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 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

This study aims to understand the role of culture in health service usage among immigrant

In document Influence of Culture on Health Behavior and Health care Utilization among Immigrant Women in Finland (sivua 22-0)