Health care on equal terms for immigrants in Sweden

Abstract

Background: There is limited knowledge about immigrant patients’ lower self-reported health (SRH) in relation to acculturation and discrimination and about immigrant patients’, interpreters’ and GPs’ experiences, reflections, and strategies during the triangular meeting.

Aims: Study I. to analyse the association between ethnicity, acculturation, discrimination and poor SRH. Study II. (i) to explore patients’ experiences and reflections pertaining to primary health care (PHC) consultations in Stockholm and to study whether demographic or migration-related factors are associated with patients’ satisfaction with the consultation and the feeling of consolation provided by the GP; (ii) to analyse whether patients’ satisfaction with the consultation and feeling of consolation are related to the time from the booking to the consultation, SRH, symptoms and patients’ experiences of the consultations; and (iii) to explore these experiences and reflections. Study III. (i) to describe some aspects of each of the three perspectives in the triangular meeting between immigrant patients, interpreters and GPs, including their experiences, reflections and interactions during the consultation in PHC; (ii) to analyse patients’ satisfaction with the consultation; whether satisfaction is influenced by respect for patients’ culture, personality and wishes; and (iii) whether interpreters or GPs experience any ethical conflicts during the consultation. Study IV. to gain insights into the participants’ perceptions and reflections of the triangular meeting by means of in-depth interviews with immigrant patients, interpreters, and GPs.

Methods: Study I. Immigrants from Poland (n = 840), Turkey (n = 840), and Iran (n = 480) and of Swedish-born persons (n = 2250) participated in 1996 in the cross-sectional Swedish National Survey of immigrants. Study II. A questionnaire was distributed to 78 immigrant patients from Chile (n=17), Iran (n=22) and Turkey (n=39) at 12 primary health care centres around Stockholm. Study III. By using questionnaires, immigrant patients, their interpreters and GPs were asked about their opinions of the communication, their experiences and reflections during the consultation and the patient’s satisfaction. In studies II and III content analysis was used for openended questions. Study IV. A total of 29 participants – 10 patients, 9 interpreters, and 10 GPs – participated in face-to-face interviews. Content analysis was used.

Results: Study I. Men from Iran and Turkey had a threefold increased risk of poor SRH than Swedes while the risk was five times higher for women. When socioeconomic status was included in the logistic model the risk decreased slightly. Study II. Most of the answers concerned communication problems because of language and cultural differences between the GP and the patient and the GP’s ability to listen. Background facts, including demographic and migration-related factors, health status and factors related to the consultation did not seem to be associated with the patient’s satisfaction and the feeling of consolation. Study III. Of the 182 respondents, 52 were patients, 65 GPs and 65 interpreters. A matched group of answers from patients, GPs and interpreters was present in 40 consultations. Eighteen of the patients experienced language difficulties. Twenty-six experienced respect for their culture; 32, respect for their personality; and 33, respect for their wishes. Ethical conflicts were rare. All three categories reported that the majority of patients were satisfied with the consultation. Study IV. Six themes were generated and arranged under two subject areas: the interpretation process (the means of interpreting and means of informing) and the meeting itself (individual tailored approaches, consultation time, patients’ feelings, and the role of family members).

Conclusions: There was a strong association between ethnicity and poor SRH which seems to be mediated by socioeconomic status, poor acculturation, and discrimination. Feelings including frustration and insecurity for patients, interpreters and GPs when interpretation and relationships are suboptimal were reported and strategies were developed. To achieve successful consultations and PHC on equal terms for immigrants in Sweden our results indicate a need for professional interpreters, for GPs to use a patient-tailored approach, cultural competence, and sufficient consultation time.