This study found that in terms of access to care, migrant women were able to access the health services they needed both primary care and specialist care. In terms of discriminatory practices that may be related to culture, there were no reports of discrimination against the participants, rather equality in the system was emphasized in the participant's experiences. Overall, the immigrant women who participated in the study found their experiences with the Finland health system to be positive. The Finnish system was overwhelmingly rated to be better organized than those of participant’s home countries which are countries in the Middle and South East Asia.
The study findings suggest that there were no systemic barriers that affected utilization by immigrant women. Migrant women demonstrate stoicism and tolerance, not seeking care
immediately as the symptom is observed. The majority of migrant women also rely on traditional remedies for minor ailments and only seek help within the system if the condition is severe or chronic.
Language differences had a slight influence on accessibility but did not prevent access to care, it proved to be a challenge for migrant women to express their feelings, describe their symptoms, and present any requests they may have. The poor English language of some health care
providers might represent a bidirectional challenge exists in terms of communication for migrant women. This challenge was identified in the study as a potential factor that can limit care-seeking behavior and utilization.
While there was some reliance on traditional medicine migrant women were accepting of western treatments and did not suggest any cultural practices as a reason for refusing care.
There was a significant expression of preference for same-gender when it comes to provider of services such as gynecological care. However, this preference appeared to be more of a personal preference than a culture-based preference.
The findings of the study have important implications for practice. The findings suggest that migrant women are to a large extent accepting of the health care context as a place where professional competency surpass cultural competency. While this statement does not mean that cultural competency among professionals is not critical, it also provides a different context for evaluating immigrant women's experiences and expectations about utilization. The findings also underscore the importance of language barriers as a critical factor in limiting utilization, while highlighting the role of legal status in facilitating full utilization of care.
Limitation and recommendations
The limitations of the study are related to the research approach. Qualitative studies are limited by subjectivity in the data collection, analysis, and interpretation process. Such limitations also apply to this study. Due to COVID 19 pandemic, online interviews replaced face to face interview method which might affect the interview quality, outcome, and participation rate. Furthermore, interviewing in a language rather than a native language may influence the interviews and some concepts might be missed during the translation process.
the study cannot be generalized to all groups of immigrants residing in Finland as it is qualitative research and the population studied were from the Middle and South-Eastern cultures which have distinct cultures and high reliance on traditional systems of medicine. Additional studies may be necessary to understand the experiences of immigrants from other parts of the world.
While the current study obtained demographic data on variables such as housing, income level, educational level, health history, marital status, age, and residency, the effect of these variables
on health care utilization was not examined. The demographic variables were obtained for descriptive statistics. Additional quantitative studies in which these variables serve as predictive variables for utilization may provide insight into the effects of the respective variables on health care utilization for migrant women. Lastly, based on the emergent theory from the study, it is recommended to explore the impact of acculturation for migrant women versus cultural competency for professional workers on utilization among immigrants.
The study setting and choice of participant's home region was based on this study researcher’s awareness and understanding of the languages and cultures of those countries as an insider approach, and it is a strength of this study.
References
Abedsaeidi J, Amiraliakbari S. (2015). Research Method in Medical Sciences and health. Tehran:
Salemi.
Agudelo-Suárez, A. A., Ronda-Pérez, E., Gil-González, D., Vives-Cases, C., García, A. M., Ruiz-Frutos, C., Felt, E., & Benavides, F. G. (2011). The effect of perceived discrimination on the health of immigrant workers in Spain. BMC Public Health, 11(1), 652. https://doi.org/10.1186/1471-2458-11-652
Bradby, H., Humphris, R., Newall, D., & Phillimore, J. (2015). Public health aspects of migrant health: a review of the evidence on health status for refugees and asylum seekers in the European Region (Health Evidence Network Synthesis Report, Issue 44).
http://www.euro.who.int/en/publications/abstracts/public-health-aspects-of-migrant-health-a- review-of-the-evidence-on-health-status-for-refugees-and-asylum-seekers-in-the-european-region-2015
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
Brown, N., McIlwraith, T., & de González, L. T. (2020). Perspectives: an open introduction to cultural anthropology. Second Edition. American Anthropological Association
http://perspectives.americananthro.org/.(Accessed February 2021)
Cambridge Dictionary. (2021). DISCRIMINATION | meaning in the Cambridge English Dictionary.
https://dictionary.cambridge.org/dictionary/english/discrimination. (Accessed April 2021) Carrasquillo O. (2013) utilization. In: Gellman M.D., Turner J.R. (eds) Encyclopedia of Behavioral Medicine. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-1005-9_885
Chauvin, P., Simonnot, N., Vanbiervliet, F et al. (2015). Access to health care for people facing multiple vulnerabilities in health in 26 cities across 11 countries. Report on the social and
medical data gathered in 2014 in nine European countries, Turkey, and Canada. Paris: Doctors of the World Médecins du monde international network.
https://mdmeuroblog.files.wordpress.com/2014/05/mdm-intl-network-full-report-11-countries-18th-may-2015.pdf. (Accessed December 2020)
Chiarenza, A., Dauvrin, M., Chiesa, V., Baatout, S., & Verrept, H. (2019). Supporting access to health care for refugees and migrants in European countries under particular migratory pressure. https://doi.org/10.1186/s12913-019-4353-1
Chiatti, B. D. (2019). Culture Care Beliefs and Practices of Ethiopian Immigrants. Journal of Transcultural Nursing, 30(4), 340–349. https://doi.org/10.1177/1043659618817589
Clarke, S. (2017). Cultural congruent care: A reflection on patient outcome. J Health Commun.
2(4), 51-54. DOI: 10.4172/2472-1654.100092
Clarke, V., & Braun, V. (2013). Successful Qualitative Research: A Practical Guide for Beginners.
London: Sage http://www.uk.sagepub.com/books/Book233059. (Accessed January 2021)
Clarke, V., Braun, V., Terry, G & Hayfield N. (2019). Thematic analysis. In Liamputtong, P. (Ed.), Handbook of research methods in health and social sciences (pp. 843-860). Singapore: Springer.
Committee on the Elimination of Discrimination against women. (2008). CEDAW Committee General recommendation No. 26 on women migrant workers (Vol. 63558, Issue 26).
https://www.ohchr.org/EN/HRBodies/CEDAW/Pages/CEDAWIndex.aspx. (Accessed February 2021)
Data protection in the EU. (2020). European Commission. The General Data Protection
Regulation. [EU: n Act 679/2016]. https://ec.europa.eu/info/law/law-topic/data-protection/data-protection-eu_en. (Accessed October 2020).
Ejike, C. N. (2017). The influence of culture on the use of health care services by refugees in southcentral Kentucky: A mixed study. Dissertations. Paper 116.
http://digitalcommons.wku.edu/diss/116
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. The Lancet, 365(9467), 1309–1314.
https://doi.org/https://doi.org/10.1016/S0140-6736(05)61027-6
Feldman, R. (2006). Primary for refugees and asylum seekers: A review of the literature and a framework for services. Public Health, 120(9), 809–816.
https://doi.org/https://doi.org/10.1016/j.puhe.2006.05.014
Fernandez, A., Schillinger, D., Warton, E. M., Adler, N., Moffet, H. H., Schenker, Y., Salgado, M. V., Ahmed, A., & Karter, A. J. (2011). Language Barriers, Physician-Patient Language Concordance, and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE). Journal of General Internal Medicine, 26(2), 170–176.
https://doi.org/10.1007/s11606-010-1507-6
Fernandez, A., Schillinger, D., Warton, E. M., Adler, N., Moffet, H. H., Schenker, Y., Salgado, M. V., Ahmed, A., & Karter, A. J. (2011). Language Barriers, Physician-Patient Language Concordance, and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE). Journal of General Internal Medicine, 26(2), 170–176.
https://doi.org/10.1007/s11606-010-1507-6
Filges, T., Montgomery, E., Kastrup, M., Marie, A., & Jørgensen, K. (2015). The Impact of Detention on the Health of Asylum Seekers: A Systematic Review; Campbell Systematic Reviews.
https://doi.org/10.4073/csr.2015.13
Friese, S., Soratto, J., & Pires, D. (2018). Carrying out a computer-aided thematic content analysis with ATLAS.ti. www.mmg.mpg.de/workingpapers
Gonzalo, A. (2020). Madeleine Leininger: Transcultural Nursing Theory. Nurseslabs https://nurseslabs.com/madeleine-leininger-transcultural-nursing
theory/#leininger’s_transcultural_nursing_theory. (Accessed October 2020)
Guest, G., Nameyid, E., & Chen, M. (2020). A simple method to assess and report thematic saturation in qualitative research. https://doi.org/10.1371/journal.pone.0232076
Harrelson, M. C. R. (2019). Life satisfaction and health care utilization among immigrants to the United States. LSU Master's Theses. 4999.
https://digitalcommons.lsu.edu/gradschool_theses/4999
Hart, P. L., Mareno, N. (2014). Cultural challenges and barriers through the voices of nurses.
Journal of Clinical Nursing, 23(15-2232). https://onlinelibrary-wiley-com.ezproxy.uef.fi:2443/doi/full/10.1111/jocn.12500
Health Care Act. (2010). Ministry of Social Affairs and Health, Finland. [Act.no. 1326/2010].
https://www.finlex.fi/en/laki/kaannokset/2010/en20101326_20131293.pdf. (Accessed January 2021).
Health care in Finland. (2013). Ministry of Social Affairs and Health Finland.
https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/69930/URN_ISBN_978-952-00-3395-8.pdf?sequence=1. (Accessed January 2021).
Henderson, S., Horne, M. orcid.org/0000-0002-6153-8547, Hills, R. et al. (2018) Cultural
competence in health care in the community: A concept analysis. Health and Social Care in the Community, 26 (4), 590-603. https://doi.org/10.1111/hsc.12556
International Organization for Migration. IOM. (2020). Key migration terms.
https://www.iom.int/key-migration-terms#Migrant. (Accessed December 2020)
Karanja JMN. (2013). Effects of language barrier on the health of African immigrant women living in Helsinki: a study on prevention and promotional tools, [master thesis, Kymenlaakson
University of Applied Sciences].
https://www.theseus.fi/bitstream/handle/10024/59199/Karanja_Jane%20Mercy.pdf?sequence=1
Keskimaki, I., Tynkkynen, L. K., Reissell, E., Koivusalo, M., Syrja, V., Vuorenkoski, L., Rechel, B., &
Karanikolos, M. (2019). Finland: Health System Review. Health systems in transition, 21(2), 1–166.
Langlois EV, Haines A, Tomson G, Ghaffar A.(2016). Refugees: towards better access to health-care services. Lancet (London, England). 387(10016):319-321. DOI:
10.1016/s0140-6736(16)00101-x.
Leininger M. M. (1991). The theory of Culture Care Diversity and Universality. NLN publications, (15-2402), 5–68.
Leininger, M. M., & McFarland, M. R. (2006). Culture care diversity and universality: a worldwide nursing theory (2nd ed.). Jones and Bartlett, Sudbury.
Lester, S. (1999). An introduction to phenomenological research. Stan Lester Developments, Taunton. http://www.sld.demon.co.uk/resmethy.pdf
Liew, H.-P., & Brooks, T. (2017). A conjoint analysis of inpatient satisfaction ratings in Indonesia.
Health Policy and Technology, 6(1), 105–113. https://doi.org/10.1016/j.hlpt.2016.11.007 Lin, C. J., Lee, C. K., & Huang, M. C. (2016). Cultural competence of health care providers: A systematic review of assessment instruments. The Journal of Nursing Research, 00(0),1-13.
doi:10.1097/jnr.0000000000000153
Macro Trends. (2020). Finland Immigration Statistics 1960-2020.
https://www.macrotrends.net/countries/FIN/finland/immigration-statistics. (Accessed October 2020).
Mayhew, M. (2018). How Culture Influences Health | Culture & Health | Caring for Kids New to Canada. https://www.kidsnewtocanada.ca/culture/influence
McFarland, M. R. (2018). The theory of culture care diversity and universality. In McFarland, M.
M., Wehbe-Alamah, H. B. (Eds.), Leininger’s transcultural nursing: Concepts, theories, research, and practice (4th ed., pp. 39-56). New York, NY: McGraw-Hill.
McFarland, M. R., & Wehbe-Alamah, H. B. (2019). Leininger’s theory of culture care diversity and universality: An overview with a historical retrospective and a view toward the future. Journal of Transcultural Nursing, 30(6), 540–557. https://doi.org/10.1177/1043659619867134
Ministry of Health and Social Affairs. (2017). Health care and social welfare for illegal residents.
https://stm.fi/en/social-security-and-services-of-asylum-seekers-in-finland/health care-and-social-welfare-for-illegal-residents. (Accessed April 2021).
Ministry of Social Affairs and Health. (2019). Social welfare and health care in Finland. 1–2.
https://stm.fi/documents/1271139/14654750/Factsheet_SocialWelfareAndHealth
care_Finland.pdf/f99fee59-aac7-036f-d2b3-b4138532bead/Factsheet_SocialWelfareAndHealth care_Finland.pdf
Naderifar, M., Goli, H., & Ghaljaie, F. (2017). Snowball Sampling: A Purposeful Method of Sampling in Qualitative Research. Strides in Development of Medical Education, 14(3).
https://doi.org/10.5812/sdme.67670
Ogbolu, Y., Scrandis, D. A., & Fitzpatrick, G. (2018). Barriers and facilitators of care for diverse patients: Nurse leader perspectives and nurse manager implications. Journal of Nursing Management, 26(1), 3–10. https://doi.org/10.1111/jonm.12498
Shrestha, A. (2017). Immigrants’ access and utilization of services in FINLAND: MAAMU Study.
[master thesis, University of Eastern Finland].
https://erepo.uef.fi/bitstream/handle/123456789/18404/urn_nbn_fi_uef-20170761.pdf?
sequence=-1&isAllowed=y
Smith, C. & Mahmood, T. & Mercer, C. (2016). Migrant women’s health issues: addressing barriers to access to for migrant women with irregular status.
https://www.euro.who.int/__data/assets/pdf_file/0017/330092/6-Migrant-womens-health-issues-irregular-status.pdf?ua=1
Statistics Finland. (2020) Finland in Figures-Population.
https://www.stat.fi/tup/suoluk/suoluk_vaesto_en.html#Migration.(Accessed September 2020).
Surood, S., & Lai, D. W. L. (2010). Impact of culture on use of Western health services by older South Asian Canadians. Canadian Journal of Public Health, 101(2), 176–180.
https://doi.org/10.1007/bf03404367
Tasa, J., Holmberg, V., Sainio, S., Kankkunen, P., & Vehviläinen-Julkunen, K. (2021). Maternal utilization and the obstetric outcomes of undocumented women in Finland – a retrospective register-based study. BMC Pregnancy and Childbirth, 21(1), 191. https://doi.org/10.1186/s12884-021-03642-7
The Center for Advanced Research on Language Acquisition (CARLA): Culture. (2020).
https://carla.umn.edu/culture/definitions.html.(Accessed December 2019).
United Nation High Commissioner for Refugees. UNHCR. (2018). Refugee Statistics.
https://www.unhcr.org/refugee-statistics/. (Accessed December 2020).
United Nations Department of Economic and Social Affairs, Population Division. (2016).
International Migration Report 2015: Highlights (Vol. 3, Issue 2).
https://www.un.org/en/development/desa/population/migration/publications/migrationreport/d ocs/MigrationReport2015_Highlights.pdf.(Accessed December 2020).
United Nations High Commissioner for Refugees. (2020). UN Refugee Agency. Figures at a Glance. UNHCR, 1–3. https://www.unhcr.org/figures-at-a-glance.html. (Accessed December 2020).
United Nations Population Division and Department of Economic and Social Affairs. (UNDESA).
(2019). https://www.un.org/en/development/desa/population/migration/index.asp. (Accessed December 2020).
United Nations Relief and Works Agency. UNRWA. (2019). United Nations Relief and Works Agency for Palestine Refugees. https://www.unrwa.org/. pdf?ua=1. (Accessed December 2020).
United Nations. (1998). Department of Economic and Social Affairs Population Division,
Recommendations on Statistics of International Migration, Revision 1, p.10, Definition of “long-term migrants”. https://unstats.un.org/unsd/publication/SeriesM/SeriesM_58rev1E.pdf.
(Accessed December 2020).
United Nations. (2016). Women Migrant Workers Human Rights, UN Women.
https://www.un.org/webcast/pdfs/160916am-migrants-women.pdf. (Accessed November 2020).
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis:
Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15(3), 398–405. https://doi.org/10.1111/nhs.12048
Walker J. L. (2012). The use of saturation in qualitative research. Canadian journal of
cardiovascular nursing = Journal canadien en soins infirmiers cardiovasculaires, 22(2), 37–46.
World Health Organization WHO. (2019). World Health Assembly Update.
https://www.who.int/news-room/detail/27-05-2019-world-health-assembly-update-27-may-2019.
(Accessed December 2020).
World Health Organization. WHO. (2020). Refugee, and migrant health - Global.
https://www.who.int/health-topics/refugee-and-migrant-health#tab=tab_1. (Accessed December 2020).
World Health Organization. WHO. (2021). Women’s health. https://www.who.int/health-topics/women-s-health/. (Accessed January 2021).
Appendices
Appendix A Consent Form
Appendix B Background questions Appendix C Interview Questions Appendix D Information Sheet
Appendix E Privacy Notice for Scientific Research