Influence of culture on health and health service usage

Culture profiles how people perceive the world and their experiences. Therefore, culture has an important impact on health. The way health providers and patients view health and illness, what they believe about the etiology of the disease (such as belief in evil spirits as the cause for some

diseases such as tetanus), and whether they will accept a diagnosis or not are influences of culture. Also, culture determines which diseases are stigmatized and why patients hold such beliefs; for instance, having depression and seeing a psychiatrist in some cultures is interpreted as meaning that the patient is a lunatic. (Mayhew, 2018.) The types of health promotion activities that are recommended, practiced, and ensured as well as people's perception of being

overweight, with some cultures considering a state of being overweight as being healthy, strong, or having affluence are impacts of culture. The ways people express pain is varying among cultures, in some cultures, stoicism is demonstrated even in the face of great pain, while in other cultures the slightest hint of pain or illness is expressed, investigated, and treated. (Mayhew, 2018.) According to Mayhew (2018), some cultures rely on western medicine primarily while other cultures rely on traditional medicines primarily, health-seeking behavior varies depending on which system of medicine the individual believes in. Patient's interaction with providers can impact by culture, some cultures do not make direct eye contact as a sign of respect, while others regard to lack of eye contact as being a negative indicator (Mayhew, 2018).

In addition to the above, culture affects how people accept and share information about the diagnosis, how preventive care is accepted and used (such as antenatal care, vaccinations, birth control, and screenings), how much control an individual has in making healthy choices, as well as perceptions regarding mortality. Communication styles and level of openness with health care providers, access to health care, and what health professionals can or cannot do in the specific area are depended on culture. Thus, health care providers who have a good understanding of the cultural beliefs of the patient are more likely to deliver successful personalized care.

(Mayhew, 2018.)

In the context of migrant utilization of health care services, these cultural influences on health may be further compounded by other barriers to health care access in the host country. Also, immigrant culture poses a challenge concerning help-seeking. Decisions relating to the use of health care services are bound by a social context. (Ejike, 2017.) The use of formal health care may be hindered by limited resources, limited access to care, and lack of knowledge. However, cultural differences regarding illness and help-seeking behavior constitute a potent factor on

their own. Accordingly, cultural health beliefs defined as ways in which people perceive illness, explain pain, define quality care, and select their caregiver represents an important concept in seeking to explore health care utilization among migrants. Migrants are also likely to live in poverty in the host country due to elements in the host country that propagate poverty for them, such that they subsequently face substantial economic barriers regarding access and use of health care services. (Ejike, 2017.)

A recent study in Finland stated that pregnant women without legal documents are considered as a vulnerable group who do not have equal access to health care services therefore it causes a delay in prenatal care and insufficient screening of infectious diseases that may lead to

pregnancy complications (Tasa et al., 2021).

2.3 The Finland context

2.3.1 Finland migration statistics

International migrant stock is a metric that represents the number of people who live in a country other than that in which they were born. The data used in estimating international migrant stock are obtained primarily from population censuses. The data can also be based on people who are citizens in another country other than the one in which they reside.

Fig. 1: The numbers of international migrants in Finland, 1990-2019

Sources: United Nations High Commissioner for Refugees UNHCR (2018); United Nations Relief and Works Agency UNRWA (2019); United Nations Department of Economic and Social Affairs UNDESA (2019)

Figure 1 reveals a consistent positive trajectory in the numbers of international migrants in Finland and a corresponding positive trajectory in the number of migrants as a share of the country’s total population (UNHCR 2018; UNRWA 2019; UNDESA 2019).

1.30% 1.90%

1990 1995 2000 2005 2010 2015 2019 2020

Finland international migrants ,1990-2019

International migrants (thousands)

International migrants as a share of total population (percentage)

Fig. 2: Finland migration statistics 2000-2015, (Macro Trends,2020).

The trajectory of immigration for Finland from 2000 to 2015 showed a significant increase (See Fig.2). The immigration statistics for the country was 136, 203 in 2000, 192,169 in 2005, 248,135 in 2010, and 315,881 in 2015 (Macro Trends, 2020).

Fig. 3: Female migrants in Finland, Europe, and Worldwide 2019 (UN DESA, 2019).

47.90%

51.40%

48.80%

46.0% 47.0% 48.0% 49.0% 50.0% 51.0% 52.0%

world Europ Finland

Females among international migrants in Finland , Europe and in the World, 2019

0 50000 100000 150000 200000 250000 300000 350000

2000 2005 2010 2015

Finland Migration Population 2000-2015

Female migrants represented almost half of the migrant populations in Finland in 2019 (See Fig.

3). This statistic followed a trend that occurred both globally and in Europe in which women represented half of the migrant populations. (UN DESA, 2019.)

2.3.2 Finnish health care system

In Finland, medical, social, and health services are guaranteed by the governmental constitution of the country. The government is responsible for social welfare and financing. The government agency responsible for social welfare and is the Ministry of Social Affairs and Health. This agency is responsible for the preparation of legislative reforms, the formulation of policies on social welfare and, and supervision of the implementation of such policies. (Keskimaki et al.,2019.) The provision of social welfare and health care services is supervised at the national level by the National Supervisory Authority for Welfare and Health (VALVIRA in the Finnish language). Private enterprises and non-governmental organizations also provide and social welfare services to the populace. The private sector provides approximately 25% of social welfare and services in the country. (Health care in Finland, 2013.)

Finnish health care service is divided into two parts, specialized medical care, and primary. The country has municipal health centres (n=142) for primary care, central hospitals, and some local hospitals for secondary care (n= 20), as well as five university hospitals for tertiary care that are operated by local authorities. The health centers provide preventive services, rehabilitation, medical care, mental health, and substance abuse services, as well as occupational. (Ministry of Social Affairs and Health, 2019.) Individuals with the European Health Insurance Card are entitled to receive the same as Finnish citizens. Similarly, immigrants residing in Finland are entitled to the same health services and benefits as provided to citizens of the country. It is important to note that women immigrants who live in Finland have no legal barriers to health care utilization.

(Health care in Finland, 2013.) This would suggest that migrant women who do not hold resident permits may experience more barriers concerning health care utilization.

2.4 Barriers to help-seeking

In modern times, health resources can be broadly differentiated into two groups, conventional or western medicine and alternative or traditional types of medicine such as home remedies, acupuncture, Tai Qi exercise, nutritional diet, herbal medicines, and health information

consumption. Health-seeking behaviors are defined in the literature as those actions taken by individuals to address health-related symptoms including seeking help from health care facilities as well as using alternative resources to try to abate the symptoms of an illness. (Ejike, 2017.) Health-seeking behaviors are a precursor to health care utilization; with the concepts being closely related. The barriers to health-seeking and the use of health care services by immigrants, with a focus on immigrant women are presented below.

2.5 Legal status

In most European countries, the right to access health services is severely limited for

undocumented migrants (WHO, 2016). A study found that legal status to be the most important factor directly affecting health and social services access for migrants and refugees. Even where migrant patients have the right to care, caregivers may be not well-educated on this right, and the health legislation affecting migrants in their country. (Chiarenza et al., 2019.) Similarly, in Finland according to national regulation only documented migrants have access to the same care and resources as citizens of the country. Nevertheless, emergency service is given to everybody irrespective of the residency status of the individual. (Health care Act, 2010; Ministry of Health and Social Affairs, 2017.) Lack of documentation, therefore, constitutes a significant barrier on its own to help-seeking behavior.

2.6 Discrimination

Discrimination is defined as being the unjust treatment of people because of race, religion, sex, etc (Cambridge Dictionary, 2021). The study showed that perceived discrimination was

associated with physical appearance, immigrant status, and workplace-related factors

(Agudelo-Suarez et al., 2011). A study in Finland conducted by the Union of Health and Social Care Professionals found that some immigrants experienced discrimination at their workplace.

Experiences of discrimination or fear of discrimination may, therefore, be a barrier to health care utilization. (Shrestha,2017.)

2.7 Socioeconomic factors

Socioeconomic factors are the society-related economic factors that shape the lifestyle and attitude of people. Major socioeconomic factors are income, education, ethnicity, occupation, place of residence, and religion. Research evidence shows that such socioeconomic factors affect access to care and health care utilization. For instance, immigrants may avoid conventional health services for traditional forms of care because of associated costs where they have low income. (Ejike, 2017; Shrestha, 2017.)

2.8 Language

Language is one of the key factors that affect access to health and the use of health care

services. Patients who are not proficient in the language of the host country may not be able to explain their health problems clearly and may not also be able to understand the information they receive from providers. Misdiagnosis and wrong treatment can also occur where language constitutes a barrier. People who do not have language proficiency may not know they can get information and the right. Such events may affect future health-seeking behavior. (Fernandez et al., 2011.) The study revealed that immigrants having limited language proficiency and who had lived in the host country for less than ten years had lower access and lower rates of health care utilization rates. (Leburn,2012).

As of late 2020, the population of Finland was 5.52 million people, with 7.6 % representing foreign citizens. The official languages are Finnish and Swedish; 86.9 % of the population speak Finnish while 5.2 % speak Swedish (Statistics Finland, 2020). In the health care sector, these languages are correspondingly predominant. Health-related Brochures in the health care

facilities are available in these languages. Immigrants who do not speak these languages may experience challenges in accessing care or in using health care services. (Shrestha, 2017.) In general, the English language proficiency of the health care provider may help immigrant patients with communication problems (Karanja, 2013).

2.9 Length of stay in the host country

The duration of the immigrant's stay in a host country has also been found to be an important determinant of the utilization patterns for migrant populations, with research findings

suggesting that utilization patterns change with the duration of stay in the host country. New immigrants tend to use emergency care services more compared to the use of primary care services. With the increased duration of stay, increasing acculturation, and a better

understanding of the system of the country, this trend changes such that the use of walk-in service becomes less while the use of regular primary care increases. (Shrestha, 2017.)

2.10 Cultural background

The cultural background of immigrants can serve as a barrier to health utilization. This challenge can be from the side of the patient or the side of the health care provider. People with different cultural backgrounds may have some preconceived regarding each other’s culture. providers may hold a certain cultural stereotype that impacts how they view the immigrant and their health needs or problem. The immigrant's communication style may also pose a challenge to the health care provider who is not familiar with other cultures or who is not culturally sensitive. This problem is often addressed using interpreters where available. Evidence shows that interpreters serve as mediators between the diverse cultures as well as facilitate the preparation and

adherence to treatment plans (Shrestha, 2017).

The impact of culture on health has been discussed previously, including how culture affects the use of services. Culture shapes how both providers and patients view illness, influences the types of health activities that are recommended, practiced, and insured, also, influence what

symptoms the patient reports, and what choices they make for the cure, formal health care services, or other alternatives. (Mayhew, 2018.) Cultural health beliefs are defined as ways in which people perceive illness, explain pain, define quality care, and select their caregiver, affect health-seeking behavior and health care utilization among migrants (Ejike, 2017).

Some factors related to ethnicity also may play a strong role in the decision-making for using health services. The phrase “locus of control” has been used by some scholars to describe an individual’s expectations regarding the degree of control they have over a situation. An internal locus of control refers to the belief that positive events are based on one’s behaviors or skills while an external locus of control represents the belief that external forces such as God,

powerful others, and fate, control events. (Ejike, 2017.) Research evidence suggests that certain ethnic groups or individuals with ties to the African race, tend to have an external locus of

control, compared to Caucasians concerning help-seeking behaviors. Researchers also posit that both structural and cultural factors may play a role in shaping differences in health-seeking behaviors among different ethnicities. Structural factors are factors such as affordability (lack of financial resources), accessibility (lack of knowledge, lack of transportation, or lack of insurance), and availability of services. Cultural factors, on the other hand, include health beliefs, acceptance of health services, and language proficiency. (Ejike, 2017.)

2.11 Environmental Setting

The environmental setting in which the migrant lives is closely related to cultural factors. This context refers to the events, situations, or experiences that give the individual finds themselves in or is passing through. It encompasses the geophysical, spiritual, socio-political, ecological, expectation of using modern or traditional care, financial resources, knowledge regarding care options, and technologic factors, that are located within the migrant's settings. Such

environmental context can act as a barrier or a facilitator for health-seeking behaviors and health care outcomes. (Ejike, 2017; McFarland & Wehbe-Alamah, 2019.)

2.12 Theoretical frameworks

2.12.1 Leininger’s transcultural nursing Theory

Transcultural nursing is a relative study of cultures to appreciate resemblances and contrast in human groups (Leininger, 1991). The goal of this theory was to help researchers and clinicians understand and explain the interdependence between care and cultural phenomena while acknowledging the differences between cultures (Leininger & McFarland, 2006). The theory proffers that nurses cannot separate cultural beliefs, worldviews, and social structure factors, from illness, health, wellness, or care in their work with cultures, as these factors are closely interrelated. Health and wellness are affected by cultural and social structure factors like religion, technology, cultural beliefs and practices, economics, family and kinship, politics,

physical conditions, and biological factors. (McFarland, 2018; McFarland & Wehbe-Alamah, 2019.)

Four tenets undergird Leininger’s transcultural care theory. The first theoretical tenet is that there are care diversities and universalities among cultures in the world. Culture care meanings must be discovered before a transcultural body of knowledge can be established. (Burkett et al., 2017; Chiatti, 2019.) The second theoretical tenet is that social structural factors such as

education, kinship, technology, religion, economics, politics, language, environment, and care factors influence cultural care expressions, meanings, and patterns in different cultures. An understanding of these factors is necessary to provide cultural groups with meaningful care and culturally based care. The third theoretical tenet is that the generic and professional health factors that occur in diverse environmental contexts influence the outcomes in health and illness (McFarland, 2018) and these factors need to be taught and applied in care practices. The fourth theoretical tenet is that culture care decisions and action modes be used to plan culturally congruent care for patients. (McFarland & Wehbe-Alamah, 2019.)

Culturally congruent care as discussed under this theory refers to “culturally based care knowledge, actions, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and

well-being, or to prevent illness, disabilities, or death” (McFarland & Wehbe-Alamah, 2019, p.547).

Culture care diversity as discussed in Leininger’s theory refers to the variabilities that occur among human beings regarding culture care meanings, lifeways, symbols, patterns, values, or other features that relate to care delivery to persons from a specific culture. Culture care universality on the other hand refers to the similar culture care phenomena among groups or individuals that serve as guides for the provision of effective care. (McFarland & Wehbe-Alamah, 2019.)

The concept of transcultural nursing derives from this theory. The goal of transcultural nursing is to deliver care that is culturally congruent or care that aligns with the values, lifestyle, and

system of meaning, of the patient. Respecting the cultural needs of patients and communities is important to the success of health care. To be effective, nursing care must integrate the beliefs and cultural values of patients, their families, and communities with the decisions and views of the team of providers. By providing culturally congruent care, the nurse bridges cultural gaps to provide supportive and personalized care for patients. (Clarke, 2017.) Besides, utilizing cultural knowledge to treat a patient similarly benefits a nurse to be liberal to therapies that can be considered non-conventional, for example, spiritual treatments like meditation and blessing (Gonzalo, 2020).

Transcultural nursing involves a comparative study of cultures to understand similarities and differences among them. The information and its meanings must be generated by the patients themselves rather than predetermined criteria. (Clarke, 2017.) Transcultural nursing advocates the adjustment of patient care procedures to accommodate current cultural contexts

(Henderson et al., 2018; McFarland & Wehbe-Alamah, 2019), underscoring the need for institutions to provide continual training in cultural competence to their nursing staff (Henderson et al., 2018). According to McFarland & Wehbe-Alamah (2019), transcultural

prepared nurses can advance culture care knowledge by uniting culture and care, by conducting research, and by applying their knowledge regarding culture and care into practice. This

approach to nursing in turn results in positive outcomes for both nurses and patients.

2.12.2 Culturally competent care The concept of immigration is closely linked to concepts such as cultural diversity and cultural competence since immigrants and their host countries have different cultures. Increasing diversity creates challenges for health care practitioners and policymakers to develop and deliver culturally competent services and to reduce inequalities in health across the diverse cultural groups in a population. (Lin et al.,2016; Henderson et al., 2018.) Diversity is an integral concept of modern nursing. Several international studies conducted regarding cultural diversity issues that nurses are facing when providing care for multicultural patient populations. (Ogbolu et al., 2018.)

In actual practice, merely being aware of cultural differences does not mean that the health care worker will deliver satisfactory care or that racial, cultural, and ethnic discrimination will be mitigated. Being aware of cultural differences will also not automatically lead to a positive interaction between the patient and the health care provider. When health care providers emphasize cultural differences and equate that to respect for their diverse care populations, they inadvertently may be promoting ethnocentrism rather than displaying cultural competence.

What is appropriate for one cultural group, may not be appropriate for another. (Henderson et

What is appropriate for one cultural group, may not be appropriate for another. (Henderson et

In document Influence of Culture on Health Behavior and Health care Utilization among Immigrant Women in Finland (sivua 17-0)