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Perceptions of unmet healthcare needs: what do Punjabi and Chinese-speaking immigrants think? A qualitative… Marshall, Emily G; Wong, Sabrina T; Haggerty, Jeannie L; Levesque, Jean-Fréderic Feb 22, 2010

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RESEARCH ARTICLE Open AccessPerceptions of unmet healthcare needs: what doPunjabi and Chinese-speaking immigrants think?A qualitative studyEmily G Marshall1, Sabrina T Wong2*, Jeannie L Haggerty3,4, Jean-Fréderic Levesque5,6AbstractBackground: Unmet healthcare needs - the difference between healthcare services deemed necessary to dealwith a particular health problem and the actual services received - is commonly measured by the question,“During the past 12 months, was there ever a time when you felt that you needed healthcare, but you didn’treceive it?” In 2003, unmet needs were reported by 10% of immigrants in Canada, yet, little is known specificallyabout Chinese- or Punjabi-speaking immigrants’ perceptions and reporting of unmet needs. Our study examined:1) How are unmet healthcare needs conceptualized among Chinese- and Punjabi-speaking immigrants? 2) Aretheir primary healthcare experiences related to their unmet healthcare needs?Methods: Twelve focus groups (6 Chinese, 6 Punjabi; n = 78) were conducted in Chinese or Punjabi and socio-demographic and health data were collected. Thematic analysis of focus group data examined the perceptions ofunmet needs and any relationship to primary healthcare experiences.Results: Our analysis revealed two overarching themes: 1) defining an unmet healthcare need and 2) identifyingan unmet need. Participants had unmet healthcare needs in relation to barriers to accessing care, their lack ofhealth system literacy, and when the health system was less responsive than their expectations.Conclusions: Asking whether someone ever had a time when they needed healthcare but did not receive it caneither underestimate or overestimate unmet need. Measuring unmet need using single items is likely insufficientsince more detail in a revised set of questions could begin to clarify whether the reporting of an unmet need wasbased on an expectation or a clinical need. Who defines what an unmet healthcare need is depends on thecontext (insured versus uninsured health services, experience in two or more healthcare systems versus experiencein one healthcare system) and who is defining it (provider, patient, insurer).BackgroundAn integral objective of healthcare systems, especiallythe primary healthcare sector, is to respond to peoples’perceived need for care. With enhanced access to careand improvements in quality of care, we would expectto see a corresponding decrease in unmet healthcareneeds. Indeed, unmet healthcare need has been identi-fied as a critical indicator of access to care within ahealthcare system [1-3] and is used to compare accessacross different healthcare systems [4].Unmet healthcare need has been defined as the “dif-ference between healthcare services deemed necessaryto deal with a particular health problem and the actualservices received” [1]. In many population-based,national surveys (e.g., Canadian Community Health Sur-vey-CCHS, National Health Interview Survey), unmetneed is measured by a question such as, During the past12 months, was there ever a time when you felt thatyou needed healthcare, but you didn’t receive it? Differ-ences in unmet needs among different populationgroups could represent either true differences in accessto healthcare or differences in interpretation by respon-dents who speak a different language or have differentcultural backgrounds. There remains a paucity of workthat examines the conceptual, operational, or* Correspondence: sabrina.wong@nursing.ubc.ca2School of Nursing and Center for Health Services and Policy Research,University of British Columbia, 2211 Wesbrook Mall, Vancouver, BritishColumbia, V6T-2B5, CanadaMarshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46© 2010 Marshall et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.psychometric equivalence of items currently measuringunmet health needs in languages other than English.Instruments, and specific items, developed to measureconstructs important to the general public may not haveconceptual equivalence [5-9] (e.g., no adequate reflectionof unmet needs important to groups who speak little orno English), operational equivalence [5,6,9,10] (e.g.,appropriate survey methods including reading level,item format, and instructions), or psychometric equiva-lence [5,6,10,11] (e.g., comparable psychometric proper-ties including reliability and validity) in groups whospeak English as a second language (ESL). Moreover,without examining the concept of unmet healthcareneeds in ESL groups, self-report measures of unmetneeds may be inadequate.In Canada, immigrants are an increasing share of thetotal population (18.4%) and constitute an increasinglyimportant segment of Canadian society; roughly 58% ofimmigrants come from Asia [12]. A majority of immi-grants (70.2%) in 2006 reported a mother tongue otherthan the official languages of English or French [13].The largest proportion of first languages spoken in thehome in childhood, among all immigrants, were Chinese(18.6%), followed by Italian (6.6%), Punjabi (5.9%), Span-ish (5.8%), German (5.4%), Tagalog (4.8%), and Arabic(4.7%) [14]. In the Unites States (US), the 2003 Censusreported that 11.7% of the US population, or 33.5 mil-lion people, were immigrants; one-quarter of immigrantswere from Asia, over 50% from Latin America, and13.7% from Europe [15]. British Columbia is home tothe second largest immigrant population in Canada,where 50% of BC immigrants are from Asia and 30%speak Cantonese, 25% speak Punjabi, and10% are notfluent in English [16]. Recent population-based studiesin Canada identified that recent immigrants reportedmore unmet needs for care compared to those thatimmigrated to Canada more than ten years ago or topeople born in Canada [17,18].Currently, there is no standardized translation of self-reported unmet healthcare needs questions in eitherChinese or Punjabi. Thus, this indicator of access maybe of limited use with these ethnic and mostly immi-grant groups. In this paper, we describe work thatexamines: 1) the conceptualization of unmet healthcareneeds among Chinese- and Punjabi-speaking immi-grants, and 2) if any primary healthcare experiences arerelated to their unmet healthcare needs.MethodsAs part of a larger study examining Chinese- and Pun-jabi-speaking people’s primary healthcare experiences,12 focus groups, each consisting of six to nine partici-pants, were conducted in Chinese (n = 6) or Punjabi (n= 6). Participants were recruited through communityorganizations and Gudwaras (Sikh place of worship,referred to as a “Sikh temple”). Leaders of the organiza-tions helped us identify and help recruit potential parti-cipants. Focus groups were conducted separately bylanguage (Cantonese, Mandarin, Punjabi) in differentlocations across the Vancouver’s lower mainland in Brit-ish Columbia (BC). Given that healthcare needs and useof care are known to vary, focus groups were conductedby different age groups (< 50 years, ≥ 50 years) and gen-der (men, women). Eligibility criteria included: Canto-nese- or Mandarin-speaking Chinese and Punjabi-speaking South Asian immigrants, aged 19-90, who hadvisited their primary healthcare provider at least twicein the past two years. We chose Chinese- and Punjabi-speaking immigrants because they represent the largestgroup of people who speak English as a second languagein BC. Upon obtaining informed consent, participantsfilled out a short survey, in Chinese or Punjabi, abouttheir socio-demographic information, self-reportedhealth, and their recent experiences in using the primaryhealthcare system, including having any unmet health-care needs in the past 12 months. All focus groups weretaped and each participant received $15 in appreciationfor their time. All procedures were approved by theUniversity of British Columbia’s Institutional Reviewboard. Each community organization was given $75 inappreciation for their help in the recruitment process.Focus groups were conducted by two trained bilingualand bicultural facilitators (English and Punjabi/Man-darin\Cantonese). Open-ended questions were askedabout people’s experiences in accessing and using pri-mary healthcare. As part of the interview schedule,questions related to unmet healthcare needs were devel-oped by the research team in consultation with keyinformant members of the Chinese and Punjabi-speak-ing communities. Examples of questions include: “Whatis the first thing you do after deciding that you needhealthcare or advice?"; “What are the most importantthings to take into consideration in choosing this speci-fic provider/place to go for healthcare or advice?"; “Dur-ing the past 12 months, was there ever a time when youfelt that you needed healthcare, but you didn’t receiveit?” This paper reports on a secondary analysis con-ducted to examine participants’ discussions of unmethealthcare needs within the context of primaryhealthcare.Data were transcribed and translated into English byone of the facilitators. Five percent of the English tran-scripts were randomly chosen to check against the tapedfocus group, by a different bilingual and biculturalresearch assistant, for accuracy of words and conceptsbeing discussed in the translation. We found less accu-racy in the English translation of the Chinese focusgroups since there were two dialects of Chinese,Marshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 2 of 8Cantonese and Mandarin, used for facilitating the focusgroups. Therefore, each Chinese focus group tape andEnglish transcript was double-checked by a bilingual,Cantonese or Mandarin and English-speaking researchassistant in their entirety. Once the English-equivalentdata were cleaned, we organized it into codes based onan agreed upon coding scheme. All transcripts werecoded by at least two members of the team. A qualita-tive software program, ATLAS.TI, was used to organizethe coded data across all participants.We used thematic analysis and a phenomenologicapproach for our methodological framework. Phenom-enology is a philosophy and a method through whichwe examined participants’ primary healthcare experi-ences and how these experiences related to the phe-nomenon of unmet healthcare need [19]. Initial dataanalysis involved immersion in the data as a whole [20],so transcripts of focus groups were reviewed by allmembers of the team in their entirety and discussed.Meaning of sentences and experiences were consideredin relation to the complete transcript. Then a disci-plined and systematic search was used to identifythemes [20]. Thematic analysis, a method for identify-ing, analyzing and reporting patterns or themes withindata [21] was used to illuminate experiences of unmethealth care needs.ResultsSeventy-eight people participated in one of the twelvefocus groups. Focus group participant’s characteristicsare shown in Table 1. For descriptive purposes, the dataare shown by language and age group, as well as thetotal. Most participants (83%) were married, had adiploma or degree (51%), and 42% reported having ahousehold income between $20,000 and $49,999; one-third were employed full-time (Table 1). Chinese partici-pants were less likely than Punjabi counterparts to havechronic conditions (41% vs. 73%) and more likely toreport being in excellent, very good, or good health(79% vs. 69%).Almost all participants (95%) reported having a regu-lar primary healthcare doctor, three-quarters see a doc-tor who speaks their native language and all participantsreported being only somewhat proficient in English.Thirty-two people had been in Canada for less than 10years and only five people reported on the survey havingany unmet healthcare needs over the previous 12months (data not shown).Thematic analysis revealed two overarching themes: 1)defining an unmet healthcare need and 2) identifying anunmet need. Participants had unmet healthcare needs inrelation to barriers to accessing care, their lack of healthsystem literacy, and when the health system was lessresponsive than their expectations.Defining an Unmet healthcare needEven though only five participants reported having anunmet need on the short questionnaire, more than one-third of focus group participants expressed an unmetneed during the discussion. Defining unmet healthcareneeds was complex for participants. While some partici-pants were confident they had no unmet healthcareneeds, others raised the question of who should identifywhether an unmet need has occurred. In particular, par-ticipants wrestled with the notion that an unmet needfor healthcare could be defined as not having access toexisting or offered services, as well as not having accessto services which are not covered by insurance benefitsor publicly-funded systems. This aspect of unmet needsrelates to definitions that people make of what constitu-tes the services one is expecting to be offered and high-lights the fact that people coming from diverse culturaland socioeconomic backgrounds also have very diverseprevious experiences and perceptions about the rangeand types of services that they expected to be available.This can impact on the declaration of unmet needs forcare. For example, many participants talked about ser-vices they thought they needed but were not availablethrough the Canadian healthcare system:“Every time when I go back to China, I must do awhole body check-up, because you can’t have ithere. They don’t allow you to do that, except [when]you really have a problem.” (Mandarin-speakingwoman, < 50 years)Speaking only Chinese or Punjabi, in part, compoundstheir understanding and reporting of unmet healthcareneed. As two Chinese-speaking women point out, notknowing what primary healthcare services are availableor the meanings of medical terminology can affectwhether they report unmet needs:“It would be convenient [having the written informa-tion available in Chinese/Punjabi], we could under-stand more because sometimes when you read them[health-related brochures] in English, you really don’tknow what they mean, particularly the medical infor-mation. The medical terminology is very hard, suchas the terms of diseases or [medical] treatments. Youhave to look them up in the dictionary. Sometimeswe just don’t bother and end without knowing themeanings.” (Mandarin-speaking women, < 50 years)“Language is a very big barrier for us Chinese. Plus,we are not doctors, of course we don’t know thosemedical terminologies. So we really don’t know whatbenefits that the healthcare system provides to us.We hear of some here or some there. It’s not com-plete. It would be helpful if we are provided theMarshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 3 of 8information in Chinese that systematically tells usthe services we can enjoy and those we are notentitled. Since the information we hear from othersare not in details and not official.” (Cantonese-speak-ing woman, < 50 years)Identifying Unmet healthcare needs?Participants’ discussions brought into question whatshould be considered an unmet healthcare needs withinthe context of primary healthcare. Some participantsreported foregoing certain healthcare services, such asdental care and speech therapy services because theywere too expensive. The acceptability of paying for cer-tain services influences people’s identification of anunmet need for care. When people receive services (theneed has been met) but have to pay out-of-pocket,unmet needs are identified based on what they expectfrom the health service delivery system. Participantsmade tradeoffs between an unmet need and paying out-of-pocket for health services:“I have seen that there is a great demand for aspeech therapist, but because they are so expensive,Table 1 Chinese and Punjabi Focus Group Participant CharacteristicsCharacteristic Language Age Groups Total (n = 78)Punjabi(n = 45)Chinese(n = 33)< 50 yrs(n = 39)50 + yrs(n = 39)Gender (%)Male 46 54 49 51 50Marital Status (%)Married/Living with a Partner 84 83 82 85 83Education (%)Less than grade 12 32 7 8 31 19Grade 12 o GED 5 20 0 26 13Some post-Sec/College 16 17 28 5 17Diploma/Degree 46 56 64 39 51Income (%)< $20,000 28 23 7 45 26$20,000 - $49,999 36 50 51 32 42$50,000 - $79,999 33 23 37 19 29$80,000 and above 3 3 3 3 3Work Status (%)Full-time 35 32 54 13 33Part-time 14 5 10 8 9Not employed (student, retired, disability, homemaker) 46 61 31 77 54Other 5 2 5 3 4Language*English-language speaking abilities(1-4)Mean (SD) 2.73 (1.12) 2.50 (0.62) 2.97 (0.73) 2.24 (0.96) 2.62 (0.92)Has a Regular provider (%)Yes 92 98 92 97 95Doctor speaks native language (%)Yes 74 81 84 71 78Don’t know 26 3 13 14 13Health Status (%)Excellent/Very good/Good 69 79 87 59 73Fair/Poor 31 21 13 41 27Chronic Condition (%)No chronic condition 27 59 67 21 441 chronic condition 30 34 28 36 322 chronic condition 27 2 3 26 143 and more 16 5 3 18 10*Note. Response categories were: very well, well, not well, not at all. A higher score = more of the concept.Marshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 4 of 8most people do not go to them. They take $75 foreach appointment; most people do not go, as it isvery expensive.” (Punjabi-speaking woman, < 50years)“He/she (the dentist) said that you have two teethwith cavities, and you have gingivitis as well. I’llmake a treatment plan for you. The total will bemore than two thousand [dollars], almost threethousand. The dentist talked about the medicalinsurance and said I need to pay half of the price.But still it’s very expensive, so I gave up the plan.”(Mandarin-speaking woman, < 50 years)“I feel many times I can’t get what I request. For exam-ple, I don’t have diabetes, but I want to check. But thebasic MSP [medical services plan] does not cover this.So even if I’m willing to pay for the test, they still can’taccept me.” (Cantonese-speaking man, ≥ 50 years)Some experiences with the primary healthcare system(PHC) were closely linked with discussions of unmetneeds, including: accessibility, health system literacy,and responsiveness of the PHC system.AccessibilityParticipants discussed unmet healthcare needs as relatedto a variety of dimensions of accessibility including: alack of choice in the gender of a provider, particularlyfor women preferring to have a female physician or alack of a primary healthcare provider who was acceptingnew patients and speaks the patient’s language. Thishighlights that their preferences for what constitutes anappropriate response to one’s needs could also deter-mine the occurrence of unmet needs. In some cases,women chose to forego cervical cancer screeningbecause they did not feel comfortable with their maledoctor providing this service:“I haven’t done my gynaecological screenings for acouple of years, because he’s a male doctor. I’venever requested him to do the gynaecologicalscreening for me. I always do the screening when Igo back to China and I pay for it.” (Mandarin-speak-ing woman, < 50 years)“I had a problem, I went to a doctor, he had to seeme from above my waist......my body, my daughterhad gone with me, I said to my daughter that if youwill get me checked by a lady doctor, then you takeme in, otherwise no. And then the doctor came, andI said in front of him, that I will not show myself tohim at all.” (Punjabi-speaking woman, < 50 years)Another dimension of accessibility is seeing a doctorwho is bilingual in English and Chinese or Punjabi. Par-ticipants likely have language barriers because manycould not read or write in English for the purpose of amedical visit and that they would wait to see theirdoctor, who spoke their language. Indeed, they experi-enced wait times in order to see their Chinese- or Pun-jabi-speaking doctor:“The time when you need care, if you don’t get theappointment at that time, then you can’t go to the doc-tor. The doctor says come after 3 days or 4 days. I don’thave time to make an appointment [3 or 4 days later].This is a difficulty.” (Punjabi-speaking man, ≥ 50 years)Health system literacyKnowing how to use the primary healthcare system andwhat resources are freely available was also discussed inrelation to unmet healthcare need. Lack of knowledgeabout health systems organizations and services relatedto the immigration process can also impact on unmetneeds for care. Some had limited knowledge on how toget needed healthcare services and what services areavailable to them (particularly those covered under theuniversal healthcare plan):“They (patients) should know which medicines arefree for them, which services are free and till whatage. These things should be told to new immigrants,because they do not know these things, and it ishard for them when they come all by themselves [toanother country] with their families. There shouldbe some classes and workshops so that they can getinformation.” (Punjabi-speaking woman, < 50 years)“I think doctors, particularly for us new immigrants,like what they mentioned, since we didn’t grow uphere, the family doctors, now that they are called“family” doctors, they should tell us when we firstsee them which services they can offer us. Otherwisewe won’t know which problems we should seek helpfrom them, doctors or nurses. They should tell uswhich problems, for example, when you have mentalproblems, you should see...It is the first time for meto know that you should see your family doctor forit. I don’t know it. I don’t know when I should go tosee him (family doctor) and when I shouldn’t. Idon’t know in which circumstances I could bereferred to a specialist. I don’t know these at all.”(Mandarin-speaking woman, < 50)All participants were immigrants who were mostfamiliar with using their home country’s (India orChina) health system. Less familiarity with the Canadianhealthcare system (e.g., primary healthcare is typicallythe first contact with the healthcare system) was asource of concern for participants. Differing expecta-tions for health service delivery was discussed in thecontext of not being able to obtain “immediate care”and having to “wait” for care:Marshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 5 of 8“We know if we went to the hospital (in China), wewent to the emergency room, we would be treatedimmediately by vein injection, dropping or whatever.They would treat you in a way that you could seethe immediate effects, so you would have a peace ofmind. But here, it takes time no matter whether youhave to experience the emotional distress. You haveto take Tylenol or whatever first for three days, eventhough sometimes you know very well that Tylenolwon’t help. That makes you worried because youknow Tylenol won’t work, so why don’t you controlthe problem with a method that works in the firstplace?” (Mandarin-speaking woman, < 50 years)ResponsivenessSome of the structural constraints on how primaryhealthcare is delivered in a fee-for-service (FFS) modelcreated more risks for unmet healthcare need. Despitelanguage concordance between the family doctor andparticipants, there was discussion across the focusgroups on how the system was not responsive to theirneeds because of limited consultation time with thefamily doctor. In the FFS system, primary healthcare vis-its have been limited to a maximum of 15 minutes withthe time per visit per patient varying based on the provi-der’s assessment of the health issue:“The doctor was very bad because when we went tosee her, she gave us a very short time. For example,she would stop us if we wanted to ask her a tiny bitmore question. Can’t ask. When the reports of thelab tests came, and when we wanted to know a bitmore about why the results were like that, she didn’twant to answer.” (Mandarin-speaking woman, < 50years)Moreover, there are no standard guidelines or bestpractices that define how a provider should be respon-sive to patients:“I have left so many messages for the family doctor,but she has not called me back even once till now. Iwanted to get some further information on how Ican get home support. We are tax payers and wehear that home support people come and take careof the old people, but I don’t know who can arrangethis for us.” (Punjabi-speaking woman, < 50 years)Although most participants had a regular providerwho could speak their native language (Chinese or Pun-jabi), participants discussed having unmet needs outsideof regular office hours with other doctors:“In India, if we see the system, whenever we needany facility, whenever we need the doctor, we can goto him at midnight also. There is 24 hour servicethere. But here we don’t get that service. Here thereare only very limited hours of service. On Saturdaysand Sundays we can’t get the [Punjabi-speaking]doctors, but in India the doctor is available to us allthe time.” (Punjabi-speaking man, ≥ 50 years)DiscussionAsking patients about unmet healthcare needs is com-plex. The analysis presented here suggests two issues inneed of further consideration. First, measuring unmethealthcare needs using single items is likely insufficientsince more detail in a revised set of questions couldbegin to clarify whether the reporting of an unmet needwas based on an expectation or a clinical need. Simplyasking whether someone ever had a time when theyneeded healthcare but did not receive it could underesti-mate unmet need. These results suggest that whodefines what an unmet healthcare need is depends onthe context (insured versus uninsured health services)and who is defining it (provider, patient, insurer). Usingthe current unmet needs question, “During the past 12months, was there ever a time when you felt that youneeded healthcare, but you didn’t receive it?” [14] maynot, by itself, be a valid indicator of unmet need. Giventhat large surveys may only have space for a single ques-tion about the presence of unmet healthcare needs, onealternative would be to conduct analyses that take intoaccount language spoken at home, recency of immigra-tion, and ethnicity. Another alternative would be to usean index reflecting different types of health needs, whichmay help people differentiate between their expectationsand their health needs. A multidimensional measurecould provide more information on the types of healthneeds that can be met by health plans. For example,Katz and colleagues [22] measured different types ofunmet needs. Unmet need for home healthcare wasdefined as needing the service in the previous sixmonths but not having received help at home (withmedical problems, personal care, house-keeping, orother services) during the same period. Unmet need foremotional counselling was defined as needing the ser-vice in the previous 6 months but not having seen amental health provider, attended a support group, orseen a spiritual care provider (e.g., minister) during thesame period [22].This study adds value to what is known about measur-ing unmet needs. How unmet healthcare needs is con-ceptualized and who defines if the need is unmet (e.g.,patient, provider, parent) warrants further investigation.Chinese- and Punjabi-speaking participants, in particu-lar, have challenges in understanding what unmethealthcare needs are or how they should be defined.Asking for a self-report of unmet healthcare needMarshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 6 of 8requires more explanation of what should be consideredan unmet need and whether self-report methods arecomplementary to other methods in measuring unmetneed such as provider reported unmet needs of patientsor whether people received services based on clinicalguidelines. In addition, collecting information aboutwhat people expect from the publicly insured healthcaresystem and what is considered uninsured services couldhelp in understanding the impact that expectationsmight have on the reporting of unmet needs for care.Patients often have specific expectations of their health-care visit and of the healthcare system [23]. Moreover,more work needs to be done in developing reliable andvalid measures that can examine the strength of therelationships between unmet need, individuals’ expecta-tions of their health visits, and utilization of primaryhealthcare.Second, experiences with a different healthcare systemcan create different expectations for the types of health-care services available and how people can access theseservices. In British Columbia (BC), Canada, primaryhealthcare provides a range of services and is the placeof first contact with the healthcare system for most peo-ple. In other countries such as China, primary health-care is not necessarily the place of first contact care.People can directly access specialists. Moreover, all par-ticipants were immigrants who had varying degrees offamiliarity with the BC health system. What was once aservice available in their country of origin (e.g., full bodycheck) was not available in BC and therefore, hadbecome an unmet healthcare need. Clearly, being ableto identify what healthcare service is needed affectswhether people will report an unmet need.Self-reporting of unmet healthcare needs is dependenton types of services (e.g., insured versus uninsured ser-vices), individual preferences, responsiveness of thehealthcare system (e.g., hours of operation), and an indi-vidual’s characteristics (e.g., language) [24,25]. Notably,people who are willing to pay out-of-pocket for unin-sured services may not report unmet needs if they canobtain the service privately or in a different countrysuch as China or India.These insights should be considered in the light of thestudy limitations. As with single methodologicalapproaches using a qualitative approach, the goal is toreach representative credibility [26]. While these resultsare internally valid to this study, triangulation of usingmixed-method approaches are needed to enhance ourknowledge about how to measure unmet healthcareneeds across groups who speak English as a second lan-guage. Notably, the use of two distinct cultural and lin-guistic groups allowed us to identify themes applicableto both groups. Using focus groups may not haveallowed for the depth of discussion that occurs withindividual interviews. However, interactions with otherparticipants can trigger memories and broadens thescope of experience that can be explored. A quantitativepsychometric analysis could begin teasing apart whetherthe single unmet healthcare need question works differ-ently across language groups or ethnicity. Finally, weexamined the concept of unmet healthcare needs amongthose people who had access and had visited their pri-mary healthcare provider at least two times in the pasttwo years. More work is needed in understandingunmet health care needs from those who do not have ausual source of care or have not accessed primaryhealthcare services recently.ConclusionsDespite these limitations, this is the first report that weknow of to examine unmet healthcare needs in Chinese-and Punjabi-speaking immigrants and it provides infor-mation on how we can move forward in more clearlydefining what is meant by unmet healthcare needs inprimary healthcare. These results suggest that the con-cept of unmet healthcare needs is multidimensionaldepending on who is defining what healthcare need hasgone unmet [27], and recall bias [28]. Self-reportedlevels of unmet healthcare need are likely to elicit themost important or most bothersome memories. There-fore, using a single question should be considered a par-tial assessment of unmet healthcare needs. More work isneeded to examine the extent to which a single questionadequately captures unmet healthcare needs since itcould either underestimate or overestimate the propor-tion of respondents who experience difficulty obtainingneeded services. Unmet healthcare need, defined from apatients’ view is a partial reflection one’s ability to iden-tify a health need, access the appropriate services, expec-tations of available services, and prior experiences usingthe healthcare system. Finally, English-language abilityand immigration and use of a different healthcare sys-tem appear to be factors that influence the reporting ofunmet healthcare needs within the context of primaryhealthcare.AcknowledgementsThe authors thank our many research assistants and the men and womenwho participated in this study. We also especially acknowledge the supportof Weihong Chen, Anureet Brar, Albert Wu and Sitaram Saroa in facilitatingcollection of data. This study was supported by the Canadian Institutes forHealth Research. Dr. Marshall was a post-doctoral fellow at the University ofBritish Columbia during the time of the data collection and analysis for thismanuscript. Dr. Wong was supported by a Michael Smith Scholar Award (CI-SCH-051) and a CIHR New Investigator Award. Dr. Haggerty was supportedby the Canadian Institutes for Health Research and the Université deSherbrooke as a Canada Research Chair.Author details1Department of Family Medicine, Dalhousie University, 5909 Veteran’sMemorial Lane, Halifax, Nova Scotia, B3H 4H7, Canada. 2School of NursingMarshall et al. BMC Health Services Research 2010, 10:46http://www.biomedcentral.com/1472-6963/10/46Page 7 of 8and Center for Health Services and Policy Research, University of BritishColumbia, 2211 Wesbrook Mall, Vancouver, British Columbia, V6T-2B5,Canada. 3Department of Family Medicine, Université de Sherbrooke, 1111Rue Saint-Charles Ouest, Longueuil, Quebec, J4K 5G4, Canada. 4Departmentof Community Health Sciences, Université de Sherbrooke; 1111 Rue Saint-Charles Ouest, Longueuil, Quebec, J4K 5G4, Canada. 5Institut national desanté publique du Québec, 945 Avenue Wolfe, Québec, G1V 5B3, Canada.6Centre de recherche du Centre hospitalier de l’Université de Montréal, 2900,boulevard Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada.Authors’ contributionsEM assisted in the acquisition of data and jointly led analysis andinterpretation of the data. SW conceived of the study and design, oversawall aspects of data acquisition and led analysis and interpretation of the data.JH and J-FL contributed to the design of the study and were involved in theanalysis of data. All authors have been involved in drafting and criticallyrevising the manuscript. All authors have given final approval of thismanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 27 August 2009Accepted: 22 February 2010 Published: 22 February 2010References1. San Martin C, Gendron F, Berthelot J, Murphy K: Access to Health CareServices in Canada, 2003. Ottawa: Statistics Canada 2004.2. Chen J, Hou C, Sanmartin C, Houle S, Tremblay S, Berthelot J: Unmethealth care needs. Canadian Social Trends 2002, Winter:18-22.3. Chen J, Hou F: Unmet needs for health care. Health Reports 2002,13:23-34.4. Lasser K, Himmelstein D, Woolhandler S: Access to care, health status, andhealth disparities in the United States and Canada: results of a cross-national population-based survey. American Journal of Public Health 2006,96:1300-1307.5. Herdman M, Fox-Rushby J, Badia X: A model of equivalence in thecultural adaptation of HRQoL instruments: the universalist approach.Quality of Life Research 1998, 7:323-335.6. Patrick D, Wild D, Johnson E, Wagner T, Martin M: Cross-cultural validationof quality of life measures. Quality of Life Assessment: InternationalPerspectives; Berlin, Germany Springer-VerlagOrley J, Kuyken W 1994, 19-32.7. Guillemin F, Bombardier C, Beaton D: Cross-cultural adaptation of health-related quality of life measures: literature review and proposedguidelines. Journal of Clinical Epidemiology 1993, 46:1417-1432.8. Flaherty J: Appropriate and inappropriate research methodologies forHispanic mental health. Health and Behavior: Research Agenda for HispanicsChicago, IL: University of IllinoisGaviria M, Arana J 1987, 177-186.9. Hui C, Triandis H: Measurement in cross-cultural psychology: a reviewand comparison of strategies. Journal of Cross-Cultural Psychology 1985,16:65-83.10. Flaherty J, Gaviria M, Pathak D, Mitchell T, Wintrob R, Richman J, et al:Developing instruments for cross-cultural psychiatric research. Journal ofNervous and Mental Disorders 1988, 176:257-263.11. Gonzalez-Calvo J, Gonzalez V, Lorig K: Cultural diversity issues in thedevelopment of valid and reliable measures of health status. ArthritisCare Research 1997, 19:448-456.12. The CANSIM database: detailed tables. http://cansim2.statcan.ca/cgi-win/cnsmcgi.exe?LANG=e&ResultTemplate=CII&CORCMD=GETEXT&CORTYP=1&CORRELTYP=4&CORID=5002.13. 2006 Community Profiles. http://www12.statcan.gc.ca/census-recensement/2006/dp-pd/prof/92-591/index.cfm?Lang=E.14. Health Services Access Survey. http://www.statcan.ca/english/concepts/hs/index.htm.15. Language use and English-speaking ability, 2000. http://www.census.gov/prod/2003pubs/c2kbr-29.pdf.16. 2001 Census Fast Facts: B.C. Immigrant Population. http://www.bcstats.gov.bc.ca.17. Sanmartin C, Ross N: Experiencing difficulties accessing first-contacthealth services in Canada: Canadians without regular doctors and recentimmigrants have difficulties accessing first-contact healthcare services.Healthcare Policy 2006, 1:103-119.18. Levesque J-F, Pineault R, Robert M, Hamel D, Roberge D, Kapetanakis C,Simard B, Laugraud A: Unmet health care needs: a reflection of theaccessibility of primary care services?. Montreal, QU: Gouvernement duQuebec 2008.19. Creswell J, Ed: Qualitative procedures. Thousand Oaks: CA: Sage 2003.20. Morse M, Field P: Qualitative Research Methods for Health ProfessionalsThousand Oaks: CA: Sage, 2 1995.21. Braun V, Clarke V: Using thematic analysis in psychology. QualitativeResearch in Psychology 2006, 3:77-101.22. Katz M, Cunningham W, Mor V, Anderson R, Kellog T: Prevalence andpredictors of unmet need for supportive services among HIV-infectedpersons: impact of case management. Medical Care 2000, 38:58-69.23. Uhlmann R, Inui T, Carter W: Patient requests and expectations.Definitions and clinical applications. Medical Care 1984, 22:681-685.24. Lave JR, Keane CR, Lin CJ, Ricci EM, Amersbach G, LaVallee CP: The impactof lack of health insurance on children. Journal of Health & Social Policy1998, 10:57-73.25. Newacheck P, Hughes D, Hung Y, Wong S, Stoddard J: The unmet healthneeds of America’s children. Pediatrics 2000, 105:989-997.26. Thorne S: Interpretive Description Walnut Creek, CA: Left Coast Press, Inc2008.27. Steinwachs D: Application of health status assessment measures inpolicy research. Medical Care 1998, 27(3 Suppl):S12-S26.28. Rhodes A, Fung K: Self-reported use of mental health services versusadministrative records: care to recall?. International Journal of Methods inPsychiatric Research 2004, 13:165-175.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/46/prepubdoi:10.1186/1472-6963-10-46Cite this article as: Marshall et al.: Perceptions of unmet healthcareneeds: what do Punjabi and Chinese-speaking immigrants think? Aqualitative study. BMC Health Services Research 2010 10:46.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMarshall et al. 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