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Institutionen för folkhälso- och vårdvetenskap

Cultural Barriers in Healthcare Delivery

from the Perspective of Patients

Author Supervisor

Fru Ngum Awasom Johanna Sjömar

Examiner

Katarina Hjelm

Examensarbete i sjukskoterskeprogrammet, 15 hp 2021

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ABSTRACT

Background

Many patients especially from minority backgrounds are typically faced with cultural barriers

during health care encounters and this hinders the delivery of culturally competent healthcare.

This study seeks to understand how cultural barriers faced by patients are crucial in attaining

the delivery of culturally competent healthcare.

Aims

The aim of this study is to examine cultural barriers in the delivery of healthcare services from

the patient’s perspective.

Method

The method is a literature review based on qualitative primary research. Ten articles were

selected from the CINAHL, PUBMED and Google scholar databases. All articles selected were

published between 2010 and 2020. The quality of the articles used were assessed using a review

template for qualitative studies. Data was analysed using the literature review matrix method.

Results

The results suggest that four main cultural barriers from the perspectives of patients impacted

healthcare delivery. These cultural barriers included the following; communication problems

arising during verbal and nonverbal interactions, mistrust and discrimination arising as a result

of previous contact with the health care system, socio-economic status and finally low

propensity to seek healthcare.

Conclusion

To conclude it is evident that patients face a plethora of cultural barriers during their

interactions with health care services and their experiences can be shaped by a number of

variables and factors. These cultural challenges hinder accessibility to proper health care

services might lead to inequality in the provision of health care services.

Keywords: Cultural barriers, Patients perspectives, Cultural competent care.

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ABSTRAKT

Bakgrund

Många patienter, särskilt de med minoritetsbakgrund, står vanligtvis inför kulturella barriärer

när de blir bemötta av hälso-och sjukvårdspersonal. Detta hindrar utformandet av kulturellt

kompetent vård. Studien syftar till att förstå hur kulturella barriärer som patienter står inför är

avgörande för att uppnå kulturellt kompetent omvårdnad.

Mål

Syftet med denna studie är att undersöka kulturella barriärer vid leverans av vårdtjänster ur

patientens perspektiv.

Metod

Metoden är en litteraturstudie baserad på kvalitativ primär forskning.Tio artiklar valdes från

databaserna CINAHL, PUBMED och Google. Alla utvalda artiklar är publicerade mellan 2010

och 2020. Kvaliteten på de artiklar som valdes är granskade med hjälp av en granskningsmall

för kvalitativa studier. Data analyserades med hjälp av litteraturgranskning enligt en

matrismetod.

Resultat

Analysen och resultaten från studien tyder på att fyra huvudsakliga kulturella barrier ur

patientens perspektiv hade avgörande inverkan på bemötandet inom vården. Dessa kulturella

barriärer inkluderade följande; kommunikationsproblem som uppstår under verbala och icke-

verbala interaktionen, misstro och diskriminering till följd av tidigare kontakt med hälso- och

sjukvården, socioekonomisk status och slutligen låg benägenhet att söka vård som är vanligt

för människor med samma kulturella bakgrund.

Slutsats

Avslutningsvis är det uppenbart att patienter möter kulturella barriärer under sin interaktion

med vården och deras erfarenheter kan formas av ett antal variabler och faktorer. Dessa

kulturella utmaningar hindrar adekvat tillgång till hälso sjukvård och kan leda till ojämlikhet i

tillgången till hälso- och sjukvårdstjänster.

Nyckelord: Kulturella barriärer, Patientperspektiv, kulturellt kompetent omvårdnad.

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TABLE OF CONTENTS

INTRODUCTION…………………………………………………………………………4

Patients perspective………………………………………………………………………..5

The Impact of Cultural Competence……………………………………………………..6

Theoretical framework ……………………………………………………………………7

Formulation of research question………………………………………………………...8

Aims of the study……………………………………………………………………,,,,…..9

METHOD………………………………………………………………………………….9

Design………………………………………………………………………………………9

Search strategy………………………………………………………………………….....10

Inclusion and Exclusion criteria…………………………………………………………11

Quality assessment of data……………………………………………………………….12

Data analysis………………………………………………………………………………12

Ethical Considerations……………………………………………………………………14

RESULTS…………………………………………………………………………………14

Communication…………………………………………………………………………,,.14

Mistrust and discrimination……………………………………………………………..16

Socio-economic status……………………………… …………………………………..17

Low propensity to seek health services………………………………………………….19

DISCUSSION ……………….……………………………………………………………19

Discussion of results……………………………………………………………………...20

Communication……………………………………………………………………………………..20

Mistrust and discrimination……………………………………………………………………….21

Socio-Economic status…………………………………………………………………………….22

Low propensity to seek health care………………………………………………………………23

Clinical relevance and basis for further research…………………………………………,24

Discussion of method…………………………………………………………………….25

Conclusion………………………………………………………………………………..26

REFERENCES…………………………………………………………………………..27

APPENDIX 1 Table presented of the quality of the reviewed articles……………….34

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INTRODUCTION

Globalisation and migration have led to an increase in the number of patients with diverse

cultural backgrounds resulting in the need for healthcare delivery mechanisms to be culturally

friendly and competent when delivering healthcare services to patients (Ergin & Akin, 2017).

The rise of migration and globalisation has promulgated the concept of cultural competency in

healthcare delivery to patients as a major objective and outcome amongst healthcare policy

makers over the last couple of decades. Several studies have defined cultural competency from

different perspectives including the organisational, individual and societal, and the education

of healthcare students at various levels (Hultjö, Bachrach-Lindström, Safipour & Hadziabdic,

2019). However, most of the definitions are all grounded in the seminal work of Cross, Bazron,

Denis and Isaacs (1989). These authors conceptualise cultural competence as:

…a set of congruent behaviours, attitudes, and policies that come

together in a system, agency or among professionals and enable that

system, agency or those professions to work effectively in cross-cultural

situations (Cross et al., 1989, p 7)

In their monograph, Cross et al (1989) opine that the definition of culture is used to signify the:

¨integrated pattern of human behavior that includes thoughts,

communications, actions, customs, beliefs, values, and institutions of a

racial, ethnic, religious, or social group” (Cross et al., 1989, p 7)

On the other hand, the word competence is used to describe the effectiveness of a system. Thus,

according to Cross et al.’s seminal work, a culturally competent system of care;

”…acknowledges and incorporates at all levels--the importance of

culture, the assessment of cross-cultural relations, vigilance towards the

dynamics that result from cultural differences, the expansion of cultural

knowledge, and the adaptation of services to meet culturally-unique

needs” (Cross et al., 1989, p 7)

Handtke, Mösjo and Schiligen (2019), argue that cultural competence plays an important role

in resolving problems faced by ethnic minority patients who are often the primary victims of

cultural barriers in the delivery of healthcare. Achieving cultural competence entails joint

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collaboration from various healthcare stakeholders such that the quality of healthcare services

rendered to patients are not compromised irrespective of their cultural background including

their race, ethnicity and religious beliefs (Saha, Beach & Cooper, 2008).

Patients Perspectives

As mentioned earlier, attaining cultural competent care is a collaborative effort which includes

many stakeholders including patients and healthcare practitioners. Drawing from the

perspectives of patients, Cornelison (2001) argues that cultural barriers faced in the healthcare

sector affect the quality of services patients receive. This situation is further exacerbated by

patients’ inability to understand the cultural context and environment in which healthcare

services are delivered. Patients’ stereotypes about health professionals impact the manner in

which they interpret their professional support. For example, patients have different ways

through which they respond and manage pain including stereotypes and perceptions harboured

by healthcare professionals about patients from minority and different backgrounds

(Cornelison, 2001).

Ngo-Metger et al (2006) state that the provision of culturally competent care is an effective

strategy used to reduce or eliminate disparities in service quality among people from different

ethnic, racial or cultural backgrounds. These authors highlight five cultural barriers cited by

patients as crucial in health care delivery; experiences of discrimination; patient – health

provider communication; experiences affecting trust or distrust; respecting patient preferences

or engaging patient in decision-making and linguistic ability. They argue that patients

especially from minority populations are sensitive to the provision of culturally competent

healthcare and this is only achievable when the patients' cultural perspectives and dimensions

highlighted above are effectively incorporated in existing conventional measures to improve

the quality of healthcare delivery. Achieving culturally competent care is a challenging task

given that many healthcare providers tend to be unaware of their deficiencies in the provision

of culturally competent care. This is so because people from minority racial and ethnic groups

tend to give lower ratings about the quality of care they received across healthcare service

providers in the country (Ellins & Glasby, 2016). This suggests there is a need to improve

responsiveness to the needs of minority service users.

In the same light, Saha et al (2008) argue that cultural competence and patient centeredness

have been promoted over the last several years as benchmarks in the practice of contemporary

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health service provision. The authors argue that adopting a patient centred approach ensures

that patients’ perspectives are considered during decision making. Patient centeredness

contributes to an improvement in the quality of services delivered because the ultimate goal of

health service provision is to restore the health of patients or support them to cope with their

condition. The underlying motive of patient-centred service is to achieve these goals and

patient satisfaction with the quality of services received and to equally respond to the needs of

patients during illness while taking into consideration their beliefs and values (Hjelm, Bard,

Nyberg & Apelquist, 2003; Hjelm & Nambozi, 2008).

The Impact of Cultural competence

There is a general consensus about the positive impact of cultural competence on healthcare

service quality. Betancourt, Green, Carilla and Park (2005) note that cultural competence

improves quality of care and eliminates ethnic/racial disparities in the quality of health care

services. Betancourt et al (2005), conducted primary research on cultural competence and

interviewed government, management and patients to get their perspectives and found that

many health care stakeholders were both conscious of the importance of cultural competence

and were working to develop initiatives that improve cultural competence. Raja et al (2015),

pointed out that achieving cultural competence is a complex task that requires the collaboration

of various healthcare stakeholders and support from the minority communities. These

communities need to cooperate by identifying their challenges and the factors which they deem

key contributors to low quality health. This approach will ensure that cultural competency

interventions are tailored to meet the challenges that they are designed to tackle.

There is an overwhelming general consensus that cultural barriers have an adverse impact on

the quality of healthcare services received by patients especially from minority backgrounds.

Furthermore, these studies suggest that the primary victims of cultural barriers existing in the

healthcare sector are patients from minority backgrounds. The main sources of cultural barriers

amongst patients include language, religious beliefs, ethnicity, and other socio-economic

factors that hinge on cultural stereotypes and biases (Raja et al, 2015; Betancourt et al, 2005).

This study also highlights a general consensus amongst scholars that it is crucial to

continuously improve cultural competency through providing person centred services to

diverse groups of patients .

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Theoretical Framework

This study is conducted within the underlying assumptions and framework of Leininger's

Culture Care Theory (Leininger, 1991; Leininger, 1994). This theory gives insights into a

holistic and cultural care worldview of a configuration of factors that are crucial in shaping the

wellbeing of patients and the practice of nursing. These include several cultural and socio-

structural factors such as religion, philosophical beliefs, kinships systems, social status,

politics, economics, and lifestyles, the environmental context, language, and ethno-history.

These factors are crucial in shaping the wellbeing of patients because they are embedded and

intertwined with people’s cultural values and belief systems. Figure 1 illustrates some of the

important factors and components of the Culture Care Theory and its relationship and relevance

in shaping cultural competent care delivery to diverse groups of patients worldwide.

Figure 1. Leininger’s Sunrise Model to depict Theory of Culture Care Diversity and

Universality (McFarland & Wehbe-Alama, 2019 p. 542).

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The main assumption here is that if all these factors are incorporated during the care process,

then health care professionals such as nurses would be able to provide holistic care to patients

of all backgrounds, including the under-privileged and undeserving. The theory therefore

provides a robust framework through which issues of culture, values and belief with the

provision of health care can be understood and explored (McFarland & Wehbe-Alama, 2019)),

In this light the Cultural Care Theory is relevant in understanding this study for the following

reasons; Firstly, the cultural care theory has been chosen because of its relevance in attempting

to explain culturally congruent nursing care practices that could be used to deliver health care

to diverse individuals, families, groups, communities and institutions.

Secondly, the theory is unique and remains the only nursing theory which explicitly focuses on

culture care. It helps to better explain the problem of cultural barriers from both the nursing

and patient perspective making it a more comprehensive model (McFarland & Wehbe-Alama,

2019).

Thirdly, the cultural care theory is holistic and covers a broad immersion of factors and

components such as politics, beliefs, values, religion and economics that are intrinsically linked

to the cultural attitudes and perspectives of patients (Leininger, 1991; Leininger, 1994). The

theory lays emphasis on care values, beliefs, lifestyles and other socio-cultural dimensions. It

seeks to explore culturally based factors that play a key role in promoting the health and well-

being of individual patients, families, or groups (Leininger, 1991; Leininger, 1994). Finally,

the components of the theory will facilitate the choice and selection of the relevant articles

based on prior themes in our general review and analysis of literature on the cultural barriers

faced by patients during healthcare delivery.

Formulation of Research Question

Today, because of the diverse backgrounds of most patients and their cultural attributes and

expectations, the provision of healthcare services is increasingly challenged to provide

culturally competent care that meets the needs of the diverse patient populations (McFarland

& Wehbe, 2015). Health care professionals are now expected to acknowledge patients’ and

families’ cultural differences and incorporate their beliefs and values in their treatment and

care plan (Wasserman et al., 2014). For example, in Sweden, Hultsjö and Hjelm (2005) found

that the main problems faced by nurses and other healthcare practitioners included difficulties

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related to caring for asylum-seeking refugees. Nurses reported some unexpected behaviours

amongst migrants because of cultural differences. For example, some migrants refused to eat

or drink in the psychiatric ward because they were not familiar with most of the types of food

served. The challenge is huge because providing culturally competent care has become a

strategic priority in healthcare organisations not just in the cosmopolitan cities, but at the

national level (Almutairi, Gardner & McCarthy, 2013). Nurses are therefore under increasing

pressure to better manage cultural barriers that are likely to have a negative impact on the

quality of services they provide to service users.

Although healthcare professionals receive the theoretical and practical training required to look

after patients, cultural barriers affect and shape the quality of healthcare services delivered to

patients. This problem is exacerbated by the fact that globalisation has resulted in a more

culturally diverse population across the northern hemisphere as people with diverse cultural

backgrounds travel to Britain, Europe, North America and Australia in search of better

economic opportunities and livelihood and are consequently part of the patient’s population

needing culturally competent healthcare (Hull, 2016).

Aim of the study

The aim of this study is to examine cultural barriers in the delivery of healthcare services from

the patient’s perspective.

METHOD

Design

This study is a general literature review based on qualitative studies of the general literature

review framework and protocol recommended for nursing research practice (Polit & Beck,

2017). A literature review is a summary of a research topic aimed at placing the research

question in context. This method was suitable because it helped in understanding the current

state of knowledge regarding the patients´ perspective on cultural barriers in health care

delivery. This design was also appropriate because it enabled data to be collected

systematically and analysed coherently.

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Search strategy

The search of relevant literature was conducted on three main databases including CINAHL,

and PUBMED and Google scholar. These databases were chosen because they were reputable

for the vast variety and quantity of journal articles they contain. Each of these databases held

more than 12 million articles. MeSH (medical subject heading) was utilised as a control

vocabulary , boolean operators And/or were used to increase or restrict the search.

The keywords used were “Patients” And “Cultural Barriers” AND “Healthcare Delivery”

including modified words such as AND, OR and NOT to ensure that the search results was

narrowed to articles that had at least one or more of the key search terms (Bettany-Saltikov,

2010).

Results following our search strategy are illustrated in Table 1. Articles obtained during the

search were first selected based on the relevance of their titles and their abstracts to the thesis.

This led to a total of fourteen articles in the first selection. In the second selection process all

articles were read diligently following the inclusion and exclusion criterias leading to the final

selection of eight articles. Two articles were obtained using what Polit and Beck (2017) refer

to as the ancestral approach, where the author traced data from reference lists of already

published articles.

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Table 1. Search Results

Databases Search words Results First

selection

Secon

d

selecti

on

PUBMED Patients

perspectives” AND

“Cultural Barriers”

AND “Healthcare

Delivery”

605 9 6

CINAHL Patients” AND

“Cultural Barriers”

AND “Healthcare

Delivery”

57 1 1

Google Scholar "patients"[MeSH

Terms] OR

Patients[Text Word]

"perception"[MeSH

Terms] OR

Perception[Text

Word]

"culture"[MeSH

Terms] OR

cultural[Text Word]

"Communication

Barriers"[Mesh]

262 4 1

Inclusion and Exclusion criterias

The inclusion criteria that was used to select studies included first articles published between

2010 – 2020. (2) Articles with a clear introduction, methodology, results and conclusion to

ensure that the outcome is justified by sound empirical and scientific methods and processes

(Forsberg & Wengström, 2008). (3) Articles published in English to prevent the problems

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associated with language barriers and misrepresentation of facts. (4) Articles that carried one

or more of the search words to ensure that articles included were relevant to the research

topic and study (5) and only articles with abstracts were selected because it was possible to

screen or get a clear synopsis of the article and make an informed choice over whether or not

to include it. (6) All articles included in the review were based on primary research implying

the authors performed original studies. Articles included were solely qualitative studies.

Articles were excluded based on the following. Firstly all articles published before 2010,

which do not have a clear methodology and structure and published in languages other than

English with no abstract were excluded. All articles based on secondary sources were also

excluded. Articles from secondary sources are based on analysis and findings from original

and primary research such as in literature reviews (Polit and Beck, 2017).

Quality Assessment of data

When carrying out a general literature review, it is important for the researcher to do a research

critique. In other words, an appraisal of the strength and weaknesses of the peer review articles

used in the study (Polit & Beck, 2017). In order to identify areas of inadequacy and adequacy

of articles SBU´s quality assessment checklist for qualitative research studies – patients’ and

clients’ perspectives has been used (Statens Beredning for Medicinsk Utvärdering [SBU],

2016). The articles are ranked high, moderate and low quality. The assessment is made on the

basis of the ‘yes’ and ‘no’ questions on the templates. There were a total of 21 questions based

on the aim, sample selection, data collection, analysis and results. A system was created for

allocating points where each question scored one point implying there was a total of 21 points.

Articles whose ‘yes’ responses ranged between 80 – 100 percent have been ranked as high

quality; this implied they scored between 17 to 21 points. Those that fell between 60 to 79

percent scored between 13 to 16 were ranked medium quality and articles under 60 percent

were ranked as low quality implying they scored less than 13. Only articles of high qualities

have been used.

Data analysis

The use of qualitative data processing and analysis helps in understanding real life research

phenomenons such as the issue of patient’s perspectives on cultural barriers in healthcare

delivery examined in this study. The qualitative analysis helps to explore our research questions

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on how cultural barriers affect and impact health care delivery. To analyse the literature the

author made use of what Polit and Beck (2017) referred to as a literature review matrix. The

author first began by formulating the research questions. The research questions and the

inclusion and exclusion criteria were then used as the basis for searching for data in the

electronic database. Selected articles were then read thoroughly by the author.

Articles reviewed were displayed on a table with detailed and crucial information drawn from

the inclusion and exclusion criteria in order to showcase the results and findings obtained and

the quality of the analysis (Polit & Beck, 2017). Additionally, these articles were placed in

alphabetical order based on the authors’ names. Pertinent information about the aims, objective,

methods, results were used as subjects in columns (See appendix 1).

This process was done with the aim of identifying, regularities, inconsistencies, patterns and

themes as well as possible gaps for future research. The information gathered was synthesised

and analysed. This method facilitated the work as data was arranged on a table making it easier

for the author to get a general overview rather than working with a stack of papers to redraw

information.

This process reinforces the trustworthiness of our study and highlights the robustness of the

results and conclusion about cultural barriers of healthcare delivery from the patients’

perspectives.

The figure below explains steps used in analyzing data.

Formulation of aim of the study

( Selecting articles, ,reading articles, making sense of data,

insert in literature review matrix)

Identifying Regularities, inconsistencies and

categories

Communication Discrimination

and mistrust

Socio-economic

status

Low propensity to

seek healthcare

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Figure 2. Authors’ figure on steps in analyzing data.

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Ethical Considerations

To avoid jeopardizing the quality of our study which is based on qualitative studies and to

ensure that our results and findings are valid and reliable, all literature review protocols listed

are followed appropriately (Polit & Beck, 2017). Articles that have an ethical clearance were

selected (Forsberg & Wengström, 2008). Search strategies have been recorded including all

relevant search words used and dates of searches. These ethical procedures are crucial in

ensuring that our methodological approach is effective and our research results and findings

are reliable and valid.

RESULTS

This study is based on ten qualitative articles from the United States of America (Cuevas,

O’Bien & Sara, 2016; Hu et al., 2013), the Netherlands (Paternotte et al., 2017), Belgium

(Peeters et al., 2015), Switzerland (Scheermesser, Bachman, Oesch & Kool, 2012), Canada

McKeary & Newbold, 2010; Singh, King-Shier & Sinclair 2020) , Norway (Straiton, Ledesma

& Donelly, 2018), Sweden (Habziabdic, Albin & Hjelm 2014) and Ghana (Sumankuuro et al.,

2019). The participants in the studies were both male and female and mostly immigrants who

were settled in another country rather than their country of origin. Participants were between

18-85 years (check appendix 1 for summary of the selected articles). The four major themes

identified from the literature review include, communication, discrimination and mistrust,

socio-economic status and low propensity to seek healthcare.

Communication

Good communication is a prerequisite to obtain fair and equal treatment for patients during

health care delivery (Cuevas et al., 2016; Habziabdic et al., 2014). The review suggested that

language barriers was one of the problems experienced by patients and was crucial in impeding

good communication between patients and health care practitioners. Patients were not

proficient in the language of their host countries and this led to misunderstanding and confusion

(Hadziabdic et al., 2014; McKeary & Newbold, 2010; Paternotte et al., 2017; Scheermesser et

al., 2012; Singh et al., 2020; Straiton et al, 2018).

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Scheermesser et al. (2012) analysed lower back pain patients’ recovery and return to work and

found out that due to communication problems, some patients from different backgrounds

misunderstood instructions. Furthermore, language barrier was also demonstrated as a major

cultural barrier in the quality of health care delivery among refugees in Canada. Language

barriers was not only restricted during consultations, but had an impact on issues regarding

subsequent appointments, prescriptions and follow ups (McKeary & Newbold, 2010).

Habziabdic et al. (2014) cited language barriers as one of the problems experienced by patients

and indicated that patients instead shied away from hospitals or took up self -treatment.

Singh et al (2020), equally identified ethnic and language differences amongst South Asian

patients in Canada as a barrier to access quality health care. However, according to Singh et al.

(2020), these barriers could be overshadowed if the healthcare professionals provided

compassion during care.

In order to overcome this cultural barrier when patients and health practitioners do not share

the same language, many health service providers used the services of professional interpreters

(Hazbiadic et al., 2014; Paternotte et al., 2017) Even though interpreters acted as guides and

communication aids, their services were unable to completely eradicate the communication

barriers that affected the quality of healthcare delivery (Habziabdic et al., 2014; Paternotte et

al., 2017). The use of interpreters made some patients insecure and others saw it as a form of

physical handicap. Some patients even felt that using interpreters could decrease their level of

interactions with healthcare practitioners, as well as increasing the chances of them to forget

vital information (Habziabdic et al, 2014).

In the same light, Paternotte et al. (2017) identified language barrier as one of the most pressing

problems faced by patients in the current globalised environment. They highlighted the

important role of intercultural communication training in improving communication between

healthcare practitioners from different backgrounds. The study highlighted the importance of

good interpretation which meets patients’ desire, irrespective of their linguistic and cultural

background. Patients also underscored the need to promote the use of interpreters who could

interpret both literally and with the use of the appropriate medical terminology including a

professional attitude. Paternotte et al (2017) indicated that due to inadequate familiarity the

Dutch healthcare system issues of interpretation and language influenced the prevalence of

poor communication between health practitioners of Dutch origin.

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Communication barriers was not just restricted at the level of verbal and oral interaction but

also extended to the doctor’s ability to interact with patients and making them comfortable. As

illustrated, patients preferred doctors to pay attention to them rather than engage in other

activities like working on the computer during patient-doctor interactions. According to them,

this made them feel they were not understood by the health practitioners (Paternotte et al 2017;

Scheermesser et al., 2012). Paternotte et al. (2017) stated that simple gestures like shaking

hands with the patients, asking them to take a seat facilitated the interaction between patients

and health practitioners. Paternotte et al. (2017) further indicated that patients felt it was crucial

for doctors to use simple language and avoid complicated medical jargons. Patients

underscored that it was necessary for health professionals to speak slowly and seek

confirmation from them.

In addition, Cueva et al. 2016, patients perceived that verbal domination by health professionals

during conversations rendered them less involved in decision making resulting in less

satisfaction. This was seen in a study carried out in America, were HIV positive African

Americans felt they were victims of discrimination in the health care setting as a result of poor

communication when compared to European Americans, hence affecting the manner in which

they enjoyed healthcare services. In another study carried out in Norway, patients who were

involved in decision making with regards to their health issues felt they were listened to by

their health professionals and this established grounds for good communication (Straiton et al.,

2018).

Mistrust and discrimination

Mistrust typically arose when recommendations given in the health care sector clashed with

already established belief and cultural values (Peeters et al., 2015; Sumankuuro et al., 2019).

In Belgium, Turkish immigrants who did not trust the level of expertise of health care

professionals did not take instructions seriously with regards to managing their type two

diabetes. Some of the Turkish immigrants preferred the use of herbal medicine than oral

hypoglycaemic agents prescribed to them in the hospitals. Furthermore, patients believed the

cause of their diabetes was as a result of stress in the Belgian society and as a result, most of

the participants did not adhere to their prescriptions when on holidays in their country of origin

(Peeters et al., 2015).

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Similarly, Sumankuuro et al. (2019), also suggested that in spite of the ban placed on the usage

of traditional birth attendants during delivery, most women in the upper west region of Ghana

felt more comfortable using the services of these traditional birth agents. The negative attitude

of nurses reinforced patients' mistrust in the healthcare system in Ghana.

In terms of discrimination Cuevas et al (2016), found out that African Americans indicated that

they experienced higher levels of discriminatory practices in the healthcare system when

compared with European Americans. This study further suggests that many African American

patients, especially women believed that their health problems and symptoms were discredited

by medical practitioners.

In some instances, medical practitioners failed to treat African American patients with respect

and upon experiencing discriminatory treatment and this left many of these patients frustrated.

Patients also felt that healthcare practitioners rejected their opinions during medical and

hospital experiences and they felt these practices were discriminatory. According to most

patients, the consequences of centuries of racial injustices were still visible in the American

society and this explained why African American patients continued to experience

discrimination and mistrust in the healthcare system (Cuevas et al., 2016).

Socio-economic status

Socio-economic factors also shaped cultural barriers to healthcare. This is because people from

diverse or similar cultural backgrounds tend to experience diverse or similar socio-economic

conditions (McKeary & Newbold, 2010; Hu, Amirehsani, Wallace & Letvak, 2013). In the

United States, many Hispanic immigrants travelled into the country under similar

circumstances and typically arrived with little or no resources, spoke no English and had to

take up low-income jobs. Consequently, they had similar socio-economic status in addition to

their cultural similarity. For example, Hispanics depicted poorer self-management of type two

diabetes when compared with non-Hispanic whites (Hu et al., 2013). The purpose of Hu et al.

(2013) study explored perceived barriers to diabetic management among Hispanic immigrants

diagnosed with diabetes and their families. The major cultural barriers faced by the Hispanic

diabetes patients were mainly socio-economic as a result of lack of resources.

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McKeary and Newbold (2010), indicate that case socio-economic barriers hinder accessibility

to competent cultural care among refugees in the Canadian society. Resettling in a new country

in most cases resulted in a loss of both economic and social status. This implied living under

the poverty line and threshold. McKeary and Newbold, (2010), noted that paying for

transportation fare to the hospital was a major challenge that restricted refugees from having

access to proper health care services. In addition, most refugees who arrived in an already

established society which felt insecure and uncomfortable since they lacked the information,

knowledge and resources needed to get quality health care

In a similar study conducted in Ghana although most maternal healthcare policy programmes

such as Antenatal care (ANC) were fee-exempted under the National Health Insurance Scheme,

there was low skilled care utilisation during pregnancy and delivery (Sumankuuro et al., 2019).

Many women did not sign up for ANC because of their low socio-economic status within their

households. This was because the decision-making power at the household level is left to the

men especially in the rural communities and many of them still believed in the traditional

maternal care customs and practices. According to Sumankuroo et al 2019, this lack of

autonomy made it difficult for many women to shift from traditional birth attendants to

attending modern maternal services.

Straiton et al (2018) noted that immigrant women experienced less access to health care in

general and mental services in particular than non-immigrant women. Immigrants were highly

diversified and came from a range of different cultural, personal, social and economic settings

which impacted their propensity to seek healthcare. Straiton et al. (2018), further examined

factors that influenced Filipina immigrants’ perceptions about seeking medical help from

general practitioners in Norway. The study found out that factors such as educational

background, socioeconomic status, and familiarity with health care services as well as

experience of mental health affected immigrant women’s impressions about seeking mental

health. Mental health disorders are highly stereotyped and stigmatised within the society hence

was a major cultural barrier that deterred Filipina women from seeking mental health support.

The case was even more severe among Filipina women who had low levels of education and

income. Overcoming this challenge was a complex task because these stereotypes had been

developed before most of these women migrated to Norway. After settling in Norway, it was

difficult for them to change their initial perceptions about mental health and wellness.

20

Low propensity to seek health services

Another major barrier to cultural competent healthcare delivery was the prevalence of low

propensity to seek healthcare in some cultures (Sumankuroo et al., 2019). In addition to western

medicine, there are alternative medicines and not all immigrants believed western medicine

was the best. Consequently, many immigrants stuck to their medical belief propagated by their

cultures even after migrating to western countries. When many of them fell ill, they stayed

home and treated themselves with their traditional medication. For many of them, the hospital

was a last resort and unless they were seriously sick, they did not go to the hospital. This was

a major cultural barrier to accessing quality healthcare services (Paternotte et al 2017; Straiton

et al 2018). For example some Chinese immigrants who were unfamiliar with the Dutch

healthcare system used alternative medicine. This constituted a barrier among immigrants from

China who had been used to an alternative form of medicine in treating certain ailment (Straiton

et al, 2018).

Straiton et al. (2018) supported this view and noted that immigrant women experienced greater

barriers to quality health care in general and mental services in particular than non-immigrant

women. Based on their study, some Filipino women did not consider mental health was an issue

that could be addressed by health professionals. Another similar situation could be seen in

Ghana where women in labour due tend not to disclose early that they were in labour because

they feared that revealing it, could lead to prolong labour. As a result, most of the women ended

up giving birth on their way to the hospital exposing them to more danger and reducing their

ability to receive proper care (Sumankuroo et al., 2019).

DISCUSSION

The findings of the results of the literature show that four types of cultural barriers from the

patient’s perspective shape delivery of culturally competent healthcare. These include

communication problems arising during verbal and nonverbal interactions, mistrust and

discrimination arising as a result of previous contact with the health care system, socio-

economic status and finally low propensity to seek healthcare which are common with people

of same cultural background. These cultural barriers have shaped the delivery of a cultural

competent healthcare system, hence crucial for many healthcare stakeholders. The discussions

below is categorized into these four cultural perspectives (communication, mistrust and

discrimination, socio-economic status, low propensity to seek healthcare) and highlight issues

21

relating to the aim of the study, theoretical framework, previous research and clinical and

ethical relevance of the results and findings.

Discussion of results

Communication

In the results communication challenges were seen as a major cultural barrier in the delivery

of health care services. Communication difficulties emerged as a result of language barriers

when patients were not proficient in the language used at the hospital setting (Habziabdic et al.

2014). Communication difficulties were also non-verbal (Paternotte et al., 2017). This reflects

the claims of authors such as Roter, Frankel, Hall and Sluyter (2006) who indicate that facial

expressions such as smiling, eye contact can help build a relationship between patients and

health practitioners of different cultural backgrounds.

It is important to note that non-verbal communication styles vary from one culture to another.

For instance, addressing an elderly person by name and looking into the person’s eyes in certain

cultures can be considered as disrespectful. This means that health practitioners should be able

to understand the implications of diverse cultural non-verbal communicative values, attitudes

and behaviours. Implying they should be able to provide what Betancourt et al. (2005) refer to

as cultural competent care. This does not insinuate that healthcare professionals have to have a

mastery of all cultures. Rather they should acknowledge the fact that different cultures exist,

in order to enhance the process of bridging cultural barriers. This is congruent with the tenets

of the cultural care theory which calls for health practitioners to increasingly acknowledge the

existence of diverse cultural values such as language during care delivery. Acknowledging and

respecting the existence of different cultural values will foster the process of meeting up with

the needs of patients (Leininger, 1991; Leininger, 1994).

One of the ways following the literature review through which these communication challenges

and differences are currently being resolved is by using interpreters to help patients from

different backgrounds (such as immigrants) communicate effectively with healthcare

practitioners (Habziabdic et al.,2014; Hultjö et al.,2019). Leininger's theory strongly

recommends that nurses should be culturally competent (Leininger, 1991; Leininger, 1994).

This means they should be able to identify the linguistic needs of a patient and provide the

22

required resources that will help eradicate communication barriers. However, this theory does

not take into consideration the fact that the presence of an interpreter implies extra costs which

in some cases the health practitioner might not have control over, but rather policy makers. In

addition, the presence of an interpreter might also be time consuming, making it practically

impossible given that health practitioners work on an already very tight schedule.

As expected from the study the presence of interpreters in most cases did not guarantee a bridge

in the communication barrier (Hadziabdic, 2014). This is congruent with the assertion of some

authors who acknowledge that the use of interpreters cannot be considered as a guarantee to

effective communication because not all interpretations can be trusted (Robb & Greenhalgh,

2006). Communication barriers can have an adverse effect on the patient's ability to receive

proper health care treatment. According to The Swedish Association of Nursing (2017b) it is

mandatory that the patient or relatives should be able to comprehend all given instructions so

that they might be able to contribute and participate in their wellbeing.

Mistrust and discrimination

From the review mistrust and discrimination are major cultural barriers to competent cultural

healthcare provision. Mistrust arouses when the patients have an already established belief

system (worldview) that clashes with established health care recommendations and procedures

(Peeters et al, 2013). This falls in line with Leininger’s cultural care theory where an

individual's cultural value and religious background influences their behavior in a different

environmental context. This implies patients typically respond to the services provided to them

based on their cultural values (Leininger, 1991; Leininger, 1994). Mistrust shapes people’s

attitude and perception towards the provision of health services and also leads to dissatisfaction

(Alpers, 2018). According to Ngo-Metger et al (2006), mistrust and discrimination is a cultural

barrier that might impede access to quality health care.

In addition, historical factors and existing social prejudice and injustices have created rifts in

the society at large. It is important to acknowledge that the healthcare system operates within

a wider society which has issues of social injustice and inequality (Cuevas et al 2016; Griffith,

Bergner, Fair, & Wilkins, 2020). These discriminatory experiences have unfortunately shaped

negative perceptions embedded within patients from these backgrounds about their health

encounters. This is consistent with the emic experiences as highlighted in Leininger's theory,

whereby the direct and indirect experiences of groups can be transmitted intergenerationally,

23

hence shaping the way they perceive the health care system. Patients who perceive

discrimination based on past experiences are less likely to be interactive and not participate

verbally during health encounters and consultations. This can make it difficult to obtain the

required information needed to help patients hence might lead to inequality in the production

of health care services (Cuevas et al, 2016; Hausmann et al, 2012). These inequalities create

ethical dilemmas which are not in conformity with the international nursing code where care

should be given equally to all those in need (International Council of Nurses, 2013).

For example, in the USA, African Americans and Latinos have a long history of receiving

inferior care in comparison to some privileged groups. Periods of unethical medical experience

on African Americans have been well documented; hence it is only logical and rational for

African Americans to be doubtful towards the health care system (Griffith et al, 2020). In some

instances, due to mistrust when healthcare practitioners make genuine mistakes it is interpreted

as discrimination. To mitigate the challenges presented by issues of mistrust and discrimination

it is crucial that the care delivery process incorporates tenets of the Leininger’s theory which

advocates for the need to maintain, negotiate and reshape the cultural values and worldviews

of patients from minority groups into the health care delivery process (Leininger, 1991;

Leininger, 1994). However, the incorporation of these cultural values and belief into the health

care delivery process poses both technical and structural difficulties as it requires resources,

time and can be costly.

Socio-economic status

Findings and results from the literature review indicated that cultural barriers emanated from

people with low socio-economic status and background (Hu, Amirehsani, Wallace & Letvak,

2013; McKeary & Newbold, 2010). This was in conformity with the socio-economic

components in Leininger’s cultural care theory which mentioned that education and an

individual's social and economic status shaped people’s attitude and behavior within a given

environment. However, no clear explanation is given to show how socio-economic factors can

be attributed as a cultural barrier that impedes access to proper care. Whilst there is little

evidence to show linkages between socio-economic status and culture, the findings from the

literature review highlight that people from certain cultural backgrounds tend to be more likely

to have different levels of socio-economic status (Hu et al, 2013; ;McKeary & Newbold, 2010).

24

In addition, socio-economic status encompasses access to material capital, human capital and

social capital, which can be defined as knowledge (education), wealth and occupation. People

with high educational levels are generally more knowledgeable about health issues and tend to

face fewer barriers to healthcare services. This is the case in countries such as the USA where

Black Americans and Latinos with low socio-economic status typically have worst health

outcomes in comparison with European American (Crimmins, Hayward, & Seeman, 2004).

Equally, in Norway for example about 71 % of Somali women refugees lacked the knowledge

on how to utilize information obtained from the hospital to improve on their health situation

(Gele, Pettersen, Torheim & Kumar, 2016). Immigrants from low-income countries tend to be

more likely to live in deprived communities and do menial jobs with low pay and are more

stressed up with integration issues into the labor market and do not prioritize health (Ahmed et

al, 2016).

From the above these imply a segment of the society will receive limited or no care because of

their socio-economic status. Accessibility to proper healthcare is a basic human right and it's

mandatory for health professionals to see that all patients regardless of their background have

accessibility to proper care (International council of nurses, 2013; The Swedish Association of

Nursing 2017a).

Low propensity to seek health Care.

Results and findings from the literature review also suggest that people of a particular

background have a low propensity to seek for health care services as a result of patients having

a strong affinity in using alternative medicines that they feel provide equal or better services

than modern hospitals (Sumankuroo et al., 2019; Paternotte et al; Straiton et al 2018). These

attitudes and behaviour are typically shaped by customary and religious beliefs. This aspect is

reflected in Leininger's theory, where she illustrates in her sunrise model how ‘cultural beliefs

and way of life’ influences an individual’s patterns or perception of the health care system. For

example, there is a general consensus that patients from the Arab cultures and traditions have

the tendency to avoid modern hospital services and resources because there is a strong belief

about the powers of their religious deity as a solution to their health issues. More specifically,

Muslim women avoid medical procedures such as breastcancer screening because the screening

25

procedures are not a priority and more often clash with their cultural and religious practices

and belief system (Salman, 2012).

Contrary to the findings from the study suggesting that migrants display low propensity to seek

health mainly because of customary and religious beliefs, it has also been noted that migrants

are not familiar with modern healthcare facilities and procedures. They typically rely on self-

medication, home remedies and view modern health facilities and procedures as stressful and

daunting, too bureaucratic and often feel their illness will be exacerbated (Kimbrough, 2007).

However, low propensity of seeking health care is also shaped by individual and household

choices about how issues of healthcare and illnesses are prioritized and not necessarily by

customary or societal beliefs. For example, people who prioritize preventive measures rather

than curable measures when faced with illnesses, have different levels of healthcare seeking

attitudes and behavior. Low propensity to seek health care will therefore lead to a rise in more

complicated medical procedures which may be more costly for both individuals and the society.

Clinical relevance and basis for further research.

This thesis highlights the cultural difficulties faced during patient and health worker

interactions during the provision of healthcare services. It can be used to alleviate cultural

barriers that are encountered and evident between health practitioners and patients. This study

highlights how cultural barriers can be mitigated and managed by identifying specific

circumstances and conditions that subject patients to cultural barriers.

The thesis can also be used as a basis for further research For example, issues of cultural

barriers from the patient's perspective in relation to nurse patient interaction is pivotal in the

health care set up and their role can never be undermined given that they provide direct care to

the patient. It is therefore crucial that more research should be done

within this area.

Discussion of method

This study was a general literature review where qualitative studies were examined with the

main purpose of identifying all relevant information that exists based on the research questions

(Polit & Beck, 2017). One of the strengths of this type of study is that it is free from bias given

26

that the analysis of the results was based on findings from the ten selected articles (Polit &

Beck, 2017). In addition, this design provides a comprehensive, thorough and up-to-date

literature that exist within the selected field given that articles selected were between 2010-

2020. More so results obtained are reproducible, as the process used to carry out the research

has been clearly defined. However, one of the weaknesses of this study was that the results

were interpreted based on the authors understanding of the articles. This in some cases can give

room to misinterpretation of data (Graneheim & Lundman, 2004).

Three main databases were used to collect relevant materials. These databases were selected

based on their reputability in having a variety of journals and articles. The three main databases

used were CINAHL, PUBMED and Google scholar (Polit & Beck, 2017). The author made

use of selected keywords to find relevant articles. Most articles found were based on the

perspectives of the health practitioners and nurses, very few articles were found based on the

perspectives of the patients. The author made use of what Polit and Beck (2017) refer to as the

ancestral approach where the author tracked down data from the reference lists of already

published articles or reports.

One of the major strengths of this work is that all articles used were graded high quality

following the SBU´s quality assessment checklist for qualitative research studies – patients’

and clients’ perspectives (Statens Beredning for Medicinsk Utvärdering [SBU], 2016). As a

result, all articles selected had a clear methodology with reliable results making the study robust

and credible. In addition, the SBU quality assessment was perfect for our research area as it

dealt with the patient´s perspectives as well.

The inclusion and exclusion criteria used helped to select the most relevant and recent articles

for this study. The ten articles selected were case studies from the United States of America

(Cuevas., et al., 2016; Hu et al., 2013), the Netherlands (Paternotte et al., 2017), Belgium

(Peeters et al., 2015), Switzerland (Scheermesser et al., 2012), Canada (McKeary & Newbold,

2010; Singhet al., 2020), Norway (Straiton et al., 2018) , Sweden (Habziabdic et al., 2014) and

Ghana (Sumankuuro et al., 2019).This reflects the fact that cultural barrier within the care

section is an international problem and challenge. It also implies the results can be applicable

in countries with different backgrounds and settings, making the work trustworthy. The results

are also applicable to today’s nursing practice, because these barriers are visible during patient-

27

nurse day to day interactions. However, it is important to recognize that each individual is

unique and has subjective experiences (Leininger, 1991,1994).

To analyse the result a literature review matrix in accordance with the description of Polit and

Beck (2017) was used. This method was suitable because it enabled the author to make use of

the large textual data and identify categories that were informed from the research question of

the study. The author thus read every article diligently with the aim of bringing out information

that was relevant to various categories. This process was time consuming given that the author

had to read several times through the ten articles in order to identify categories. In doing so the

author was able to identify patterns and regularities as well as gaps within this area of study.

In addition, when categorizing there is always the risk that the author might not be objective

but rather subjective because the researcher's personal experience has the potential of

influencing his or her interpretation. To minimise the risk of subjectivity the author had to read

the articles thoroughly. Articles used were those with an ethical clearance (Forsberg &

Wengström, 2008). These ethical procedures are very important in ensuring that our findings

are reliable and valid. More so, ethical considerations in alliance to what Polit and Beck (2016)

refer to as research misconduct was taken into consideration, including avoiding plagiarism

and accrediting all information and sources that was not from the author.

Conclusion

To conclude it is evident that patients face a plethora of cultural barriers during their

interactions with health care services and their experiences can be shaped by a number of

variables and factors. These cultural challenges might hinder accessibility to proper health care

services thus leading to inequality in the provision of health care services.

28

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complications in rural ghana. BMC Pregnancy and Childbirth, 19(1), 260-260.

doi:10.1186/s12884-019-2414-4

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Quality, 36(3), 5-16. doi:10.1111/jhq.12065

35

APPENDIX 1

TABLE PRESENTED OF THE QUALITY REVIEWED ARTICLES.

Author, year,

country

Titel Aim Method Participants Results Quality

Articles1

Cuevas, A. G., O'Brien, K. &

Saha, S., 2016

United States

of America

African American

experiences in

healthcare: "I always feel like

I'm getting

skipped over"

The aim of the study is to

examine

Africans Americans

experience and

the barriers they face in

health during

health encounters.

The article also

examines their perception

when it come

to race in the patient

provider

relationship.

Qualitative method Focus groups

69 african Americans

Ranging from

the ages of 24

to 89

Patients, especially women, felt they

were being

discriminated upon if their symptoms

were not taken into

consideration. Poor communication,

disrespect affected

patients' perspectives of the

care section.

High 18 points

Hadziabdic, E.,

Albin, B. &

Hjelm, K., 2014

Sweden

Arabic-speaking

migrants'

attitudes, opinions,

preferences and

past experiences concerning the

use of

interpreters in healthcare:

The aim of the

study is to

study Arabic speaking

individual

attitudes, expectations

and preferences

when it comes to using

interpreters

within the health care

sector in

Sweden.

Qualitative

Method. A post

cross-sectional survey using

structured self-

administered questionnaires.

53 Arab

speaking

immigrants

Ranging from

the ages of 18-59 years

Most participants

perceived

interpreters as a communicator aid.

They also felt it was

of importance to be able to trust your

interpreters. Trust

was also solidified based on the quality

of the interpreter. A

good interpreter should have a good

mastery of the

language, the medical

terminologies, have

the same background and

sex.

High

17 points

Hu, J.,

Amirehsani, K., Wallace, D, C.

& Letvak, S., 2013

United States of America

Perceptions of

barriers in managing

diabetes: Perspectives of

Hispanic

immigrant patients and

family

members.

To examine the

barriers faced by Hispanic

immigrants in managing their

diabetes.

Qualitative

Method. Focus groups

73 Hispanic

immigrants with 37 family

members. Participants

where from 18

years

Language barrier

was a major problem. Socio

economic problems and little

understanding as to

how the health care system function was

another factor.

High

19 points

McKeary, M. & Newbold, B.,

2010

Canada

Barriers to care: The challenges

for canadian

refugees and their health care

providers.

To examine the barriers faced

by hispanic

immigrants in managing their

diabetes.

Qualitative Methods. Semi

structured in depth

interviews

14 health professionals

Language barrier was a major

problem. Socio

economic problems and little

understanding as to

High 18 points

1 SBU´s quality assessment checklist for qualitative research studies – patients’ and clients’ perspectives (Statens

Beredning för Medicinsk Utvärdering [SBU], 2016) was used in grading articles quality. This manual had a total

of 21 questions and one point was allocated per question. Grades were awarded on the basis of Yes or No, that is

to say a point was allocated to every yes and zero to every NO. An article could be awarded a maximum of 21

points. Articles were then ranked based on high, medium and low scores and quality. Articles which scored

between 17-21 points were considered as having high quality. Articles that scored between 12-16 were seen as

medium and those that scored less than 12 were considered having low quality. All selected articles scored high.

36

how the health care

system function was

another factor.

Paternotte, E.,

Dulmen, S. v., Bank, L.,

Seeleman, C.,

Scherpbier, A. & Scheele, F.,

2017.

Netherlands

Intercultural

communication through the eyes

of patients:

Experiences and preferences.

To observe

how patients with non dutch

background

perceived intercultural

communication

between themselves and

their doctors

Qualitative

Methods. Semi-structured

interviews.

30 patients

were interviewed.

Language barrier

was a major problem but it was

much better when

the health giver was professional. The

doctor's attitude

also helped est2ablish the

patient's

relationship.

High

17 points

Peeters, B.,

Van Tongelen,

I., Duran, Z., Yüksel, G.,

Mehuys, E.,

Willems, S., Pemon Jean

Paul., &

Boussery, K., 2015.

Belgium

Understanding

medication

adherence among patients

of turkish

descent with type 2 diabetes:

A qualitative

study.

To have an

understanding

of factors that determine

adherence to

medications to patients of

turkish origins

in Belgium

Qualitative

Methods

In Depth interviews

21 patients

were

interviewed. Ages 30-69

Religious and

cultural beliefs help

in determining how patients will adhere

to their medications.

The lack of social support, the doctors

medical expertise

and depression were other

determinants.

High

18 points

Scheermesser,

M., Bachmann,

S., Schämann, A., Oesch, P. &

Kool, J., 2012.

Switzerland

A qualitative

study on the role

of cultural background in

patients'

perspectives on rehabilitation

To explore

possible

barriers that hinder patients

with

southeastern backgrounds t

o attain a

successful

rehabilitation.

Qualitative

Methods. Semi

structured in depth interviews

13 patients

were

interviewed ages

38-60 years

Patients prefer

passive rather than

active strategies recommended by

doctors in dealing

with health issues. Communication

problems between

the patients and the

doctors can be seen

to be a major

barrier.

High

17 points

Singh, P., King-Shier, K.

& Sinclair, S.,

2020

Canada

South asian patients'

perceptions and

experiences of compassion in

healthcare.

Aim at identifying

south Asians

patients' views on the use of

compassion in

the delivery of health care

studies.

Qualitative Methods

Semi structured

interviews

19 patients were

interviewed.

Participants believed

compassion had a

great role in bridging cultural,

ethnic differences

between healthcare professionals

High 18 points

Straiton, M. L., Ledesma, H.

M. L. &

Donnelly, T. T., 2018

Norway

It has not occurred to me

to see a doctor

for that kind of feeling": A

qualitative study

of Filipina immigrants'

perceptions of

help seeking for mental health

problems.

To explore the perceptions of

Filipina women

in accessing healthcare in

Norway.

Qualitative Method. Semi-

structured

interviews

14 women were interviewed

Ages 34-49 years.

The women's values, experience

and stigma

influenced their perception of

seeking health care.

Structural barriers also impede their

access to the health

care systems.

High 18 points

Sumankuuro,

J., Mahama, M.

Y., Crockett, J., Wang, S., &

Young, J., 2019

Ghana

Narratives on why pregnant

women delay

seeking maternal health

care during

delivery and obstetric

complications in

rural Ghana

Aim at identifying

south asians

patients views on the use of

compassion in

the delivery of health care

studies.

Qualitative Method. Individual

depth interviews

and focus group

discussions.

16 health professionals,

three traditional

birth attendants and 240

community

members Range from the

ages of 20-69

Participants believe compassion had a

great role in

bridging cultural, ethnic differences

between healthcare

professionals and patients.

High 18 points