2 Literature review
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 al., 2018.) A clear understanding of the concept of cultural competence and its dimensions is very important for health care providers. Therefore, providing culturally competent care is one of the priorities in organizations. (Hart & Mareno, 2014.)
In the health care context, cultural competence is defined as the ability to identify, appreciate, and respect the preferences, values, and expressed needs of patients. It includes the ability to resolve conflicts and identify solutions to problems in ways that reduce interference from culture. (Henderson et al., 2018.) There are several other definitions of cultural competence in the literature. One definition proffer that cultural competence is a set of congruent attitudes, behaviors, and policies within a system or group that enables that entity to work effectively in cross-cultural situations. Applying this definition to the health system, cultural competence represents the capacity of the health care system to deliver its goals of improving health by integrating culture into its processes and policies for the health services delivery. Another
definition of cultural competence is the integration of knowledge, skills, and attitudes that
enhance cross-cultural interactions and communication. This second definition in the health care context focuses on the ability of providers and health organizations to deliver health services
that effectively meet the cultural needs of patients. (Henderson et al., 2018.)
Lin et al. (2016) conceptualized cultural competence as comprising of three domains, cultural awareness and sensitivity, cultural knowledge, and cultural skill. Cultural awareness refers to the individual's recognition and acceptance of their cultural background, their ability to perceive cultural differences in others, and the appreciation that cultural perspectives and personal prejudice or values are influenced by personal views. Cultural awareness leads turn into cultural sensitivity. Health care providers who have cultural awareness are considered as being culturally sensitive. (Lin et al., 2016.) The second domain, cultural knowledge, is the knowledge regarding the concepts, theories, and evaluation of culture. The third domain, cultural skill refers to the application of the knowledge of culture to clinical care. It implies the ability of providers to perform culturally-based assessments and offer accurate diagnoses as well as the ability to use resources effectively while considering and respecting the beliefs and values of the patient.
(Henderson et al., 2018.)
To be able to translate cultural knowledge and awareness into culturally sensitive care, the nurse will be able to conduct the cultural assessment. The purpose of such culture assessment is to obtain reliable information from the patient that enables the nurse to create a care plan that is both acceptable and culturally relevant for all the health problems that the patient may have.
(Chiatti, 2019.) The nurse and all health care providers should have the skills to carry out a systematic cultural assessment that involves the values, practices, and beliefs of patients and their families (Clarke, 2017).
2.13 Literature summary
This section presents a review of the literature regarding the key constructs in this study.
Suboptimal utilization of health care services carries negative consequences for the health status of affected populations. With the rate of immigration increasing across the globe, the health status of this population becomes increasingly important within health care research. Migrants contribute to societal and economic development at their full potential when they are in good health. Issues such as lack of access to, interrupted care, poor living conditions, and unfair working conditions, reduce their productivity. The rate of migration is similar for men and women; however, the experience affects women differently. Female migration is affected by factors such as gender inequality, gender-based violence, traditional female roles, the gendered structure of the labor market, and the global feminization of poverty.
The construct of HCU describes the use of available services. Factors that influence HCU, include the cost of service, location of service, length of stay, type of service, and quality of service as well as some interrelating factors such as culture, society, and ecology. These intersections of factors in health care utilization, support the need to understand health care utilization among the immigrant population especially women, and the factors that either promote the use or otherwise serve as a barrier to the use of services.
The key topics in the literature were about how culture affects migrant’s perception toward health and illness, how they seek health services, and the choices they make about the type of medicine and treatment (modern or alternative). Cultural barriers can be inherent in the host society that prevents health-seeking such as discrimination and language barriers. Culturally competent care involves providing care in ways that respect the needs, values, and beliefs of all patients. 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.
3 Aim and objectives
This study aims to understand the role of culture in health service usage among immigrant women to highlight their healthcare utilization patterns. Moreover, to find out about migrants’
perspectives on health care professional cultural competency.
The study objectives are to explore views and experiences about possible cultural barriers when using healthcare services, to investigate information about immigrant women's health-seeking behaviors, and to explore the expectations or needs of migrants as being clients in the Finnish health care system.
The research questions are as below:
What are the experiences of women immigrants with Finnish health care services?
What are the cultural barriers that prevent access to quality health care services for migrant women in Finland?
4 Methodology
4.1 Study design
A qualitative descriptive study with a phenomenological approach was performed to define migrants’ women’s views on health care usage experiences and barriers or difficulties in
receiving culturally competent care. Qualitative research is a structured technique of explaining an individual’s experiences and inner emotions (Abedsaeidi and Amiraliakbari, 2015). The
phenomenological research method is mostly used in qualitative research where researchers try to understand the individual’s experiences in certain situations (Lester, 1999). It could be stated that qualitative research produces an exhaustive and profound outline of a phenomenon through data collection and introduce a rich report using an adaptable technique for research.
(Naderifar et al.,2017).
4.2 Participants and study setting
The participants involved in this study were immigrant women who live in different cities of Finland and were selected through purposive sampling. A total of 13 women have voluntarily participated. The inclusion criteria were migrant women age 18 and above, duration of residency in Finland was 5 years or less, born and raised in Asia particularly from Middle Eastern and South-eastern Asian countries, Legal immigrant, and to be fluent in English or Persian language.
(researcher’s mother tongue). The exclusion criteria were the second generation of immigrant women and undocumented migrant women as well as immigrant women with a residency of more than five years in Finland.
4.3 Description of data
Participants responded to join in the semi-structured in-depth interviews about cultural barriers, their challenges, and their experiences when accessing services. The open-ended questions were used. Probing techniques were used to provoke more information from participants by
confirming the slight pieces of information received during the interview. The interview produces information from participants in their own words. It allowed the researcher to examine the opinions and inherent cultural values to collect additional information that is not possible by the limitations of a questionnaire. Besides, demographic information (Appendix B) was collected from participants containing different dominoes (age, place of birth, education, marital status, employment, housing, income, Finnish Residency duration, mother tongue, Finnish language skill, health history, frequency of health services usage and use of traditional healing methods).
4.4 Recruitment and data collection
The study participants were recruited by sending the study flyer via social media (i.e., Facebook) and E-mail in the cultural centers and Finnish language courses of different cities in Finland. The study flyer included the research title, selection criteria, data collection period, type and the place of interview, name, and contact of the researcher.
The interviews took place from 4th November 2020 until 28th January 2021. In the early stage when reaching the target participants was difficult and recruitment progress was slow, snowball sampling or chain-referral sampling was used to recruit required samples for the study.
Snowball sampling is a comfort sampling technique that is used when subjects with objective qualities are difficult to access. In this technique, the current study subjects provide referrals to subjects amongst their contacts. (Naderifar et al.,2017.) Sampling was continued until the researcher reached data saturation. Data saturation is the most commonly used approach for approximating sample sizes in qualitative research (Guest et al.,2020). Saturation is an
instrument employed for guaranteeing that sufficient and quality information is gathered to help the study (Walker, 2012).
The interview questions were pilot tested before the main interview. Afterward, some slight changes were made to the interview questions (Appendix C). Overall, 16 participants showed interest to participate in the study but later only 13 participants responded to email or phone calls. Each participant was contacted by phone to explain briefly about the study process and after obtaining verbal approval and agreement about the time and date of the interview, a
The interview questions were pilot tested before the main interview. Afterward, some slight changes were made to the interview questions (Appendix C). Overall, 16 participants showed interest to participate in the study but later only 13 participants responded to email or phone calls. Each participant was contacted by phone to explain briefly about the study process and after obtaining verbal approval and agreement about the time and date of the interview, a