Background
Norwegian and southern European healthcare
Theoretical framework
Methods
Study participants
Total (n = 20) | ||
---|---|---|
Gender | Women | 15 |
Men | 5 | |
Age distribution | 30–35 | 2 |
35–40 | 7 | |
40–45 | 9 | |
45–50 | 2 | |
Country of origin | Spain | 15 |
Italy | 2 | |
Greece | 2 | |
Portugal | 1 | |
Civil status | Single | 1 |
Registered partnership | 4 | |
Married | 15 | |
Education | Primary | 2 |
Secondary | 4 | |
University | 14 | |
Employment status | Employed | 19 |
Unemployed | 1 | |
Number of children | 1 Child | 8 |
2 Children | 11 | |
3 Children | 1 | |
Years lived in Norway | 1–5 | 7 |
5–10 | 11 | |
10–15 | 2 |
Data collection and analysis
Method of data collection | Country of origin of participants | Gender | Years lived in Norway | Language used | Total participants | |||||
---|---|---|---|---|---|---|---|---|---|---|
Italy | Greece | Portugal | Spain | Women | Men | < 5 | > 5 | |||
FGDs | ||||||||||
FGD 1 | 2 | 2 | 0 | 2 | 6 | 0 | 0 | 6 | English | 6 |
FGD 2 | 0 | 0 | 0 | 4 | 4 | 0 | 4 | 0 | Spanish | 4 |
Interviews | ||||||||||
Individual Interviews | 2 | 2 | 1 | 7 | 9 | 3 | 3 | 9 | English (4) Spanish (8) | 12a |
Couple Interviews | 0 | 0 | 0 | 2 | 2 | 2 | 2 | 2 | Spanish | 4 |
Methodological considerations
Reflexivity
Results
Themes | Sub-themes |
---|---|
Expectations concerning diagnosis and treatment | • Expectations concerning diagnosis • Expectations concerning treatment |
Pathways to healthcare | • Seeking healthcare in the private sector • Seeking immigrant health providers in Norway • Navigating healthcare through Norwegian social networks • Negotiating with Norwegian health providers in Norway • Alternative strategies for treatment and diagnosis |
Expectations concerning diagnosis and treatment
Expectations concerning diagnosis
My daughter had chicken pox. We thought so; it wasn’t like the doctor thoroughly checked her to see what she was suffering from. (Spanish mother, FGD 2).
Although the participants prioritized the use of diagnostic tests as a measure to prevent health concerns, the participants who had lived in Norway for a longer period of time reflected on the risks of overdiagnosis, a practice they linked with their countries of origin.[…] Doctors lack basic knowledge of pediatrics. They don’t do any [diagnostic] tests either. How can you trust them? (Portuguese father, individual interview).
There are both bad and good things about that (fewer diagnostic tests), because in Greece, it’s like, “I have [something in] my head, I run to the doctor and.…” (Greek mother, FGD 1)
Have an X-ray. (Italian mother, FGD 1)
To make sense of the less interventionist healthcare approach encountered in Norway regarding diagnostic practices, the participants pointed out the authorities’ intention to save economic resources. They also reported that the use of diagnostic tests would prevent possible problems:“… you get crazy.’ Whereas here, because you know it’s not that easy to go and check your finger, then ‘OK, maybe it’s not something serious.” (Greek mother, FGD 1).
When I got pregnant, well, in Spain, you usually take blood tests to see your sugar levels. Here, I called [and said], “I want an appointment because I think I’m pregnant. I want to confirm that and maybe take some tests.” “OK, you are younger than 37, so you don’t have to come until week 14.” “But aren’t you going to check if I’m fine?” “No, because miscarriage can happen during the first trimester.” (Spanish mother, FGD 1)
But what they say is true. (Spanish mother, FGD 1)
But it’s stressful when you come from another country. (Italian mother, FGD 1)
It’s just to save money to the system, which is great […]. (Spanish mother, FGD 1)
But a lot of things can be prevented. (Italian mother, FGD 1)
Another factor that reinforced distrust toward the diagnostic practices encountered in Norway was the medical devices used, which the participants considered to be low-tech. This perception was especially strongly voiced in the accounts of the participants who had given birth in Norway and shared their experiences with prenatal screening and the use of noninvasive devices such as the Pinard stethoscope:That’s true as well. (Spanish mother, FGD 1)
Few participants reported that health providers had explained to them why fewer diagnostic tests were conducted in Norway than in their countries of origin. The participants usually appreciated such explanations as a practice that helped them understand the diagnostic practices in Norway.[During pregnancy], the check-ups were very funny, “I check the belly, the heart, with a piece of wood,” very rudimentary. (Greek mother, individual interview).
[…] I just told the doctor I was worried because in Greece, I‘d take […] something like an ultrasound every month, or every two months. She [the doctor] explained to me that ultrasounds are much safer than X-rays, but we don’t really know its effects in the longer term. […] This conversation calmed me down. I understood why they do things the way they do. It wasn’t random; they have their reasons. (Greek mother, individual interview).
Expectations concerning treatment
There isn’t a need to go there [to a consultation]. You go and they say, ‘Paracetamol for children.’ (Spanish mother, FGD 2)
It’s terrible. GPs do nothing […] they just speak to you. (Spanish mother, FGD 2)
The lower frequency of the prescription of antibiotics was understood as part of a more ‘natural’ approach that guides Norwegian healthcare providers.They solve everything with water. (Spanish mother, FGD 2)
This clash in the different countries’ prescription practices was more evident to the participants in consultations for their children.We are very interventionist: “I give you a medicine, I cure you, I monitor you.” Here, that doesn’t exist. In Sweden, Germany, and Denmark, it’s the same because the concept of health is different. Their approach is more natural, and this has a positive side because they don’t intervene when it isn’t necessary, but it’s scary for us, because it’s a new approach. (Spanish mother, FGD 2).
Although the participants acknowledged the advantages of the Norwegian approach (avoiding an increase in antibiotic resistance and reducing the number of unnecessary treatments that may cause harm), they also considered this approach a potential threat to their health and that of their children. This was especially the case when children had fever or infections, as the participants believed antibiotics were the only effective treatment to overcome these problems.Don’t ever think of taking a baby (to the doctor) and asking for medication, because they’ll look at you as if you came from Mars. (Spanish mother, FGD 2).
Statements such as “the concept of health is different” or “doctors think things are cured naturally” show that the participants understood the divergence in treatment practices from a cross-cultural perspective; that is, they understood treatment practices as being shaped by contrasting cultural health beliefs. The participants’ expectations about pharmacological treatment also mirrored their beliefs about health providers’ competence and roles. The participants did not approve of GPs who could not tell them immediately which dose of medication their children should take without consulting the National Treatment Guidelines for Health Personnel or the Internet. This clash between their expectations of a competent GP and adequate pharmacological treatment versus the practices they encountered led to feelings of dissatisfaction, frustration, and abandonment.They (doctors) think things are cured naturally. They don’t intervene a lot […] which is good to some extent: children’s immune system, not taking too many antibiotics… but if the child has patches of pus, you must intervene, and they don’t! (Spanish mother, Individual interview).
He (the GP) prescribed me ibuprofen. I asked him about the dose, […] he looked at the directions for use on his phone […] (Spanish mother, FGD 2)
[…]
A doctor always knows! In Spain, we trust doctors because they act with determination and wisdom (Spanish mother, FGD 2)
The lower frequency of the prescription of antibiotics was also described as a sign of health providers’ lack of competence and knowledge, especially regarding an accurate diagnosis, effective treatment, and pediatrics.[…] […] You get a feeling of abandonment, as if you aren’t being cared for. (Spanish mother, FGD 2).
Doctors are afraid (to intervene) because they don’t have the knowledge. […]‘A child! I’m very afraid to prescribe antibiotics.’ (Portuguese father, individual interview).
Pathways to healthcare
Seeking healthcare in the private sector
The participants made use of the private sector to have tests that were not offered by Norwegian public healthcare services or when they wanted a second opinion. An example is provided in the next quote, in which a father shared his experience of seeking healthcare for his child who was sick with laryngitis.When I was pregnant, I wasn’t worried, because I had an ultrasound in the private clinic, and it was OK. (Spanish mother, individual interview).
We (my wife and I) went to a private doctor. We wasted our time because […] the treatment offered in the public hospital was so preventive. It took a month until my son was prescribed with a corticoid! The public hospital has a therapeutic approach that is completely conservative, whereas hers (the private doctor’s) was more interventionist against the illness, more aggressive but suitable and effective. (Portuguese father, individual interview).
Seeking immigrant health providers in Norway
Having a rich social network in Norway that would allow access to immigrant healthcare providers was seen as a resource that would facilitate navigation through the Norwegian healthcare system.When I knew I could change my GP, I looked for an Eastern European or Latino name because I guessed immigrant GPs would understand us (immigrants) better. They wouldn’t look surprised if I disagreed with paracetamol as the best treatment (Spanish mother, individual interview).
I was lucky because a friend of a friend is a gynecologist who is also an immigrant. When I had problems and was given a very late appointment, I got in contact with him. […] “I think that date is too late for a check-up. I’m going to see what I can do. I’ll speak to somebody.” […] You need to know people. (Spanish mother, individual interview).
Navigating healthcare through Norwegian social networks
My wife’s auntie knows some doctors, and this really helps and calms you down, because […] she knows how to ask for things with the Norwegian touch, because in many cases, the Spanish touch collides with the Norwegian one. (Spanish father, couple interview).
This Spanish couple shared their opinions of Norwegian healthcare services that do not offer frequent prenatal visits to monitor a pregnancy. In their attempts to obtain the expected diagnostic tests, they approached a Norwegian relative who “speaks the same language” as providers. The couple made it explicit that speaking the “same language” also refers to having knowledge about culturally appropriate communication in the context of healthcare consultations.Doctors will listen to her because they speak the same language, and I’m not talking just about Norwegian, but […] she knows they don’t intervene a lot; then, if she asks for that test to identify Down syndrome during pregnancy, the doctor won’t think that she is a fussy immigrant pregnant woman. (Spanish mother, couple interview).
Negotiating with health providers in Norway
The GP’s described action can be seen as an attempt to “meet in the middle”, to offer a treatment that would leave both parties satisfied. However, as we show next in the subtheme ‘alternative strategies for treatment and diagnosis,’ this participant did not see this approach as an effective solution to her daughter’s needs but as a waste of time that confirmed the pointlessness of consulting Norwegian health providers and her need to look for an alternative solution.I said [to the GP], “Look, she has ear pain, […] maybe she needs antibiotics.” “Well, she might, she might not. I’m going to leave it prescribed in the pharmacy; if you see that the girl gets worse in five to seven days, pick up the antibiotic, but if she gets better, the antibiotic prescription will expire.” (Spanish mother, FGD 2).
You have a lot of decision-making capacity. It’s really good […] In Spain, it’s a bit more like you get there [to the hospital] and are treated like a patient, as if you are sick: “Come here, sit down, don’t.” Here you are listened to more. (Spanish father, individual interview).
Alternative strategies for treatment and diagnosis
I came out of the consultation and said to my daughter, “See? We shouldn’t have come. I have medication at home. I’m going to cure you.” (Spanish mother, FGD 2).
If I say, “My daughter needs treatment,” the GP will look at me as if I were overreacting because I’m from the South, “where people are so dramatic.” I have medication at home. I can help my daughter. (Spanish mother, FGD 2).
Traveling to their countries of origin to access care for nonurgent health concerns and diagnostic tests was also a common practice among participants.I bring everything [medication] from Spain. I worked in a pharmacy; I know them [pharmacists], and they give me things. (Spanish mother, individual interview).
If it isn’t that serious, you wait until holidays to consult about whatever you are concerned about with your doctor [in Spain]. (Spanish mother, FGD 2).