The answer to our first research question on whether the perceived health status of Turkish and Moroccan (children of) immigrants has changed over time is that the mental health of the Moroccan group improved between 2001 and 2005, making this group significantly healthier than the Turkish group in 2005. Physical health status of both groups did not change in time.
The second focus question of this paper was whether changes in health status were paired with a change in health care utilization. In our results, the Turkish group shows a significant decrease in GP contacts during the past two months, while the Moroccan group does not show any change. In the multivariate model, changes in GP contacts were significantly explained by changes in mental and physical health.
This study is based on self-report. The chosen measuring instrument might not be valid in a cross-cultural perspective, although the chosen 36-items health questionnaire might be more reliable than the often used one-item measurement . Likewise, self-report in the number of contacts with the GP is also subject to possible bias (for instance recalling incorrectly the exact number of consultations with the GP in the past two months), and would need to be compared with information in medical records in order to assess its validity. However, a previous study indicates that self-report provides a valid estimation of ethnic differences in health care use .
Some kind of selectivity might have taken place in the response, as only 27.6% of the respondents on the first wave also took part to the second wave. However analysis of both groups for socio-demographic characteristics showed no significant difference between them, except for a slightly younger age.
Finally, small sample sizes carry the risk of not revealing some relevant statistical associations. This is often the case in research among groups hard to contact, such as ethnic minorities .
Changes in health status
In 2001, both groups scored under the population norm on their physical and mental health status. As explained in the methods section, the U.S. norm has been proven comparable to that of the general Dutch population. In 2005, the Moroccan group reaches the norm on mental health status, as opposed to the Turkish group that remains under that norm. Obviously, comparison with the general population is also time-dependent, as the standardization is based on figures dating back from the 1990s. As our data show, self-reported health varies in time, and it is likely that this is also the case for the general population. It is therefore impossible to draw definite conclusions for the comparison of health status of both groups with the general population on the two different time-points. Standardization occurred mainly for scale-construction purposes in this paper (see Ware et al. ).
In the multivariate models, some differences between both health indicators changes need to be highlighted. One of them is the coincidence of change in work situation and mental health change. This relationship does not exist for physical health change, where a positive or negative change of the work situation does not seem to play a part. Another interesting difference is the propensity of the Moroccan group, compared to the Turkish one, to see improvement of their mental health status in time, while no difference between both groups is shown on physical health status change. Likewise, civil status seems to play a role in change in mental health, with divorced respondents more likely to show a decrease in mental health. This is not the case for physical health, where, in turn, educational level seems to be more relevant for explaining changes (people with a higher educational level are more likely to have experienced an improvement in physical health in the past four years).
The main difference regarding health status on both time points concerns therefore the mental component. The Turkish group has a significantly worse mental health status in 2005 than the Moroccan group. It can therefore be argued that part of the explanation could be found in cultural differences. The measuring instrument has been translated and is in the process of being validated within each group. However, this does not allow any conclusion on cross-cultural comparability of its outcomes. In a recent paper, Agyemang et al.  showed that the one-item self-reported health status was not valid in a cross-cultural perspective, arguing that different groups rated their health differently while showing comparable morbidity figures. The cultural component could also play a role in using the 36 items of our instrument, although factual information rather than perception of general health is the starting point of this component. However, other differences could play a role in explaining the difference in mental health. Several media, opinion polls and research findings all pinpoint the Turkish group as less satisfied with the social climate in the Netherlands. A recently published research report of the Social and Cultural planning Office of the Netherlands  shows that the Turkish group stands out as having the most negative views on matters such as acceptation of the own group by the Dutch, and the hospitality of the Dutch. Likewise, the Turkish group has a more negative view on the Dutch than the Moroccan group does. In line with these results, the media have sometimes emphasized the fact that the wish for return migration is stronger among Turkish people than among Moroccan people [14, 15].
An interesting next step in the presented analyses would be to take several cultural and discrimination indicators, and examine how these explain the relatively different mental health status of our sample. As earlier mentioned, multiculturalism is no longer agreed upon in the Netherlands. The way ethnic minorities perceive this fact can influence their (mental) health status. Moreover, differences between groups might exist, as to how cultural tensions are perceived, and this might, in turn, lead to differences in (mental) health status.
Changes in health care use
When we examine variables that can explain changes in GP health care use, we can see that changes in mental and physical status largely explain the variation in the change (adj. R2 = 0.535), with an improvement in health status being associated with a decrease in health care use. When we add the socio-demographic characteristics to the model, age and ethnicity turn out to be the only predictors of change in health care use, with the Moroccan group and the elderly showing a larger propensity to increase their health care use.
Data on self-reported health care use among Dutch patients are not available for 2005, but registration data show that the yearly average of GP contacts among Dutch patients increased by 8,4% between 2001 and 2005, which is less than the increase reported by Moroccan respondents .
A step we consider interesting at this point would be to look at the perception of the quality of GP care and its change over time and to examine if, and how far it could explain differences between both groups in changes in GP consultation. We could hypothesize that patients who are less satisfied about the quality of GP care would call less often upon their GP, especially if their physical health (vs. mental health) is not at stake. Likewise, changes in use of alternative health care, such as ethnic medicine or health care in the country of origin could possibly play a role in such a development. Our data show that Turkish and Moroccan groups do not differ significantly in their use of health care in the country of origin, but that they use health care in the country of origin considerably, i.e. 12, 7% of the Moroccan and 16, 9% of the Turkish made use of some kind of health care in their country of origin in the past year, 2001. Unfortunately, we do not have this information for 2005, which makes investigating changes impossible. This forms another point on the research agenda, in addition to the possible influence of perceived discrimination.