Filio Degni Sakari Suominen Birgitta Essén Walid El Ansari Katri Vehviläinen-Julkunen

Transcription

1 J Immigrant Minority Health (2012) 14: DOI /s ORIGINAL PAPER Communication and Cultural Issues in Providing Reproductive Health Care to Immigrant Women: Health Care Providers Experiences in Meeting Somali Women Living in Finland Filio Degni Sakari Suominen Birgitta Essén Walid El Ansari Katri Vehviläinen-Julkunen Published online: 5 April 2011 Ó Springer Science+Business Media, LLC 2011 Abstract Communication problems due to language and cultural differences between health care professionals and patients are widely recognized. Finns are described as more silent whereas one concurrent large immigrant group, the Somalis, are described as more open in their communication. The aim of the study was to explore physicians-nurses/ midwives communication when providing reproductive and maternity health care to Somali women in Finland. Four individual and three focus group interviews were carried out with 10 gynecologists/obstetricians and 15 nurses/midwives from five selected clinics. The health care providers considered communication (including linguistic difficulties), cultural traditions, and religious beliefs to be problems when working with Somali women. Male and female physicians were generally more similar in communication style, interpersonal contacts, and cultural awareness than the nurses/ midwives who were engaged in more partnership-building with the Somali women in the clinics. Despite the communication and cultural problems, there was a tentative mutual F. Degni (&) S. Suominen Department of Public Health, University of Turku, Turku, Finland defilio@utu.fi B. Essén Department of Women s and Children s health, International Maternal and Child Health, University Uppsala, Uppsala, Sweden W. El Ansari Faculty of Sport, Health and Social Care, University of Gloucestershire, Oxstalls Campus, Oxstalls Lane, Gloucester GL2 9HW, UK K. Vehviläinen-Julkunen Department of Nursing Sciences, University of Kuopio, Kuopio, Finland understanding between the Finnish reproductive health care professionals and the Somali women in the clinics. Keywords Communication Culture Reproductive health Immigrant Somali women Finland Background Communication is an exchange of ideas, information or thoughts in writing or orally during social interactions between two or more groups of individuals. It is the verbal or nonverbal transfer and exchange of information between entities [1]. While culture is a complicated social phenomenon with broad to narrow definitions, it is also defined as deposit of knowledge, experience, belief, values, actions, attitudes, meanings, religion, notions of time, spatial relations, concepts of the universe of group of people [2]. Communication is also regarded as cultural [3]. Indeed, communication between individuals from different ethnic and cultural backgrounds is a symbolic exchange process (intercultural communication) whereby these individuals negotiate shared meanings in an interactive situation [4]. In the intercultural communication process, when people of dissimilar cultural backgrounds interact with one another, they are likely to rely on the preconceived stereotypes that they have concerning certain cultural groups in the uncertainty-filled events [5]. Of particular importance is the interpersonal intercultural interaction between physicians and patients because it involves two parties that have divergent forms of communication that do not normally mesh well in the medical settings [6]. Health care providers must first overcome their cultural differences and beliefs in order to communicate with patients on their health related concerns [7].

2 J Immigrant Minority Health (2012) 14: Theoretical Framework As effective intercultural communication and cultural sensitivities are found to be inter-related [7], communication difficulties due to language and cultural differences between health care professionals and patients are widely recognized as a major barrier in providing health care services. Miscommunication has serious consequences at all levels of health care. Effective communication between the health care provider and the patient is a critical element for improving patient satisfaction, treatment compliance, and health outcomes. Patients who understand the nature of their illness and its treatment and feel that the health care provider is concerned about their well-being show greater satisfaction with the care received and are more likely to comply with treatment regimens [8]. A previous study has shown effective communication being associated with positive health outcomes [9]. Expectations about encounters between providers of health care and patients may differ from case to case since each patient is an individual. Patients and providers may also face other problems, such as lack of privacy during the communication, time constraints due to heavy patient loads or family pressures, or fear of lack of cultural knowledge or of confidentiality. Since the early 1990s, attention to improving the quality of family planning services highlighted the need for clientcentered services, including courteous treatment of clients and greater clarity of the interaction involving them [10]. The emphasis on the importance of positive communication between the clients and the service providers including interaction in family planning and other reproductive health services gained more ground after the 1994 International Conference on Population and Development (ICPD) held in Cairo [11]. Today, communication between clients and service providers and the interaction in family planning clinics is characterized not only by courtesy and clarity, but also by more listening and less telling on the part of the providers; encouraging patients to ask questions and seek clarification; attention to sexuality and gender issues; discussion of side effects of contraceptive methods; and inquiry about the patient s risk of sexually transmitted infections and other features [12]. The quality of the communication between clients and the service providers and cultural knowledge may determine whether patients go on to use modern birth control methods or not and consistently, how they react if problems arise, and for how long they continue using family planning [13]. In the relationship between patients and the health care providers, the number of meetings with the same provider and patient and the nature of the interaction affect the quality of the care [14]. According to some anthropologists, the patterns of behavior, attitudes, beliefs, and ways in which people communicate are culturally significant [15, 16]. In the social roles of the health care providers and patients, the role of the physician is viewed as complementary to the role of the patient. Just as the patient is expected to cooperate fully with the physician, the physician is expected to apply his specialist knowledge and skills for the benefits of the patient. This argument identifies the general expectations that guide the behavior of physicians and patients, and shows how these roles facilitate interaction in the consultation, as both parties are aware of how each other is expected to behave [17]. The most common complaints about physicians by patients and the public relate to communication, and particularly that physicians are perceived not to listen, not to provide enough information and show a lack of concern or lack of respect for the patient. As a result, many patients leave the consultation without asking questions about things that are troubling them or do not receive what they regard as a satisfactory response [18]. Although having less power than the physician in the consultation, patients can influence the interaction and the physician s communication skills, characteristics and behavior. The patient s passive communication styles and unwillingness to provide information to the physician might not only influence the relationship with the physician but also decisionmaking in the treatment options and procedures. In this context, the medical and nursing services are complex and often fragile. They require time and an understanding of culture and cultural concepts to enhance and facilitate the health care. Previous studies have shown that the use of cultural knowledge in community-based health care practice begins with the provider s careful assessment of patients and families in their own environments [19]. During the assessment phase, discussions with the patient and family are held in order to develop mutually shared goals [20]. Religion and other cultural factors may play a crucial role not only in fertility decision making, but also in the way in which individuals experience and perceive their bodies. Like it has reported, religious beliefs and traditional perceptions are culturally patterned since the structure and functioning of the body are a reflection of culturally determined cognitive categories. Taking into account religious influence and culture on body knowledge, an examination of compliance must consider the cultural acceptability of methods. Acceptability is not acceptance, but rather the compatibility of the method with the values, norms, and beliefs of the patients. Evidence seems to indicate that assessment of compliance must begin with the patient s understanding of the provider s recommendations. However, understanding and acceptability, while crucial to correct use and continuation, are not sufficient, because culturally determined perceptions can influence compliance [21]. In comparative analysis of cultural differences, attention has been drawn to the understanding of the nature of people; a person s relationship to the external environment;

3 332 J Immigrant Minority Health (2012) 14: the person s relationship to other people; the primary mode of the activity; people s orientation to space; and the person s temporal orientation. According to one study, these dimensions are used to explore differences in language and communication styles of people [22]. Compared to other Western Countries, Finland has been a culturally and linguistically homogenous society. Its nonnative population is 2.5%, which places Finland among the lowest in the European Union [23]. The Finnish language is part of the Finno-Ugric language family and most closely related to Estonian. Most of the Finnish people (94%) speak Finnish and 5% speak Swedish as their mother tongue [24]. Most of the Finns (84%) are members of the Evangelical Lutheran Church of Finland, and almost 4% are members of the Finnish Orthodox Church and other religious groups. Only 13% of the Finnish people not members of any religion [25]. In social interactions, Finns are perceived as rather silent people who do not usually practice much small talk. They are considered modest and polite, and somewhat difficult to approach. In Finland, it is considered desirable to keep silent, not to speak too much, to talk in moderate tones and not to do anything to draw attention to yourself, listen to the speaker, and withholding oneself from interrupting since it is considered rude [26]. In contrast, previous studies have revealed that Somalis are known to have a rich oral tradition and are oriented towards storytelling and that storytelling is a unique human skill shared between people and by telling stories, people of different backgrounds and cultures can build up a sense of community [27]. Somalis are also culturally and linguistically homogenous people. Compared with Finns, Somalis are divided in clans, they are almost entirely Muslims (Sunni), and their traditional Muslim beliefs prescribe defined gender roles. Men are the heads of the households. Other Somali beliefs attributed to Islamic tradition is the female genital mutilation (FGM) practice. As it reported that 98% of all Somali women have undergone the female genital mutilation, the large majority of Somalis believe that the practice is linked with Islam and the belief that every Muslim woman must be subjected to it is strong in the traditional Somali society [28, 29]. Cultural diversity is increasingly important in the working place and particularly in health care organizations that are facing demographic shifts [7]. The current study focuses on Somali women, because Somali immigrants remain in Finnish immigrant history, the first sizeable group of asylum seekers. The resettlement of approximately 6,000 Somali refugees during the 1990s in Finland represented a cultural shock for the Finns [19], including the health care professionals [30]. Somalis represent a unique group, vulnerable to health and social challenges because many of them and particularly women had experienced high stress due to the social instabilities or violence they experienced in Somalia. As this study explored the Finnish health care providers communication and cultural sensitivities in providing reproductive health care to Somali women living in Finland, the rationale for our choice to study Somali women is threefold: First, Somalis are visible in the society, particularly the women. Somalis are also specific and well known immigrants in Finland, because of their tradition of having several children (five to twelve children) and genitally mutilated, a practice that has raised discussions in the Finnish reproductive health care providers. Second, we wished to explore the challenges of communication and cultural sensitivity issues that Finnish health care providers face in providing reproductive health care to Somali women. Third, as little research has assessed such challenges, the current study contributes to the literature of intercultural communication between health care providers and patients who speak a different language and are from different cultural backgrounds. Methods We used the qualitative approach as described by Sandelowski [31]. In this naturalistic, interpretive approach, open-ended questions are used to elicit physicians and nurses-midwives experiences in such a way to allow researchers to derive implications to improve patient-provider communication and cultural awareness in practice. We employed a qualitative design in recognition that in health care, it is important to understand the perspectives of the providers in order to develop interventions that are relevant to their relationship with the patients in medical encounters. Thus, rather than gathering data from large numbers of health providers (physicians, nurses and midwives) and describing the statistical means of providers, we gathered in-depth data from a smaller group of health providers in order to allow a dense description of the communication, cultural issues and perceptions about patients attitudes to reproductive health services including contraception services. Participants Finland has been a homogeneous country until the arrival of sizeable populations of refugees, asylum seekers and immigrants from Russia, Iraq, Iran, Afghanistan, Somalia and Congo in 1990s. In contrast to other Western and particularly to the other Nordic countries, foreign migration to Finland is a relatively new phenomenon [32]. The resultant demographic shift sent a clear message that the Finnish health care policies and practices would have to address the needs of these immigrants and their communities. Previous studies of immigrants living in Finland

4 J Immigrant Minority Health (2012) 14: suggested that immigrants experienced communication and cultural difference difficulties when interacting with Finnish health care providers [33 35]. Such difficulties were probably due to the lack of trans-cultural competencies of the health and medical professionals and as a consequence, cultural awareness, knowledge and sensitivities had traditionally not been considered during the delivery of health care [36]. Compared to other immigrant groups in Finland, the Somali traditional cultural triad of female genital mutilation, women s abstinence of birth control practice and religious beliefs related to health care had raised the need for cultural awareness within the Finnish health care services [32]. For these reasons, we interviewed health care providers in order to explore their trans-cultural awareness, mainly on communication and other cultural issues in providing reproductive health care to Somali women. Table 1 Participating physicians, nurse and midwives by gender, number, and city of residence Health provider Gender N Resident city Gyn/Obst Female 2 Turku Gyn/Obst Male 1 Turku Gyn/Obst Female 2 Helsinki Gyn/Obst Male 1 Tampere Gyn/Obst Male 4 Helsinki Nurse (1psychatric) Female 3 Turku Midwife Female 2 Turku Nurse Female 1 Tampere Midwife Female 2 Vantaa Nurse Female 2 Vantaa Midwife Female 4 Helsinki Nurse Female 1 Helsinki Gyn gynecologist, Obst obstetrician Data Collection The health care providers that were interviewed for this study were selected from five family planning and maternal clinics from the cities of Helsinki (2 clinics), Vantaa (1 clinic), Turku (1 clinic) and Tampere (1 clinic). Prior to the interviews, a participant information letter inviting gynecologists/obstetricians and nurses/midwives to participate in the research was sent to the corresponding cities Medical Ethics Committee. Each Medical Ethical Committee proposed physicians (gynecologists/obstetricians), nurses, and midwives from its medical services that provided reproductive health care to immigrant women. A total of 15 physicians and 17 nurses/midwives were listed. From these potential 15 physician interviewees, five declined the meeting from which three from Turku indicated they did not know enough about immigrant women; and two nurses/midwives from Vantaa apologized that they did not have time to participate in the study (Table 1). Totally four individual interviews with four gynecologists/obstetricians and three focus group interviews were carried out in English. All individually interviewed persons took also part in one focus group interview. Two focus group interviews comprised only gynecologists/obstetricians. One of these groups comprised six obstetricians and the other one four gynecologists. Moreover, one focus group interview comprised six family planning nurses, eight midwives, and one psychiatric nurse. Each individual interview lasted approximately 1 h whereas one focus group interview lasted about min. In order to observe anonymity and confidentiality and maintain the identities of the participants anonymous throughout the data analysis, a coding system was employed (M/F male or female respondent, followed by a number). Only the research team could identify the participants. Analysis The data analysis process goes through the stages of transcribing the interviews, sorting field notes, organizing and ordering data, and listening to and reading the material collected over and over again. This process also includes coding and categorizing of participants anecdotes, and the gradual building up of themes according to the participants responses [37]. The interview data of the current study were analyzed using content analysis. Silverman [38] affirmed that the use of content analysis in qualitative research results in the analysis presented as illustrative quotations. The data was searched according to two main themes: communications and culture. The recorded focus group and the individual interviews were edited separately. In the current study the data collection and analysis were undertaken concurrently: in this way, insights from each interview informed the subsequent ones. In addition, the findings emerging from each focus group interview were compared with the findings of the individual (single) interviews. This process continued until differences and similarities in participants responses were grouped and categorized under headings which helped to generate the qualitative findings presented below. Results Physicians-Somali Women Relationships The gynecologists hardly ever saw Somali women in family planning clinics because most of these women were not interested in contraceptive use and did not wish to talk about their sexual health, at least not with male physicians.

5 334 J Immigrant Minority Health (2012) 14: However, some of these women might have come in order to gain information when they had to make up their minds about contraceptive use. The obstetricians saw and talked to the women during the compulsory two or three regular visits to the maternity clinic during pregnancy in order to obtain the maternity benefits, such as maternity package and child allowance. Those visits are usually of short duration and therefore physicians do not have time for thorough interaction with the patients. Apart from the regular medical check up during a pregnancy without complications, they maternity health care providers did not see the women until the time they were admitted to the clinic for delivery. The physicians reported that nurses usually had more contact with the Somali women because they saw them often for other medical routines. One physician commented that: We doctors, we do not have time to socialise with our patients. We have very limited time for each consultation because we have several patients a day. We have little time for the medical checking for each patient, and then go through her medical report to see what to do during her next visit. It is the nurses who have more time to communicate and interact with the patients than we physicians (M1). Another physician felt that: The nurses have good relationships with the Somali women, although it is sometimes difficult to communicate in the same language with them, but anyway, they do understand each other (M3). The physicians highlighted that they are not able, due to language problems, to communicate directly with several of the Somali women in the consultation room. They reported that the large majority of the women do not speak Finnish or English and therefore they have to use an interpreter, in order to communicate with them. A female physician felt that: We are frustrated because of the interpreters poor knowledge of Finnish or inability to translate our words correctly to the women and we believe that the women were not getting the right information (F1). In each clinic, physicians expressed their frustrations for using interpreters who did not know any medical terminology, and did not speak fluent English or Finnish. From each physician s point of view, the persons employed as interpreters were not qualified to be medical interpreters. The physicians felt that those persons undertaking the interpretation were not professionally educated and not trained to work as an interpreter. Hence, the physicians believed that their words were sometimes wrongly translated to the patients and vice versa. Thus, these non-qualified persons or adolescent children used as interpreters were making the communication and language problems between them and the Somali women more difficult. At each clinic that participated in the current study, physicians mentioned the general lack of professional medical interpreters in Finland that could help them to communicate with Somalis who were not speaking Finnish or English. Unfortunately, the available interpreters did not speak Somali language and thus were not used in the medical consultation. Two physicians reported their daily routine of using non-medical interpreters commented that: How can we properly do our work when we have language problems to communicate with the women? How can we do our work, when we physicians but also the patients, we are not comfortable discussing sensitive or personal issues with a third person in the consultation room? The interpreters we are using are not educated as medical interpreters, and do not understand the medical terms we are using to describe our patients health problems (M5 & F8). The physicians interviewed had consensus that the worst scenarios were those where children aged 8 10 years and teenagers aged years old were used as interpreters in the meeting with patients. One male physician who had very often used years old Somali teenager girls as interpreters felt that: The worse cases are the use of kids as interpreters in meetings with the patients. To preserve their privacy, many women prefer to bring their kids to be interpreters in the examination. Using children as interpreters is as well worse as using non-medical interpreters, because in both situations, the physicianpatient s miscommunication and misinterpretations of the medical instructions might have great consequences. While medical interpreters or translators must be educated for medical interpreter career, they must speak fluently the language of the physician and that of the patient, and must have an in-depth knowledge of medical terminology (M1). One female physician commented on Somali women s attitudes and interpretations of the physicians beliefs about them: The large majority of Somali women maintain ethnocentric attitudes toward health, reproductive and maternal services but at the same as they think that, we physicians do not interact or are not friendly with them. I must say that, we do not have time to socialize or have special relationship with our patients, not even with our Finnish patients. The

6 J Immigrant Minority Health (2012) 14: Somali women must understand as we say in Finland maassa maan tavalla in English when in Rome, do as the Romans do. Our work is to provide good health care when they come to our clinics and not to gossip with them (F10). Another female physician felt that: We female physicians, we have same communication and cultural problems with Somali women as our colleague male physicians. The fact that, we are females does not mean that we should treat them differently or they treat us differently than the male physicians. We have the same communication and cultural problems with the immigrant women and particularly with the Somalis (F8). Another female physician affirmed that she was confident that in many cases in the reproductive and maternal health care clinics, nurses and midwives know better and have more contacts with the immigrant women including the Somalis than the physicians (F4). Nurses/Midwives-Somali Women Relationships Compared to the physicians, the nurses and the midwives met more often with the Somali women in the clinics, because several of the women had given birth many times so that they had become regular clients of the maternity clinics. Some nurses and midwives had also visited the homes of some of these women who had just delivered their babies. The three nurse and two midwife interviewees, having visited Somali women s homes described their visits as opportunities to build up personal relationships with the women and to understand their culture. Three of the midwives who had visited their Somali patient s homes commented that: The best way to get the Somali women to communicate with us is to interact with them, when we can. By interacting socially with them, we can teach them our culture and we also can learn their way of life, their cultural norms and religious beliefs. We think that it is interesting to know our ethnic minority patients way of life, respect their culture, religion and at the same time explain to them the benefits of our health care services. Particularly in the family planning services, we can explain to the men and women the good use of contraception in their sexual relationship. What we have learned from Somalis, when we have visited some of our Somali women patients homes is that social interaction is extremely important to Somalis. Once they get to know you, they can trust you, they talk with you about any issues, including those we Finns think are taboo in their culture and religion. I have also learned from the Somalis culture that the visitor is always served food. For Somalis, a guest is a great honour to the family (Mw1). In a focus group discussion, three midwives talking about their visits to Somalis homes concluded that: In our opinion, to give confidence to Somali women and other immigrant women to accept our cultural norms, way of life, and health care services, we need to interact with them, listen to them and use all the means to communicate with them (Mw 2,3,5). Another two nurses who had also visited their immigrant patients homes several times felt that: It is not easy to build a good relationship with a person who does not speak your language, does not know you, who has been traumatised by civil war, been abused sexually, does not trust anybody and feels like living in a different world. At the first meeting, Somali women are interested in discussing personal problems, and they are interested in discussing contraception. In order to come closer to them, to build up a relationship with them, you need to listen to them telling their histories, starting from the civil war and its consequences on families and women to the Somalis difficulties to be integrated in Finland. To build up a good relationship with Somali women, do not ever start talking about contraception or their religion (Islam) to them until they are the first to talk about those things (N 4,6). Particularly for the psychiatric nurse, the relationships with the Somali women depended on the nurse s, the midwife s or the physician s understanding of these women s history, culture, religion and the changes in their lives in Finland, because these factors all have an impact on their mental health and trust of a health care or a social worker. This psychiatric nurse interviewee elaborated on her experiences in keeping up a good social relationship with her Somali women patients: Several of these Somali women have severe depression, posttraumatic stress disorder, lack of sleep and stress. All these symptoms are caused by severe psychiatric disorder, because of the civil war in the country and to the problems of integration in Finland. The best way to know each other is to build up trust, visit them in their homes, listen and support them psychologically, so that they feel that I share their problems with them. Somalis like to invite you at their homes, cook for you. One of the first things that I have learnt from Somali culture with those women is communication, listening, courtesy and compassion (Psych N).

7 336 J Immigrant Minority Health (2012) 14: Not all the nurses had personal relationships with the Somali women. Particularly the family planning clinic nurses very seldom saw Somali women in their clinics because the women were not interested in family planning services and were not using contraception. Even when a Somali woman decides to use contraception and comes to the clinic to receive the method, she never comes back. Even those using an intrauterine device (IUD) seem not to dare to come for checkups. One family planning nurse justified her attitudes to the nurse-patient relationship stating that: Some of the nurses like me we have our personal and professional reasons of keeping distance from the Somali women and other patients, because in Finland, it is not our culture in the health care profession to interact with our patients outside the work. I have heard that some nurses visit some of their Somali patients but I would not like to do so, because I do want to know about my patients lives (N5). Communication problems were obstacles for many nurses to interact or to have a personal relationship with Somali women. In addition, after work or during their days off, several nurses, naturally preferred to stay at home and take care of their own families or do things they are not able to do during the working days. Two of the family planning clinic nurses who never visited their patients homes and did not have any special relationship with Somali women clients felt that: It is difficult to communicate with the Somali women, because they do not understand Finnish and one can not talk with them directly, one always needs an interpreter. If we visit them at their homes, we would not have anything to say, because we do not understand each other. Even many of them do not speak English. We hope that, with time, they will learn Finnish so that we can communicate directly when they come to the clinic (N5 &1). In an interview meeting, these nurses again expressed their difficulties to communicate with the Somali women and particularly the use of kids and teenagers as interpreters in the examination room. They expressed their experiences and those of other nurses: The communication and cultural attitude problems in providing health care to the Somali women in Finland is common in each hospital, health care centres and the family planning or maternity clinics. The more frustrating and hopeless situations are the use of these women s 8 to 10 years old kids or 11 to 16 years old teenagers, who compared with their mothers speak better Finnish but do not know what we are really talking about. It is so difficult to tell a kid what he or she does not understand or should not know. We could never be sure if the kid understood and reported the right thing to the mother. We sometimes, understand the women s decision to bring the kids or children to be the translator, instead an unknown person that would hear their personal issues (N5&1). For many of the nurses/midwives, hugging Somali women was reported to be a culturally difficult new thing for Finns even though this was perceived as compassion or comfort to the Somali women. In each clinic, nurses/ midwives highlighted the Somali culture of hugging as a difficulty when the women came in and went out of the consultation room. For the nurses/midwives, this nature of nursing that involves hugging and touching clients was a new situation for them, because in the Finnish culture such a way of comfort is often interpreted as inappropriate professional behaviour unless you are very familiar with your patient. One of nurses/midwives commented on Somali women s habit s of hugging or touching: In the beginning, many of us were embarrassed in hugging the Somali women. When the women came in, they just came into your hands and did the same when they went out. We Finns, we are not used to hugging our patients neither other people in our private life. We might sometimes touch or hug children in the clinic but not an adult patient. We might also hug our children or close relatives that we have not seen for many months or many years. Hugging and touching are not ordinary parts of Finnish culture. Now, we have learned and understood the cultural meaning of hugging the Somali women, so that some of us can do it more easily than before (N2). Two of the nurses pointed out that the nurses/midwives relationships with the Somali and other immigrant women are following professional standards being supportive, casual and not close, so that they do not cross boundaries. In this relationship, nurses/midwives are responsible for maintaining professional nurse-patient relationships regardless of the women s culture and of how they behave (N3 & Mw2). Physicians Perceptions About Somali Women s Cultural Attitudes to Reproductive Health in the Clinics The Somali women s cultural attitudes were described as problems in providing reproductive health care to the women. Two physicians argued that it was challenging to treat the Somali women because of their cultural attitudes to male physicians. Once the Somali woman saw a male physician in the examination room, she went out. Or if she

8 J Immigrant Minority Health (2012) 14: was told that the physician was male, she refused to come to the examination. Several Somali women just told the nurses, they do not want to be examined by a man, because in their religion, a woman is not allowed to be naked in front of a man who is not her husband, so they want a female physician and not a male (M3 & M4). Another physician was frustrated when a Somali woman refused to come to his consultation: I have been in this medical profession for several years already, and no woman has ever refused my services because I am a man. I felt insulted and humiliated when the nurse told me that a patient said she does not want to come to the examination because I am a man. Her attitude was a shock to me, but there was nothing to be done about it, so I accepted it. As time passed, changes have taken place and now the same woman and others have started to come to me to be physically and gynaecological examined. I must say that the changes have also become possible because of the nurses and midwives good contacts and communication with these women. They are the ones who persuade the women to seek help from the doctors and provide them all information, including that about all types of contraceptive methods if they want to prevent pregnancies (M1). In another clinic, a male physician affirmed that there have been some instances where some of the women waited until a female gynecologist or obstetrician was available. In some clinics, male physicians reported that it was the husband that calls the clinic for an appointment on behalf of the wife, but then insists that she should be examined only by a female physician. One physician commented that: One day, the husband came with his wife into the examination room to see what I was doing (M3). Another male physician revealed his experiences that Somali women refused to talk about their menstruation history to male physicians because according to them, it is forbidden in their culture for a woman to talk about her menstruation to a man who is not her husband. So, the portions of information that some women provided about their gynaecological history were usually incomplete and insufficient to understand their gynaecological and obstetrical problems: Several women do not want to talk about their menstruation but are also not able to remember its history (their duration and frequency) that might be important information for a gynaecological diagnosis. If the women could provide us the information of past gynaecological problems that could help us to better understand the present situation, but because they do not want to tell us or are not able to remember, it is very often difficult for us to guess. The other problem we are facing with the large majority of these women is that it is the husband who has the final word on the wife s informed consent. Sometimes, specific gynaecological investigation problems are difficult or take time to be solved, because we have to wait for the husband s approval (M4). Female physicians that were interviewed felt shocked by Somali women s attitudes to male physicians duties of carrying out physical and gynaecological examinations. One reported that Somali women s attitudes to male physicians were humiliating but also frustrating, adding that: Somali women should understand that if they are going to live in Finland, they have to accept medical services provided by male physicians because, there are more male gynaecologists in our Finnish hospitals and clinics than females (F1). The physicians recognized the Somali women s right to reject or accept the medical services provided to them and also their right to choose the providers but they could not be expected to impose their cultural traditions on the physicians on how and what to do in the clinic. One female physicians felt that: When a Somali woman comes to the medical examination, she does not come alone but with all the family, so there is no privacy. You cannot tell her personal things or you do not know what to tell her, because you do not know if she wants all family to hear what you are telling her (F3). Another female physician iterated that: What shocked me with one of these women, is, one day, in the middle of the examination, she wanted to go and pray and come back and I asked why?, but her answer was that it is time for her to pray. I just told her that God sees what we are doing and I am sure he will forgive you for not praying at this time (F2). One male gynecologist/obstetrician commented that: Talking about physical and gynaecological examination to some of these Somali women, one of my worst experiences with one of these women was in delivery theatre, when her husband refused me to carry out the delivery because I am a man but also did not want his wife to give birth by caesarean section. According to him, the medical services proposed were not allowed in Islam and therefore he wanted a female obstetrician to carry out the delivery and not a

9 338 J Immigrant Minority Health (2012) 14: male and he wanted the wife to give birth by vaginal delivery and not by caesarean section. The midwives explained to him that no female obstetrician was available in the clinic to carry out the delivery and according to the wife s health condition, caesarean was the only way by which she could deliver the baby. This man told the midwives that he would not let me come near his wife neither do the caesarean to her because of his cultural and religious beliefs. As the situation was getting bad, we were advised to get help from the Islamic community by calling the Imam to come and talk to this man, which the midwives did. He came to the maternity clinic and talked to this man so that I could finally do my work (M6). Somali women s cultural traditions and religious beliefs in the clinics were unfamiliar to physicians. For the male physicians, it was insulting when the Somali woman refused to come into the consultation because the physician was a male, and if she came in, she could not shake hands because he was a male. Two male physicians expressing similar experiences also found those Somali women s cultural and religious behaviours of not shaking hands with a strange man was an insulting social behaviour: We have heard that Somali women said that physicians do not notice them in the clinic. How can they say that, we do not pay attention to them, and that we do not have enough time for them when they do not want to come to the consultation done by male physician or do not want to shake hands with a male? It is a bit difficult to communicate with a person you do not see or who does not give you the opportunity for interaction (M7). Nurses/Midwives Perceptions About Somali Women s Cultural Attitudes to Reproductive Health Care According to the gynecology and the family planning nurses, only 5 10% of the Somali women visiting their clinics used contraceptives. Contraceptive use is a culturally sensitive matter to discuss with Somali women, even with those with 5 10 children. The majority of women refuse to use contraception because it is forbidden in their religion, Islam. Even when a Somali woman with more than five children is asked if she still wants more children, her answer is if only Allah gives them to me. Altogether 90 95% of Somali women never took the decision to use contraception without the husband s permission, they always respond indicating that I will ask my husband, my husband will decide or to be polite, some said I will think about it. The midwives in maternity clinics interacted with Somali women more often than did the nurses at the family planning clinics, because according to the midwives, Somali women gave birth every second year as the women did not want to use contraceptives and their husbands did want to use condoms because of their religion. Two midwives highlighted that Somali women give birth frequently: We know very well our clients because they give births every year. They do not want to use any birth control methods and neither their husbands. Somalis rely on the natural methods which unfortunately do not work so that the women are pregnant after 8 to 10 months (Mw 7& 8). The Somali women s inconsistence in contraceptive use was regarded by the nurses and midwives as a result of lack of knowledge of birth control methods among at least some of the women. For example, once the IUD users have menstrual disturbance, bleeding, or infections, they come to the clinic to have the device removed immediately, when it had been possible (and better) for them to come to the regular checkups agreed upon after the insertion. Similarly, for the oral contraception (OC) users, once they had side effects, such as nausea, headaches, or bleeding, they frequently stopped using the pill. Other Somali women do not take the pill on regular daily basis like they have been advised. For one maternity nurse who had assisted several Somali women to deliver, the challenge of Somali women using contraception was strongly associated with cultural attitudes and religious beliefs. This nurse felt that the large majority of these women were not educated, worked hard at home, including taking care of several children and the husband, so they did not remember to take the pill everyday as the gynecologist had prescribed. A small minority who used contraception were not affected by cultural traditions and religious beliefs. In regard to the behavior of such a small number of women, two family planning nurses expressed that: Although few Somali women have started to use contraception, we are sure that with changes in the social and cultural adaptation, many more will follow in the coming years in order to compromise between religion, culture and the use of contraception, including abortion and sterilization as birth control methods. Now many of these women do not want to hear about these methods (N 3& 5). Somali women s understanding of keeping an appointment time with the physician or with the nurse and following the medical instructions were also reported to be associated with problems when providing reproductive health services to these women. The women did not arrive on time to the appointment. They often came 1 h late to the

10 J Immigrant Minority Health (2012) 14: consultation or did not come at all. For the nurses, Somali women s idea of setting time for an appointment had a rather different meaning in their culture than that in the Finnish culture. One nurse pointed out the changes that were taking place in some of these women s life: For the past one year, some Somali women have started to come on time to the consultations, some also have started to accept physical and gynecological examinations done by male physicians. Although those changes in the women s cultural traditions and religious beliefs took time, we are very happy that they have learned and they will learn more and more about our society and its social, cultural and health systems (N6). Discussion Several findings from this study have implications for future research. First, communication and cultural sensitivity in providing health and reproductive health care to immigrant women is of central importance Second, health care provider s communication style implicates that the provider should take an active and even a controlling role in the interaction. Culturally appropriate actions are most directly predicted by awareness that culture is relevant to medical care and that negative preconceptions can hinder service efforts. Therefore, there are many demanding roles for health care professionals. While several studies have recognised that communication plays a vital role in the management and control of patients [39, 40], the failures of the relationships between providers and patients are also partly due to a number of factors including communicative culture, interpersonal contacts, personality, identity, socialization, linguistic skills and gender differences [41]. Even though Finland still lags behind other Western countries in hosting foreign populations, its minority population has increased since the 2000 s. There are 155,705 foreign nationals living permanently in Finland, about 2.9% of the total Finnish population. Somalis are the largest African population and the fourth among the immigrants, after the Russians, the Estonians, and the Swedes, comprising 4% of the total immigrant population [42]. On the one hand, such increase of the immigrant population has raised a growing awareness of cultural care in the Finnish health care services [35]; on the other hand, all citizens living in Finland, regardless of their ethnic, religious and racial backgrounds have the same rights and get the same medical treatment as the local Finns. But for the health care providers, the assessment of patients from a different culture is more complicated that of the mainstream. Qualitative studies of Somali women s experiences in the Finnish local health care centres have reported that women were often confronted to language and cultural differences of the health care providers [34, 35]. Another qualitative study found that health care providers, especially nurses constructed Somalis as problematic patient groups as they were compared to other immigrant patients [43]. These studies might suggest that the themes that emerged from our data might seem to be unique to Somali women in Finland. As regards to relationships between the physicians and Somali women, like it has been reported, physician-patient relationships are vulnerable to communication problems, many medical problems are said to be hard to solve, and medical care often engages physicians and their patients in emotionally painful and challenging situations. These situations are all difficult and yet fall within the range of the expected and accepted challenges of practicing medicine. By contrast, 10 20% of patients provoke a level of physician distress that transcends the expected and accepted level of difficulty. These patients have often been labelled as problem or difficult patients. Patients whom physicians find to be difficult are also heavy users of health care services, but at the same time dissatisfied with the service they receive as their physicians are upset while giving it [44 46]. These previous studies support our findings demonstrating the situation of the Finnish physicians when providing reproductive health care to Somali women in Finland [19]. In the context of health care culture, physicians, like other individuals, might deeply imbed in their own cultural beliefs, perceptions, values already formed in childhood, due to religion and during professional training [47]. Physicians need to recognize that differences not only exist among themselves and all patients, but also among patients of different cultures. They may not be aware of unconscious attitudes that may influence their behaviours with individual patients [48]. Experience with specific health beliefs and behaviours by some individuals of the same ethnic group with similar culture may lead physicians to assume that these apply to all members identified with that same background, thus influencing the physicians sociocultural attitudes and communication styles, like we assume it to be in the encounters of physicians with Somali women. Referring the revealed changes in Somali women s cultural adaptation, we are again assuming that beliefs and attitudes to physical, pelvic examination and contraceptive use of some of these women could also be associated with the social environment (income, educational level or language skills) than culture or religion. Previous studies have indicated that female physicians are often engaged in more partnership-building, are less directive, express more interest in psychosocial aspects of health and are more explicitly reassuring and encouraging than male physicians [49, 50]. However, to infer that