Health After Resettlement: Predictors of health status and primary care utilization among Somali refugees living with chronic illness

Background: As the leading cause of death globally, chronic conditions have come under major focus in recent years, with refugees–particularly from Africa–confronting documented disparities in disease burdens and premature deaths. Health service utilization (HSU) is cited as an effective point of intervention for both mitigating complications arising from chronic illnesses and alleviating related health disparities. While the decision and ability to utilize health services are complex, self-assessed health status consistently emerges as a powerful predictor. Evaluation of key contextual factors associated with health status and primary care utilization can support migrant wellbeing. The purpose of this study is to: (a) identify the predisposing, enabling, and need factors at both the contextual and individual levels that are associated with HSU among Somali refugees with chronic conditions, and (b) explore the effects of pre and post migration stress on HSU for this population

Methods: Adopting an integrative model merging Andersen’s Expanded Behavioral Model, the Basic Behavioral Epidemiological Model, and the Immigrant Health Service Utilization Framework, within a broader socio-ecological perspective, this study utilizes a cross-sectional, structured survey design to examine health status and HSU among Somali migrants living in the U.S (n=165). Data was collected on participants’ utilization of primary care services within the past six months, their pre and post migration trauma and stress exposures, health status, ethnic density, and perceived prevalence of within-group morbidity. A hierarchical logistic regression and a path analysis model was conducted to assess the comparative significance of variables in the model, as well as the strength and direction of their structural relationships.

Results: Overall, 69% of the sample had multiple chronic conditions, and 32% reported poor health. Most (81%) had difficulty affording basic expenses; 22% were uninsured, and 61% experienced insurance loss in the past year. Findings from the logistic regression revealed that insurance coverage (OR = 6.40, p = .015) and health status (OR = 3.54, p = .037) are the strongest direct predictors of HSU, with individuals who were insured and those reporting moderate health status more likely to access care. Additionally, within the path model, participants who perceived elevated levels of illness within their ethnic community were less likely to seek care (β = -0.36) , suggesting that perceived normalization of illness may discourage care-seeking behavior. While post-migration stress did not directly predict healthcare utilization within the path model, it significantly increased unmet health needs, which in turn were associated with lower utilization (β = -0.28). Finally, state of residence was a significant moderator in the relationship between post-migration stress and unmet health needs, suggesting geographic differences in experiences with post-migration stress and healthcare access.

Implications: The results from this study underscore the importance of considering the health effects from forced displacement, community-level perceptions, and contextual disparities—such as state-specific differences—in shaping the health experiences of Somali refugees with chronic conditions. Primary implications include expanding insurance coverage and availability, considering resettlement of newly arrived refugees in ethnically concordant settings, and reducing geographic inequities in care.