284
5.16

Western countries
1346
4.57
800
2.71
633
2.15
596
2.02

East Europe
347
6.03
154
2.68
89
1.55
130
2.26

Africa
97
3.11
141
4.52
80
2.56
50
1.60

Asia
701
4.92
390
2.74
229
1.61
300
2.11

Latin America
55
2.03
85
3.14
52
1.92
19
0.70

Table 3 Logistic
3regression estimates (marginal effects) showing age-and gender-adjusted predicted probabilities for the use of
specialist healthcare for circulatory system diseases during 2008-2011 among psychiatric patients

Regions of origin
Specialist healthcare for circulatory system diseases

Outpatient
Admission

β (se)
95% CI
β (se)
95% CI

Table 4
4Logistic regression estimates (marginal effects) showing age-and gender-adjusted predicted probabilities for the use of specialist healthcare for infectious diseases during 2008-2011 among psychiatric patients Regions of origin Specialist healthcare for infectious diseasesOutpatient
Admission

β (se)
95% CI
β (se)
95% CI

Norway
0.026 (0.001)
0.025-0.027
0.026 (0.001)
0.025-0.027

Western countries
0.028 (0.001)*
0.026-0.030
0.026 (0.002)
0.023-0.028

East Europe
0.027 (0.002)
0.023-0.032
0.018 (0.001)**
0.014-0.021

Africa
0.047 (0.004)***
0.039-0.055
0.034 (0.004)*
0.027-0.041

Asia
0.028 (0.001)
0.025-0.031
0.019 (0.001)***
0.016-0.021

Latin America
0.033 (0.003)*
0.026-0.041
0.027 (0.003)
0.020-0.035

AcknowledgementsThe availability of cleaned and linked registered data was through the research project "Health care utilization among immigrants in Norway", funded by the Research Council of Norway (project number 222100).FundingThis study is part of the postdoc research project "Patterns and courses of somatic illness and the utilization of health services among patients with substance use disorders and/or mental disorders in Norway", funded by the Southern and Eastern Norway Regional Health Authority (project number 150901). The funder had no role in the study design, data collection and analysis, and interpretation of data and in writing the manuscript.Availability of data and materialsThe data file was constructed from administrative registers managed by Statistics Norway, Norwegian Patient Register, and Norwegian Directorate of Health. The register data can be made available for research projects approved by Norwegian Regional Committee for Medical and Health Research Ethics and Norwegian Data Protection Authority.Authors' contributions DSA initiated the study, analyzed the data, interpreted the results and drafted the manuscript. LL and JIE contributed to the interpretation of the study results and approved the final version of the manuscript submitted for publication.Ethics approval and consent to participateThe research project has been approved by the Norwegian Data Protection Authority and the Norwegian Regional Committee for Medical and Health Research Ethics (REC South East). The unique personal identification number, assigned to all registered inhabitants in Norway, was used for linking data but subsequently deleted from the data file. Variables that could potentially be used for identifying individuals have either been deleted or recoded into broad categories, as stipulated by the Norwegian Data Protection Authority.Consent for publicationNot applicable.Competing interestsThe authors declares that they have no competing interests.
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