Healthcare Access Barriers Among Older Refugees In the United States: A Multilevel Ecological Analysis Using an Adapted Immigrant Health Promotion Model

Background and Purpose:
Older refugees in the United States face significant healthcare access barriers shaped by forced displacement, age-related health needs, and the multifaceted demands of resettlement. Many arrive with chronic conditions, disrupted care histories, and limited familiarity with the U.S. healthcare system, yet research on this population remains scarce. Existing studies often rely on small, community-based samples and emphasize individual-level explanations rather than broader ecological conditions shaping access. Guided by the Older Adult Immigrant Adapted Model for Health Promotion, this study examines how individual, interpersonal, community, and structural factors influence healthcare access among older refugee newcomers, with particular attention to whether structural and social conditions outweigh individual characteristics.

Methods:
We analyzed data from the 2020-2022 Annual Survey of Refugees, a nationally representative survey of refugees in the U.S. The analytic sample included 840 refugees aged 50 and older. The outcome was a cumulative count of healthcare access barriers, including difficulties related to cost, transportation, language or communication, knowing where to go for care, and obtaining appointments. Predictors including physical health, emotional distress, English proficiency, social capital, neighborhood safety, perceived welcome, discrimination, insurance coverage, and resettlement-related challenges represented ecological domains in the model. Poisson regression with LASSO regularization was used to identify the most salient predictors while minimizing overfitting. Missing data were handled using multiple imputation, and model performance was evaluated using cross-validation and classification metrics.

Results:
The final model showed strong explanatory and predictive performance, accounting for 65% of variance in healthcare barrier counts and demonstrating excellent discrimination in identifying respondents with high barrier burden (AUC = 0.858). Structural and social conditions were the strongest predictors of healthcare access barriers. Resettlement challenges had the largest effect, with each one-unit increase associated with a 60% increase in expected barrier count (IRR = 1.60, p < .001). Participants who reported discrimination showed greater barriers than those who reported no discrimination (IRR = 1.49-1.52, p < .001). A lack of neighborhood safety was associated with a 34% increase in barriers (IRR = 1.34, p < .01), and feeling unwelcomed in one’s community was also linked to elevated risk. Poorer physical health was associated with higher barriers, though more modestly (IRR = 1.14, p < .05). By contrast, living in the U.S. for 2-3 years was associated with fewer barriers (IRR = 0.81, p < .05), suggesting a limited adaptation period. Demographic characteristics and several individual-level predictors were less influential than broader structural and social conditions.

Conclusions and Implications:
Healthcare access barriers among older refugees are shaped more by structural adversity and social exclusion than by individual factors alone. These findings support ecological frameworks by highlighting that access to care is embedded in broader resettlement, neighborhood, and discrimination contexts, emphasizing the need for multilevel responses, including stronger resettlement coordination, culturally responsive healthcare navigation, anti-discrimination strategies, and community investments that promote safety and belonging. The findings have important implications for social work research, policy, and practice aimed at advancing health equity among aging refugee populations in the United States.