Overlooking health acculturation : a grounded theory study illustrating the complexity of intercultural consultation in Swedish primary care

Background: Intercultural consultations are perceived as complex by physicians and when asked why, ‘cultural differences’ are often mentioned. With increasing patient diversity in primary care, because of increasing global migration, there is a need to address this. Cultural competence has long been considered useful in health care, one reason being that it may aid in addressing disparities of health. Nonetheless, there is no clear agreement on how to facilitate cultural training for family medicine residents.

Aim: The overall aim was to explore the physician-patient interaction in intercultural consultations in primary care, while considering how to apply the findings in a family medicine residency training context.

Methods: A grounded theory approach was used for Studies I and III, in which patients with foreign backgrounds and family medicine residents were interviewed on their experiences of intercultural consultations in primary care. Analysis of the interviews also directed the aim for Study II, a systematic literature review exploring the informal curriculum of family medicine. Study IV was guided by ideas from the previous studies as it included developing and testing the use of virtual patient cases in cultural training in a family medicine context. Data was collected through semi-structured interviews and analyzed using qualitative content analysis. Finally, a core variable theory, generated through grounded theory methodology and based on data from Studies I-IV and additional material, is also proposed in this thesis.

Results: The core variable theory generated in this work was labelled ‘overlooking health acculturation’ and incorporates how acculturation may take place through intercultural interactions in a primary care context but remains unrecognized. Acculturation is an established concept, but health has to the best of my knowledge so far been discussed only in terms of its outcome. This thesis argues it should also be considered a dimension and suggests the concept ‘health acculturation’ to describe changes in an individual’s external practices and internal domains, related to health and illness, when being exposed to another culture. The core variable theory was built on data from Studies I-IV. Studies I and III identified behaviors and approaches in the consultation which did not seem to facilitate mutual understanding or consider the process of acculturation. Despite general agreement that cultural competence should be part of medical training, in Swedish primary care it has not been applied in a way that residents seem to find relevant; instead, informal learning is relied on, as illustrated in Study II. Study IV showed that cultural training for family medicine residents may be facilitated through interactive virtual patient cases stimulating discussion and reflection.

Conclusions: This is I believe a first attempt to outline a core variable theory of what happens in the physician-patient interaction in intercultural consultations in a Swedish primary care context. In summary, the process of acculturation was overlooked, possibly reflecting its being disregarded in residency training. To address this, three suggestions on how to facilitate cultural training for residents are proposed: discuss and disclose the informal curriculum, apply existing knowledge on informal learning and add contemporary perspectives on culture, such as the proposed ‘health acculturation’.

List of scientific papers

I. Rothlind E, Fors U, Salminen H, Wandell P, Ekblad S. Circling the undefined-A grounded theory study of intercultural consultations in Swedish primary care. PloS one. 2018;13(8):e0203383.
https://doi.org/10.1371/journal.pone.0203383

II. Rothlind E, Fors U, Salminen H, Wandell P, Ekblad S. The informal curriculum of family medicine - what does it entail and how is it taught to residents? A systematic review. BMC Fam Pract. 2020;21(1):49.
https://doi.org/10.1186/s12875-020-01120-1

III. Rothlind E, Fors U, Salminen H, Wandell P, Ekblad S. Primary care consultations on emotional distress – a part of the acculturation process in patients with refugee backgrounds. A grounded theory approach. [Submitted]

IV. Rothlind E, Fors U, Salminen H, Wandell P, Ekblad S. Virtual patients reflecting the clinical reality of primary care – a useful tool to improve cultural competence. [Submitted]