HEALTH AFTER RESETTLEMENT: PREDICTORS OF PRIMARY CARE UTILIZATION AMONG SOMALI REFUGEES LIVING WITH CHRONIC ILLNESS

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. 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). Given the complexity of migrant health experiences, a multifactorial and ecological analysis of the drivers of health status and service use is essential. The purpose of this dissertation 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. Findings revealed that insurance coverage and health status are the strongest direct predictors of health service use, with individuals who were insured and those reporting moderate health status more likely to access care. Additionally, participants who perceived elevated levels of illness within their ethnic community were less likely to seek care, suggesting that perceived normalization of illness may discourage care-seeking behavior. While post-migration stress did not directly predict healthcare utilization, it significantly increased unmet healthcare needs, which in turn were associated with lower utilization. Finally, state of residence was a significant moderator in the relationship between post-migration stress and unmet healthcare needs, suggesting geographic differences in experiences with post-migration stress and healthcare access. The results from this dissertation 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.