Influence of Culture on Health Behavior and Health care Utilization among Immigrant Women in Finland

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Influence of Culture on Health Behavior and Health care Utilization among Immigrant Women in Finland

Massoumeh M.H. Zadeh

Public health- Health Promotion in Nursing Science

University of Eastern Finland Faculty of Health Sciences School of Medicine

May 2021

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University of Eastern Finland, Faculty of Health Sciences School of Medicine

Public health

Health Promotion in Nursing Science

M.H. Zadeh, Massoumeh: Influence of Culture on Health Behaviour and Health care Utilization among Immigrant Women in Finland

Master's thesis, 73 pages, 5 appendices (16 pages).

Thesis instructors: Professor Hannele Turunen, RN, PhD University Teacher Maliheh Nekouei, BSN, RN, MNSc May 2021

Key words: Health service accessibility, health behavior, cultural competency, immigrant.

Abstract

Background: The world has become an international society due to the high rate of international immigration. The percentage of migration is similar for men and women; however, the

experience affects women differently. Finland is a homogeneous society which confronted an increment in migration population in recent years. There is a paucity of research concerning culturally diverse residents and their health behaviors as well as the cultural barriers faced by migrants in health care usage.

Aim: 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.

Method: A qualitative descriptive study approach with semi-structured in-depth interviews was conducted. The purposive sampling with a snowball approach was used to recruit 13 women.

Participants were women age 18 and above, with a residency duration of 5 years or less in Finland, and originally from Asia (particularly from Middle Eastern and South-Eastern Asian countries). The exclusion criteria were the second generation of immigrant women and

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undocumented migrant women. Before the interview, background information was collected by a questionnaire from participants. Due to the hit of COVID 19 pandemic interviews were mainly conducted online, audio-recorded, and transcribed verbatim. Data were analyzed with thematic analysis, deductive orientation, and use of the Atlas. ti 9 software.

Results: Four main themes and thirteen sub-themes emerged from the thematic analysis process. The major themes are health beliefs, health behavior, impact of culture on the use of health care services, and migrant women's experiences of cultural competency in the Finnish health services.

Conclusion: Overall, participants had positive experiences in the Finland health care system.

They were able to access health services either at the primary or secondary level based on their needs. Language differences had a slight influence on accessibility but did not prevent access to care, the poor English language of some health care providers might represent a bidirectional challenge that exists in terms of communication for migrant women. Migrant women are to a large extent accepting of the health care context as a place where professional competency surpass cultural competency.

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Foreword

First and foremost, I would like to extend my gratitude to my thesis advisors and supervisors, Professor Hannele Turunen and University Teacher Ms. Maliheh Nekouei. Without their

assistance and dedicated involvement in every step throughout the process, this research would have never been accomplished. I would like to thank you very much for your support and

understanding and for guiding me in the right direction over the past year.

Many thanks to Immigrants women who participated in this study, for their precious time and without expectation sharing their valuable experiences on health care services usage and highlighting their cultural patterns. The study would have been impossible without their contributions.

I would also like to thank the experts, professors, and teachers of the Department of Nursing Science and Institute of Public Health and Clinical Nutrition, Faculty of Health Science at the University of Eastern Finland who were involved in teaching, guiding, and sharing their

knowledge and expertise in the different area during my study in Public Health: Without their passionate participation, input, and the support the study process would not be successful.

Finally, I must express my very profound gratitude to my family for providing me with unfailing support and continuous encouragement throughout my study.

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List of figures

Fig. 1: The numbers of international migrants in Finland, 1990-2019 Fig. 2: Finland migration statistics 2000-2015

Fig. 3: Female immigrant in Finland, Europe, and worldwide 2019 Fig. 4: The process of data generation and data analysis

Fig.5: Six steps of thematic Analysis Fig.6: Participants place of birth

Fig.7: The study participant’s country of origin (Map) Fig.8: Migrant’s women city of residence in Finland Fig.9: Participant’s annual use of Health care Services

List of tables

Table 1. Study participants’ region, length of residency in Finland, age, and level of education Table 2: Study participants’ marital Status, housing, employment, income

Table 3. Health and cultural factors Table 4: Main themes and sub-themes

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Abbreviations

CAQDA Computer Assisted Qualitative Data Analysis

CARLA The Center for Advanced Research on Language Acquisition CEDAW Committee on the Elimination of Discrimination against women CINAHL Cumulative Index to Nursing and Allied Health Literature

EBCOG European Board & College of Obstetrics and Gynaecology

EU Europe Union

HCU Utilization

IOM International Organization for Migration

TCA Thematic Content Analysis

UN United Nations

UNDESA United Nations, Department of Economic and Social Affairs UNHCR United Nations High Commissioner for Refugees

UNRWA United Nations Relief and Works Agency

VALVIRA National Supervisory Authority for Welfare and Health (Sosiaali- ja terveysalan lupa- ja valvontavirasto)

WHO World Health Organization

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1 Introduction

The world is turning into an international society with numerous individuals moving to remote nations to live either for a short time or forever. Worldwide, the number of migrants has increased. Throughout the period 2000 to 2017, the entire number of international emigrants’

growth was 49 percent. (WHO, 2019.) Almost one-third (76 million) of all international migrants live in Europe. Women include marginally less than 50 percent of all international migrants, but female migrants exceed male migrants in Europe. (United Nations, Department of Economic and Social Affairs, 2016.) Finland’s migration data for 2015 show 27.3 percent growth since 2010 and Finland’s immigrants from outside Europe increased compared to other migrants in 2018 (Macro Trends, 2020).

The constant immigration argument has been inspired more by worry about the culture of the health care system in the nation, mainly with the expanding diverse immigrant residents and the health and wellbeing of the migrants. Immigrants may have higher rates of morbidity due to contrasts in disease occurrence at their origin country, the mental and physical pressure of relocating, and the adjustment to new social and physical atmospheres. When in the host country, these refugees more expected to live in poverty and face considerable financial obstructions comparative to access and use of medical care. (Ejike, 2017.)

To perceive the comprehensive manners by which women are influenced, migrant’s women ought to be studied from the view of gender inequality, the traditional social role of women, a gendered workforce, the worldwide occurrence of violence against women, universal poverty in women and women migrant worker (Committee on the Elimination of Discrimination against women, 2008).

During recent years, Europe confronted a sharp increment in migration. The primary factors adding to this expansion are both natural and human-produced disasters, including social, economic, and political uncertainty. (Bradby et al., 2015.) The rising number of refugees presents a massive challenge to the health care systems of the receiving nations (Feldman, 2006) Also,

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there is a general absence of preparedness to deal with and comprehend the health care needs of the immigrants amongst health care experts (Fazel et al., 2005). Information about the

migrants’ experiences of the health care systems of their host countries is required to improve the quality of health care provided just as to provide chances for better access (Langlois et al., 2016). In line with Surood and Lai (2010), apparent logic exists to assume differences in health care use between migrants due to the influence of culture on health. Consequently, migrant culture creates a challenge in the quest for help.

To our knowledge, there are few qualitative studies and insufficient information about immigrants’ women perceptions of cultural influences on health behavior and health care utilization in Finland. Besides, it is important to explore cultural barriers to utilize services in Finland to fill the gaps that exist. Furthermore, acquiring knowledge of the subject to improve the cultural awareness with an emphasis on teaching and training nurses to alter interventions that address the patient's needs and to pay more attention to the cultural needs of multicultural patients.

This study aims to understand the role of culture in health service usage among immigrant women in Finland. Moreover, to get information about immigrant women's health-seeking behaviors and their views and experiences about possible cultural barriers when using health care services.

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2 Literature review

Sub-optimal 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 and policy dialogues.

2.1 Migrant health

United Nations describes a migrant as “a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or

permanently, and for a variety of reasons” (1998, p.10). The number of international migrants across the world grew rapidly over seventeen years, (2000–2017), the number expanded from 173 million to 258 million, a growth of 49% (WHO, 2019). The United Nations International Migration Report 2015 reveals that About 76 million (One third) of international migrants live in Europe, 75 million in Asia, 54 million in North America, 21 million in Africa, 9 million in Latin America and the Caribbean, and 8 million in Oceania. The 157 million in 2015 migrants globally originate from middle-income nations. Women make up slightly less than 50% of all international migrants; 49% in 2000 and 48% in 2015. (United Nations, Department of Economic and Social Affairs, 2016.)

Globally, migration is currently the most pressing problem due to the displacement of populations around the world. Aside from planned migration, millions of people have been forcefully displaced from their home countries; the UN Commissioner for Refugees (UNHCR) (2020) estimated that 79.5 million people had been forcibly displaced from their homes as a result of conflict, persecution, violence, or human rights violations, at the end of 2019. Such forcefully displaced persons are known as refugees, officially described as someone who due to

“well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country” (Langlois

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et al., 2016). The refugee population globally was estimated 19.6 million individuals in 2015, with half of that number comprised of children. The number of refugees globally continues to rise. In 2015, the European Union received over a million refugees and migrants. (Langlois et al., 2016.) The World Health Organization (2020) estimates that there are one billion migrants across the world today, with 272 million being international migrants and the rest internal migrants.

While migration contributes to sustainable economic growth and development globally, migrants themselves are among the most vulnerable populations in host societies. They often work longer hours, receive less pay, and work under poor conditions compared to national workers. They also have fewer protections and are often the first to lose their jobs where there is a negative event in the workplace. Many migrants also endure abuse, discrimination, and human rights violations. Migrant women and children are easily exploited and fall victims of human trafficking.

Despite this experience, for people in many parts of the world who seek to escape violence, persecution, and poverty, migration remains their only option. (United Nations, 2016.)

Similarly, refugees experience poverty, vulnerability, marginalization, and high levels of stress (Langlois et al., 2016). Evidence suggests that this population often has trauma and acute mental health problems such as Post Traumatic Stress Disorder (PTSD) and depression (Filges, 2015).

These conditions are related to experiences such as human rights violation, resettlement,

torture, and traumatic migration experience. They may also have various physical problems and disabilities. Refugees have a high burden of conditions such as malnutrition, anaemia, and treatable diseases which are exacerbated due to lack of access to regular medication. Displaced persons also have low access to maternal and obstetric care. Furthermore, while many

immigrants and refugees experience discrimination due to people’s fear of communicable diseases, there is no systematic association between migration and the importation of diseases.

(Langlois et al., 2016.)

From the foregoing literature, the importance of exploring migrant health care utilization cannot be overemphasized. Irrespective of their state of physical health at the time of departure from their home countries, the experiences of migrants such as discrimination and abuse suggest that

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this population experiences a high degree of mental trauma, among other health needs (International Organization for Migration, 2020). Differences in diseases in the host country compared to the home country, the mental and physical stress associated with moving, and the biological and emotional resources it takes to adapt to a new environment affect migrant health (Ejike, 2017). The International Organization for Migration (IOM) describes ‘Migration health’ as a public health theory and practice related to the assessment and action on the migration

associated factors that can affect the health, mental, and social well-being of migrants and their host communities (2020). Migrant-friendly health systems are those systems into which the needs of migrants are considered; in such health care systems, there is conscious and systematic incorporation of the needs of migrants into planning, policy, health financing, program

implementation, and evaluation. Factors taken into consideration in such systems include the epidemiological profiles of migrant groups, language, cultural, and socioeconomic factors, as well as the impact of the migration process itself on the health of migrants. (IOM, 2020.)

The provision of health services for migrants is an obligation rooted in fundamental human rights. Improving access to essential health services for migrants and refugees is important; host countries are recommended to address the exclusion of these populations from health care services as well as address their unmet health needs (Langlois et al., 2016). 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. Governments have the responsibility and face the challenge of

developing a migrant-friendly health care system so that every person can access it when they need it. (WHO, 2020.)

2.1.1 Migrant women’s health

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. (UN, 2016; WHO, 2021.) Women are also affected by intersecting forms

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of discrimination based on factors such as race, poverty, and ethnicity. All these factors in turn affect the health, physical, social, mental, and economic well-being of the female migrant. The situation is even direr for migrant women who do not have residence status. Such women not only experience insecurity but also are faced with legal barriers to obtaining health care.

(WHO,2021.)

The impact of poor access or exclusion from health services for migrant women includes delayed access to screening, delayed or complete absence of access to treatment and care, limited access to gynecological care, heightened experiences of discrimination, as well as gender- based violence (Chauvin et al., 2015). Throughout Europe, migrant women disproportionately experience poor pregnancy and difficult pregnancy outcomes such as low birth weight, child delivery without professional assistance, lack of access to antenatal care, inadequate access to medical care, and infant and maternal death (Chauvin et al., 2015; WHO, 2021). For the migrant women who are held in detention, detention itself represents a cause of diminished health and well-being, as well as a limitation to access to care (Filges et al., 2015; WHO, 2021).

In many European countries, undocumented migrant women have no access to screening services, family planning, or regular health check-ups. Developing and implementing human rights and evidence-based policy to assure access to all migrant women regardless of their migration status, is important. It is important to address access to health care for migrant women both from the perspective of human rights as well as for economic purposes. (Filges et al., 2015; WHO, 2021.) As stated previously, access to health care should be a basic human right for all publics (Langlois et al., 2016). In terms of economics, research has also shown that

providing preventive care for migrants even when they are undocumented, results in cost savings for health systems (WHO, 2021). When a portion of the population is excluded from access to health care services, it contradicts public health goals of preventing, treating, and managing communicable diseases, driving up health care costs in the long run. Whereas, providing care for all segments of the population reduces health care costs. (Smith et al., 2016.)

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A study conducted in Finland stated that undocumented immigrant women used prenatal care later than suggested and most of them got insufficient prenatal care and some women did not get prenatal care by any means. The infectious diseases incidence was remarkably higher and insufficient prenatal screenings are done among undocumented pregnant women. (Tasa et al., 2021)

Implementing the standard of care developed by the European Board & College of Obstetrics and Gynaecology (EBCOG) is an important step towards assuring equitable care for migrant women. The standard recommends that all pregnant women receive information regarding the full range of options that are available to them throughout pregnancy and early parenthood;

maternity services should be comprehensive and culturally sensitive; effective systems of communication should be set in place between all health care team members and with women and their families; interpreting services should be made available for women who do not speak the local language as a first language; services should be flexible to meet the needs of diverse groups such as pregnant teenagers, women with disabilities, women from ethnic minorities, hard to reach groups, as well as asylum seekers and refugees; special attention should be paid to the needs of migrant women due to their heightened risk from previously undiagnosed medical conditions; local protocols should be designed to support equal access to services for vulnerable groups, including migrants; clinics should operate based on cultural sensitive norms;

migrants who are in an irregular situation but who come to seek health services should not be apprehended at the health care facility or next to such facilities; and, lastly, clinics should ensure that frontline staff receive regular training on communication skills, equality and diversity, cultural/gender awareness, and safeguarding of vulnerable individuals. (Smith et al., 2016.) The EBCOG standard of care thus demonstrates specific awareness of the issues that serve as a barrier to migrant women’s unique health care challenges, the factors that serve as a barrier to utilization of health care both from structural and cultural contexts and emphasizes practices that can help improve help-seeking and use of services for migrants and other vulnerable groups.

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2.2 Conceptualization of culture and health

2.2.1 Concept of culture

The Center for Advanced Research on Language Acquisition (CARLA) defines culture as “the shared patterns of behaviors and interactions, cognitive constructs, and affective understanding that are learned through a process of socialization and these shared patterns identify the

members of a culture group while also distinguishing those of another group” (2020). Similarly, Brown et al. (2020, p.41) defined culture as “a set of beliefs, practices, and symbols that are learned and shared. Together, they form an all-encompassing, integrated whole that binds people together and shapes their worldview and lifeways”. Cultures are characterized by factors such as language, age, ethnicity, sexual orientation, religion, gender, spiritual beliefs, socioeconomic class, geographic origin, upbringing, and education. Culture is often identified through its manifestations such as music, language, dress, and behaviors. Diversity exists between different cultures because of the differences in the factors that influence the culture. (Mayhew, 2018.)

Culture is commonly categorized as either collectivistic or individualistic, with most cultures falling along the continuum between such that they have some characteristics from both categories. Collectivist cultures focus on the community, promote relatedness, value respect, and family, focus on group goals, and the collective good. People from collectivist cultures focus on the welfare of the group, as against their interests. Individualistic cultures, on the other hand, focus on the individual, value autonomy, emphasize individual achievement, and focus less on collective good or collective goals. In such individualistic cultures, people place their welfare as individuals above the collective welfare. An understanding of these categories of culture is important in health care as the categories are associated with different views of health, treatment, and causes of disease. Understanding where a patient fits within the cultural continuum helps the practitioner plan for personalized care. (Mayhew, 2018.)

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2.2.2 Health care utilization

Given that the subject of the current study is health care utilization, a clear presentation of the concept is necessary. Health care systems provide many services such as treatments for health problems, preventive care, screening services, health promotion, and health education. The construct Health Care Utilization (HCU) describes the use of available services (Carrasquillo, 2013). It is a commonly used measure in health research and, HCU is a quantification or description of services used by people to treat or prevent health problems, obtaining information regarding one’s health and future health prospects, and promoting health and wellbeing (Carrasquillo, 2013). The term encompasses all the use of medical services such as outpatient clinic visits, inpatient and outpatient surgery, emergency room visits, hospitalization, nursing home stays, doctors’ visits, home health, use of prescription drugs, as well as dental and orthodontic care (Liew and Brooks, 2017). It also involves visits to primary care physicians, specialists, occupational and physical therapy, and rehabilitation services (Harrelson, 2019).

HCU is reported using a variety of metrics such as the number of services used in a period of time divided by the population denominator, percentage of persons using a certain service compared to individuals who are eligible for that service across a given period of time

(Carrasquillo, 2013). Thus, the measurement of HCU may consider attributes that include the cost of service, location of service, length of stay, type of service, and quality of service.

Furthermore, measurements for health such as HCU occur in a complex context comprised of interrelating factors such as culture, society, and biology. (Harrelson, 2019.) 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.

2.2.3 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

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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

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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.

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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%

2.60%

3.70%

4.30%

5.70%

6.90%

0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08

0 50 100 150 200 250 300 350 400 450

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)

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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

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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.

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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-

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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

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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

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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.)

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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-

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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.

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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

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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).

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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.

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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).

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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.

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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 detailed email was sent about the study procedures with attachments of the consent form (Appendix A), background questionnaire (Appendix B), participant information sheet (Appendix D) and privacy notice for scientific research (Appendix E).

All documents were written in English first and then translated into the Persian language too.

Interviews were done only after receiving a signed consent form and filled background

questionnaire through E-mail. All interviews were conducted through Zoom software except for 3 participants who requested a face-to-face interview. Of which, 10 interviews were in English, and 3 interviews were in the Persian language. All research documents were saved on the password-protected file at the interviewer's computer which in this case is the writer of this thesis. The duration of interviews on average was about 30 minutes and all were audio recorded.

Before the start of the interview ensured that participants read and understood the information that was sent to them and briefly explained to them the purpose of the study. Moreover,

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participants were asked if they have any concern or query before starting the interview and remind them not to mention their names or any other identifier during the audio-recorded interview so their confidentiality would be maintained. The interview atmosphere was positive and comfortable, and participants were approachable. The rich data collected with an average of 11-pages (with line spacing of 1.5 cm) transcript of each interview. After finishing interviews, recorded audio files also were saved with code assigned to each participant file and password protected. summary of data generation and analysis shown in figure 4.

Fig. 4: The process of data generation and data analysis

4.5 Data analysis

In this study, thematic analysis with the deductive orientation was used. The six steps of the thematic analysis process included Familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining, and naming themes, and producing the report. In the deductive approach creating code and themes are based on existing knowledge or theory.

(Clarke et al. 2019.)

Demographic Questionnaires Interview Quetions

Pilot Interview

Digitally recorded interviews data

Transcribe using a Microsoft Word format

Thematic Analysis & Use of Atlas.ti software

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Data produced by digitally recorded interviews were transcribed with a made-up name allocated for each participant. The participant read the written copy and approved correctness or altered the transcript. Data analysis started by listening and observing during the interviews and then reading the interviews several times. The recorded interviews transcribed verbatim using Microsoft Word. When applicant checking was completed, the software of ATLAS.ti 9 was used for data analysis and data management as well as principles of coding, constant comparison, and theoretical sampling.

The ATLAS.ti software is a case of CAQDA (Computer Assisted Qualitative Data Analysis), which has been utilized by experts and numerous researchers from the various knowledge base, for example, management, education, anthropology, along with health care specialists like nurses, physicians, and psychologists (Friese et al., 2018). ATLAS.ti could be used with various theoretical methodologies and different data analysis procedures. The utilization of Thematic Content Analysis (TCA) defined by Braun and Clake (2006), is one of these potential approaches, and it is an asset for analyzing data in qualitative research (Vaismoradi et al., 2013). The ATLAS.ti

software's role in qualitative data analysis is to store and manage all data gathered for the research project at one spot. This implies that the researcher will no longer experience issues with manual works of removing parts of the story, framing a collection of papers and banners, or creating spreadsheets and blueprints to organize qualitative data. ATLAS.ti offers structures to integrate all the vital data for getting sorted out one’s research and has components to empower data analysis to be done in the software itself, intervened by the analyst, who keeps on assuming the main function in the analysis process being the basic scholar. (Friese et al.,2018.)

Thematic Analysis is an adaptable data analysis plan that qualitative researchers use to produce themes from the information of the interview. This method is flexible since there is no particular research design related to thematic analysis. This data analysis plan is ideal for both beginner and professional qualitative researchers as the stages are not difficult to follow; however, thorough enough to produce significant findings out of data. (Vaismoradi et al., 2013.)

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Thematic analysis, like content analysis, is a blanket term for qualitative data analysis (Friese et al., 2018). According to Braun and Clarke (2013), thematic content analysis is a method of recognizing, analyzing, and writing themes within data. It slightly categorizes and defines the data set in full detail. Nevertheless, often it goes beyond this and interprets several features of the research topic. Braun and Clarke (2013) recommend that thematic analysis should be a primary method for qualitative analysis as "thematizing meanings" is among the rare

widespread generic abilities over qualitative analysis and it tends to be practical across a scope of epistemological and hypothetical methodologies.

Fig.5: Six steps of thematic analysis, (Clarke et al., 2019)

4.6 Ethical consideration

Participants read and signed written informed consent (Appendix 1) before the study. Informed consent indicates the right of voluntary participation and different aspects of the research in plain language. Participants received an information sheet (Appendix 4) which included the nature of the study, the participants’ potential role, the identity of the researcher, the research objectives, and the way the results will be stored and used. In addition to clarifying that

1 Familiarizing

with data

2 Generating initial codes

3 Searching for

Themes

4 Reviewing

Themes

5 Defining and

naming Themes

6 Producing the report

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participants will not benefit directly from participating in this research, however, there is a potential indirect benefit of contributing to knowledge about cultural beliefs and values that impact immigrant women's use of health care services, their health conditions, and health results.

The personal data processed according to the European Union General Data Protection

Regulation (EU: n Act 679/2016) and current national regulation (Data protection in the EU, 2020).

Detailed information on data protection management specific for this study was provided to a participant in advance as “Privacy Notice for Scientific Research” (See Appendix E). To keep personal information, secure data storage methods and elimination of identifier components were used. Information was accessible only to the researcher in the password-protected files and interview materials will be destroyed in 2024. Participants have withdrawal right from the study anytime they wish. Ethical concerns such as anonymity and confidentiality were applied throughout the research process.

5 Results

5.1 Demographic information of participants

A sample of 13 participants contributed to this study. The participants were migrant women originally from countries like India, Pakistan, Bangladesh, Nepal, Sri Lanka (South Eastern

countries) as well as Iran, Bahrain, and Syria (Middle Eastern countries) (See in Figures 6 & 7). The participants were living in different cities of Finland (See Figure 8).

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Fig.6: Participant's place of birth.

Fig.7: The study participant’s country of origin (Microsoft map chart created by the researcher)

2 2 1 3 2 1 1 1

13

Count of Place of Birth

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Fig.8: Migrant’s women city of residence in Finland

Table 1 shows the background information of study participants including region, length of residency in Finland, age, and level of education. Most of the participants were from South Eastern Countries while 5 women were from the Middle East. Therefore, the experiences

described in the data would pertain to migrant women in Finland who are from Eastern cultures.

The participants were living in Finland between 1 to 5 years. Most of the participants were young women age between 18-39 years old and only one participant was in the age group of 40-49. The study participants were also highly educated with 11 participants holding a higher education degree (Ph.D. and Master) and about half of the participants were health professionals (n = 7).

1 1 1

9

1

Helsinki Joensuu Jyväskylä Kuopio Oulu

City of residence

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Table 1. Study participants’ region, length of residency in Finland, age, and level of education

Background information N

Region

Middle Eastern Countries¹

South Eastern Countries² 5

8 Length of residency in Finland

Less than 2 years 2-3

4-5

4 8 1 Age

18-29 30-39 40-49

4 8 1 Education

Higher Academic Degree

Lower Academic Degree 11

2

1.Middle Eastern countries (Iran, Bahrain, Syria)

2.South Eastern countries (India, Pakistan, Bangladesh, Nepal, Sri Lanka)

Another part of demographic data (table 2) indicates that eight women of the sample were single or divorced. This data corresponds with the data on housing. The housing arrangements of migrants are important because it would indicate whether other persons influence their health behaviors and health decision-making. Most of the sample either live alone or live with student roommates (n=11), indicating that for the majority of the sample, their health decisions are made independently. Only six participants were employed full-time, and seven participants had an annual income between €10,000 - €30,000, whereas the rest of the participants either

working part-time or have been unemployed with low annual income.

Influence of Culture on Health Behavior and Health care Utilization among Immigrant Women in Finland