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TRADITIONAL MEDICINAL PRACTICE IN AFGHANI CULTURE

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TRADITIONAL MEDICINAL PRACTICE IN AFGHANI CULTURE

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A vital role is played by the traditional medicine in health care rooted in primitive techniques in Afghani culture. In this culture, a commonly held belief is the use of 'Unani' medicine. It was more of a system known as 'Greco-Arabic' system that balance the humor of body that include phlegm, yellow and black bile, and blood (Safadi,2024). They believe that this system not only prevents, but also treats the diseases with the help of modified diets, natural therapies and herbal remedies. The practitioners of Unani are trusted the most in rural areas due to the limitation to conventional healthcare.

Reference:

Safadi, R. (2024). The liver in Greco-Arabic and Islamic medicine. Clinical Liver Disease, 23(1). https://doi.org/10.1097/cld.0000000000000137

Nizamoglu, C. (2022, November 7). Natural drugs in Greco-Arabic and Islamic Medicine - Muslim heritage. Muslim Heritage. https://muslimheritage.com/natural-drugs-in-greco-arabic-and-islamic-medicine/

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The Afghan refugees are significantly impacted by two critical social determinants identified by WHO when they arrive in Australia. The policies focused on these determinants give them a sense that they belong, mental well-being is prompted, and reduced stress. Discrimination leads to poor health and causes mental health issues. Afghan refugees face various challenges like different culture and language barriers proving that social inclusion is equally important when seeking healthcare(World Health Organization: WHO, 2019b).

Reference:

World Health Organization: WHO. Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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TYPICAL HEALTH CONCERNS AMONG AFGHAN REFUGEES IN AUSTRALIA

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TYPICAL HEALTH CONCERNS AMONG AFGHAN REFUGEES IN AUSTRALIA

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The arrival of Afghan refugees in Australia is full of health challenges as most of them have tuberculosis (TB). The prevalence of TB is quite higher in Afghanistan because of the crowded living conditions and limited healthcare(Essar et al., 2023). This is why detecting it early at the time of screening upon their arrival is essential. One of the most common option for treating TB is to put a refugee on antibiotics like rifampicin and isoniazid for six months and monitor regularly to assure that they are taking their medication . Using the interpreters and providing culture-sensitive care is essential to enhance care.

Reference:

Essar, M. Y., Siddiqui, A., & Head, M. G. (2023). Infectious diseases in Afghanistan: Strategies for health system improvement. Health Science Reports, 6(12). https://doi.org/10.1002/hsr2.1775

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AFGHANI PSYCHO-SOCIOCULTURAL MODELS FOR HEALTH

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AFGHANI PSYCHO-SOCIOCULTURAL MODELS FOR HEALTH

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The Psycho-sociocultural Models of health from the perspective of Afghani culture emphasize on factors like culture, social, and mental factors in determining health outcomes. In a war-torn country like Afghanistan, various social determinants influence critically. Severe challenges are faced by Afghani people as determinants like healthcare access, education, and poverty are common in their lives(Dastan et al., 2021). On the other hand, Australia as a multicultural society emphasize on equitable access even though one can see the disparities faced by ethnic communities. The deeply-rooted religious beliefs in Afghani people impact their behavior of seeking healthcare. By understanding these models, healthcare providers can provide services to Afghan refugees in a much better way.

Reference:

Dastan, I., Abbasi, A., Arfa, C., Hashimi, M. N., & Alawi, S. M. K. (2021). Measurement and determinants of financial protection in health in Afghanistan. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06613-y

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CULTURALLY SAFE NURSING CARE TO AFGHANI PATIENTS

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CULTURALLY SAFE NURSING CARE TO AFGHANI PATIENTS

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By understanding the distinctive health practices and beliefs of the Afghani patients, a culturally safe care can be provided to them. It must be understood by the nurses that most of the Afghani patients rely more on traditional medicinal practices and involvement of family will be their when making decisions on healthcare. Nurses should understand the gender-specific considerations as males from the family take most of the decisions on healthcare(Chakraverty et al., 2020). The factor of trauma should also be included when providing healthcare to Afghani people because of recent history of Afghanistan. By respecting and understanding these nuances, nurses can provide much better healthcare to refugees from Afghanistan.

References:

Chakraverty, D., Baumeister, A., Aldin, A., Jakob, T., Seven, Ü. S., Woopen, C., Skoetz, N., & Kalbe, E. (2020). Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany. International Journal of Environmental Research and Public Health, 17(7), 2189. https://doi.org/10.3390/ijerph17072189

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Medical Psychology | Neuropsychology and Gender Studies & Center for Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany

Research Unit Ethics, Faculty of Medicine and University Hospital of Cologne, and Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (CERES), University of Cologne, 50931 Cologne, Germany

Evidence-Based Internal Medicine, Department I of Internal Medicine and Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany

Author to whom correspondence should be addressed.

1. Introduction

Health care can broadly be defined as the entirety of measures and activities promoting the health of human beings on a community or individual level [ 1]. The opportunities for achieving optimal health vary between different groups of people, with structural and social determinants influencing access to health care services and interactions between patients and health care providers. In order to gain a deeper understanding of these interactions it is important to look at factors shaping health opportunities.

The terms sex and gender originally used to be synonyms, both applied to indicate whether a person was male or female [ 2]. After Simone de Beauvoir's seminal work The Second Sex in 1949 [ 3] the debate about the social constructiveness of being a man or woman led to the term gender now widely used for gender role. In contrast, the word sex usually serves for the biological distinction between male and female persons [ 4]. As of today, gender and queer theory has evolved far beyond the man-woman dichotomy [ 5, 6]. Still, it is important to look at differences between men and women as the social and societal roles associated with these genders are important factors regarding individual health. For example, men and women partly suffer from different diseases and deal with them in different ways, which demands gender-sensitive diagnostic and therapeutic techniques [ 7, 8]. This is even more so because gender also influences the way patients are diagnosed and treated by medical personnel [ 9]. Gender roles, gendered power relations, religious and cultural understandings of sexuality, and gender-specific access to educational resources can vary between the world's regions [ 10, 11, 12]. As the number of transnational migrants has risen to an estimated 258 million in 2017 [ 13], a growing number of persons with different understandings of gender encounter each other within the health care systems of the host countries.

In the recent history of Germany there have been several phases of intensive immigration, the most recent one concerning refugees mainly from Syria and Iraq in 2015 [ 14]. In the 1950s, massive numbers of workers from Italy, Greece and above all Turkey were recruited to work in the factories of the up-and-coming German industry [ 15]. Although it was planned that these workers would return to their home countries, many of them decided to stay in Germany with their families. As a statistical category, the term "persons with a migrant background" has subsequently become established as a term for people who themselves or at least one of their parents were born without German nationality. This accounts for around 25% of the German population [ 16].

In a recent representative study conducted in Germany, 54% of the German population indicated to have limited health literacy while with a migrant background it was 71% of persons. This is in line with international studies comparing migrant's health literacy with that of the general population [ 25]. Considering overall health literacy, correlations have been found between health literacy scores and gender [ 26, 27, 28, 29, 30]. However, the strength and the direction of the effects found in these studies are highly inconsistent and do not allow for a derivation of conclusive statements. It is still unclear how and in which direction gender aspects affect health literacy, especially in persons from culturally diverse backgrounds.

Within the health care systems, encounters of persons with a migrant background and HCPs typically take place in a treatment setting, with an HCP representing and acting on behalf of the health care systems of the receiving countries. HCPs work at the focal point of health literacy, where health information is obtained, understood, appraised and applied. Many of them interact with men and women of numerous different origins. The exploration of experiences from their everyday work has the potential to help in gaining a more profound understanding of how gender may affect health literacy in cross-cultural encounters in health care. There is a growing body of research on health literacy in the context of migration [ 31], and gender aspects in providing health care for migrants are slowly receiving attention [ 32]. However, relating the influence of gender-specific aspects of interactions between HCPs and migrants to the concrete steps of processing health information is a new approach which might help to comprehend the role of gender in this context.

It is important to note that this study cannot provide "objective" data on migrants and their health literacy. It can only offer the HCPs' subjective perspective on the health literacy of migrants derived from their interactions with them in the treatment setting.

This research is part of a an overarching project regarding Gender-Specific Health Literacy in Individuals with Migrant background (GLIM) which consists of systematic reviews [ 33, 34, 35] and a further qualitative analysis concerning organizational health literacy which is not within the scope of this study. The main objective of this study was to explore the views of health care professionals on how gender as a personal determinant of health literacy may affect their interactions with migrant patients. The interrelated challenges, needs, and applied solutions were analyzed from a health literacy perspective.

2. Materials and Methods

2.1. Focus Group Discussions (FGD)-Method and Ethical Clearance

For explorational research questions, the choice of qualitative methods is recommended [ 36]. An FGD is a qualitative method frequently used in health research and education as "a research technique that collects data through group interaction on a topic determined by the researcher" [ 37]. FGD can be used to obtain sufficient information within a short time to determine the participants' perspectives on a topic [ 38]. It is a moderated discussion procedure in which small groups are stimulated to discuss a given topic by means of an information input. Current studies show that with the implementation of two to three FGDs, usually at least 80% of the topics to be explored can be covered [ 39]. In this study, five FGD had to be conducted until saturation was reached with regard to the categorized responses. The study was approved by the Ethics Committee of the Medical Faculty of the University of Cologne (n 17-406).

2.2. Guideline Development

A guideline for the FGD was developed including the starting question and a set of probing questions for deepening topics or steering the conversation to aspects not yet mentioned in the respective discussion [ 40]. For the purpose of pretesting, two FGD were conducted with researchers from the department of Medical Psychology and CERES (Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health) of the University of Cologne. In these FGD, the guideline was tested for consistency and structure. After the pretests, the format including the guideline, moderation and setting (guideline, length of discussion, seating order) were discussed with the participating researchers.

2.3. Participant Recruitment

Participants were recruited via purposive and snowball sampling. At first, practices and institutions listed in the Health Guide for Migrants [ 41], provided by the city of Cologne, were contacted via email and telephone. The guide is an electronic document which includes a list of health care institutions (hospitals, pharmacies) and practices (medical doctors, physiotherapists, midwives etc.,) which offer multilingual services. Further participants were recruited through online search, professional contacts of the researchers, and by putting a call for participation on the intranet message boards of hospitals in Cologne and the surrounding area. We included participants with a degree or certificate in a health-related profession who had been working with patients with a migrant background on a regular basis for at least two years. HCPs signaling general interest in taking part in one of the FGD received further information about the study as well as a written consent form including a data protection agreement. The material was sent to those willing to participate by e-mail or in written form. To avoid uneasiness, participants sharing a hierarchical work relation or working in the same department did not take part in the same FGD. Additional participants were recruited until saturation was reached [ 42].

2.4. Implementation of the FGD

At the beginning of every FGD, the participants received information material for the study and a socio-demographic questionnaire containing questions about their gender, migrant background and occupation. They were given sufficient time to read the material before signing the informed consent. Three researchers were present throughout the discussions with one being the moderator while the other two researchers posed additional probing questions in case they felt the need to dive deeper into a topic. A research assistant wrote a protocol in order to simplify the assignment of statements to the participants when transcribing the audio recordings. Two audio recording devices were used to avoid data loss.

The researchers introduced themselves and shortly explained the study purposes. The stimulus was set by introducing the concept of health literacy verbally and visually (in a poster format), the project-specific definition of a migrant background and gender as a personal determinant of health literacy. Following this, conversation recommendations were announced by the moderator including the request not to interrupt other participants and to treat everything said in the FGD as confidential. The participants were encouraged to elaborate on their own experiences, may whether they were in line with those of the other participants or not. The audio recordings were started before the participants introduced themselves, shortly describing the context in which they usually interacted with persons with a migrant background on a professional basis. After the introductions, the moderator invited the participants to share their experiences as follows: "Well, you all work in a health care context with women and men who have a migrant background. Please take three minutes time to remember concrete situations from your day-to-day work, for example a treatment situation with the persons themselves or with their relatives, that was very typical or maybe even special and which you still have vivid memories of - regardless of whether it was solved satisfactorily. You are also welcome to take notes on this." After three minutes, the discussion was opened by the moderator. Probing questions were set to examine the needs and applied solutions that arose from the situations described (e.g., "How satisfied were you with the outcome of the situation?" or "What did you miss in this situation and what would you have needed to meet the challenge?"). If situations were described that only affected one gender, the HCPs were asked to talk about similar situations with other genders involved ("Does anyone else in this group have experiences regarding this kind of situation when treating male/female patients?"). If gender-specific aspects were not mentioned during the discussions, additional probing questions were posed to gently encourage the participants to consider potentially relevant gender aspects (e.g., "What role did your own gender play in this situation?").

Every FGD reached the maximum of 120 min. At the end of each FGD, participants were asked for their opinion regarding the discussion, its format and what they felt needed improving. They were offered to receive information about the results. Participants received a reimbursement of 25 €.

2.5. Data Analysis

The audio records were transcribed verbatim. A qualitative data analysis software MAXQDA [ 43] was used to analyze the transcripts in the German language. Quotes displayed throughout this manuscript were translated and back-translated by a researcher fluent in English.

Following the recommendations for qualitative content analysis according to Kuckartz [ 44], a combination of deductive application of categories and inductive development of categories was performed by the involvement of two researchers (D.C. and A.B.). First, three main categories were deductively derived from the research question including perceived Challenges, Needs and Applied Solutions related to the treatment and care of people with a migrant background. In a second step, according to the guiding framework [ 24], additional deductive categories were applied including the four steps of health information processing Access, Understand, Appraise and Apply health information and subordinated to each of the three main categories to ensure that all inductively evolving subcategories related to health literacy could be identified. Inductive subcategories that were considered to be directly or indirectly related to Gender as a personal determinant of health literacy were exclusively derived from the data. Other inductive subcategories that arose from the text were subordinated to the three main categories Challenges, Needs, and Applied Solutions whenever possible without a considerable loss of information.

2.6. Reliability and Validity

Two researchers (D.C. and A.B.) independently coded the first FGD transcript, each researcher building inductive categories and subcategories of the deductive categories. In a second step, the two category systems were integrated into one. The two coding researchers then independently coded each of the remaining four FGD transcripts based on the preliminary category system, again reconciling and reflecting on the deductively and inductively derived main- and subcategories after a phase of independent coding. All potential discrepancies were resolved by consulting the mediating researcher (A.A.), who was highly involved in the whole research process. This research followed The Consolidated Criteria for Reporting Qualitative Studies [ 45].

3. Results

Between January 2018 and May 2019 we conducted five FGD with n = 31 participants at CERES. An overview of the characteristics of the participants is presented in Table 1.

The classification of the statements in this scheme shows which processing steps of health literacy were primarily influenced by gender. This could occur in two ways: (a) as a direct influence, described by gender subcategories or (b) as an indirect influence, which is represented by general subcategories. An overview of the most important categories is shown in Table 2.

3.1. Narrative Elements Used by the HCP

3.1.1. Specific Situations, Generalizations and Possible Biases

The statements of the HCP often related to specific situations that were meant to act as examples for challenges, needs and applied solutions when interacting with migrants. This must be seen with the caveat that the selection and description of these situations may give a biased picture of the interaction with migrants, as stereotypes about migrants are very common in the general population, including HCPs [ 46]. When a phenomenon was perceived to occur frequently, the HCP talked about it in a more general way. Generalizations, especially about minority groups, are particularly prone to be stereotypical. As stereotypes can be internalized by members of the stereotyped group as well [ 47], this reservation accounts for the statements of all HCPs including those who themselves were first or second generation migrants. Therefore, the statements should be regarded as subjective and selective narratives.

3.1.2. Migrant Generations and Countries of Origin

While the research question was set out to explore the experiences of HCPs in the interaction with both first- and second-generation migrants, the HCPs reported almost exclusively on their experiences with first-generation migrants. Apart from very few exceptions, the second-generation migrants were not mentioned as patients, but rather in the treatment situation where they supported their parents during the visits to and the interaction with the HCPs. Hence, gender aspects in the interaction with second-generation were also rarely addressed or mentioned. Therefore, the term migrants is used in the following section of this paper to address first-generation persons with a migrant background. The HCPs did not always specify the countries of origin of their patients. The countries that were mentioned most often were, first and foremost, Turkey, followed by countries from the Arab regions. Patients' affiliations with the Islamic faith were also frequently mentioned. Only very few statements concerned gender aspects in the interaction with people from other religious or regional backgrounds.

3.2. Challenges

Most statements addressed challenges. Within this main category, gendered issues affecting access to the treatment or care situation were most prominent, followed by more general challenges regarding the understanding of health-related information. No statements related primarily to the influence of gender on the processing step of applying health information.

3.2.2. Gender-Specific Challenges Regarding the Understanding of Health Information

3.3. Needs

The HCPs reported their needs for solving gender-related issues within the health care setting almost exclusively on a general level addressing the understanding of health information. These needs were not limited to interactions with migrants of specific regions of origin or religions.

3.4. Solutions

The applied solutions described were related to general issues concerning the interaction with migrants as well as to challenges that had a gender-specific aspect to them. Similar to the challenges stated by the HCP, the statements related to the processing steps access, understand and appraise.

3.4.1. General Solutions Regarding the Processing Step of Understanding Health Information

Cultural and Language Mediators/Interpreters

We currently have a mentally ill pregnant woman, and we thought all the time, she is not allowed to go out and she is so mentally impaired that she does not go out alone, but then [it occurred] in a conversation that she does not know it from home, that they live in such a group of houses, inside is a yard, where the women meet, where the women move, but outside this yard, they don't go anywhere and so she can't find her doctor and doesn't come to any psychologist and we had thought the whole time, the man doesn't want that and then we had a video interpreter with us and then it came out that the man is actually completely open and just his wife isn't used to going any ways alone.

- Physician (female, ≥55 years)

3.4.2. Gender-Specific Solutions Regarding Access to Health Information

3.4.3. Gender-Specific Solutions Regarding the Appraisal of Health Information

4. Discussion

This qualitative study explored the perceptions of health care professionals of gender aspects of their interactions with migrants mainly from Turkey and Arab countries. The interrelated challenges, needs and applied solutions were analyzed from a health literacy perspective. By relating the statements of HCP to the processing steps of health literacy, gender-specific challenges could be identified primarily regarding the access to health care and the appraisal of health-related information. Described needs and applied solutions mainly concerned mutual understanding between HCP and migrants.

Most of the statements concerned challenges the HCP experienced when dealing with persons with a migrant background. Three main gender-specific challenges related to the access to health information emerged from these statements: Husbands as gatekeepers regulating access of their wives to health care, the gender of HCP as a factor that could keep migrant women from receiving treatment or care from male HCPs, and shame in the health care situation hindering proper examination especially of Muslim women. The HCP rarely tried to provide explanations for such situations. Even though such situations seemed to occur mainly in the interaction with patients who were identified as Muslims by the HCP, they did not speculate on the exact role of religion in these cases. This may illustrate a lack of knowledge about Islam on part of some HCPs, but it was also the case for HCPs of Arab or Turkish origin who were more familiar with this religion than their colleagues. From the HCPs' statements, it seemed that religion was usually not addressed directly in the treatment situation. Thus, many relevant aspects remained unclear, such as whether the patient was indeed a Muslim, what Islamic subgroup he or she belonged to or how important religion was to the patient. With gender equity being comparably low in most predominantly Islamic countries [ 48], relating gender aspects in the interaction with migrants to their religion may be tempting but probably a premature conclusion. For example, regulating the gender relations is not exclusive to Islam but can be found in many religions including Christianity, usually putting men in the more powerful position [ 49]. In a highly secular country as Germany, some observations of gender aspects might be misunderstood as specific to persons of Islamic faith while they may rather be connected to religiosity in general. The understanding of health as an individual matter, as it prevails in Germany, is not shared in many countries, especially not in Islamic regions, where the health of a person is often perceived as a family affair [ 50]. Thus, Muslim husbands may feel responsible for the health of their wives in a more pronounced way than non-Muslims [ 51]. Also, mistrust in authorities was sometimes mentioned by the HCP regarding migrants from countries with authoritarian political systems. This might also play a role in the protective behavior observed in some migrant husbands. There is some evidence for the importance of gender concordance with the HCP for women of Islamic faith in general [ 52] and for Turkish women in Germany [ 53] as well as for a restraint in Muslim women concerning nudity [ 54, 55]. Again, the HCPs did not elaborate on how religion might influence the women's perceived preferences. These categories describe that cultural differences in the personal determinant of gender were observed to primarily influence access to health care and health-related information. They also show that gender may be a personal determinant, but its impact on health literacy within the health care situation depends on the genders of all persons involved and on their respective interpretations and expectations regarding gender roles. These findings underline the social and relational character of health literacy.

The general subcategory Systemic lack of time describes a phenomenon well known in health care [ 56, 57]. On average, primary care consultations in Germany last only 7.6 min; in a current systematic review, this was found to be one of the shortest durations among Western industrial nations [ 58]. Systemic lack of time can be interpreted as an omnipresent stressor concerning all actors within health care, with particular effect on the interactions with migrant patients. Research in social psychology has shown that people resort to stereotypes under time pressure [ 59]; this might have influenced the HCPs' perceptions and descriptions of the interactions with migrant patients as well. With systemic lack of time as a backdrop, the second general challenges subcategory regarding the understanding of health-related information directly relates to a migration-specific issue: Language barriers. If communication was impaired due to language barriers, examinations and treatments were perceived to be compromised. This is in line with research demonstrating language barriers to be a serious disadvantage for migrants trying to obtain health care [ 60, 61, 62, 63]. Time pressure seems to have an even stronger impact when it comes to dealing with patients who need more time due to the necessity of overcoming language barriers. This impact is further reinforced by gender-specific aspects of language barriers. The comparably low level of German proficiency within the group of elderly Turkish women has already been documented by researchers in Germany [ 64]. Additionally, the HCPs reported a high prevalence of depressive symptoms combined with a rather dismissive attitude towards psychotherapy within this group. This corresponds to current research which identified first generation migrant women from Turkey as especially vulnerable for depressive disorders [ 65] and skepticism towards psychotherapy to be more common in first- and second-generation migrants from Turkey than in the general population [ 66]. This connects to further gender-specific challenges which could be identified regarding the processing step of appraising health information. Although skepticism towards psychotherapy is generally known to be more common in men than in women [ 67, 68], the HCPs mentioned it especially regarding men from Turkey and Arabia. Some saw a part of these men to favor a more traditional interpretation of masculinity, which has been found to be common for example in Turkey [ 69], and which is connected to a tendency to reject psychotherapy [ 70]. On the other hand, the availability of insurance-covered psychotherapy is special to Germany [ 71] and not common in Turkey [ 72]; unfamiliarity with the method may contribute to the skepticism against it. The importance of motherhood the HCPs observed in migrant women was regarded as a minor challenge, illustrating how persons from different cultures may evaluate the same piece of health information differently based on the relevance it has to their lives. In Germany, voluntary childlessness is much more common than in other countries [ 73], so that the significance of motherhood for migrant women could be an indication of the special situation in Germany rather than a particular feature of migrant women.

Gender aspects seem to act as a reinforcing factor for the general time problem within health care in Germany. In the case of migrants, overcoming language barriers takes time. If these barriers are higher, for example due to gender-specific reasons as in the case of the elderly Turkish women, communication takes even more time. In case it is necessary for these patients to undress in the health care setting, shame may additionally slow down the process. If the HCP is a male person, shame may play an even more important role and can stall the process even further. These phenomena were mostly seen in specific subpopulations, and we may not be able to understand them without considering cultural and religious aspects that should be analyzed in further research.

The HCPs also reported on applied solutions to solve the challenges they had elaborated on. Regarding access to health care, the gender-specific solution of covering parts of the body to mitigate shame of Muslim women was seen as a feasible, albeit cumbersome solution. As a general solution for addressing the processing step of understanding, some had already worked with cultural and language mediators/ interpreters, most of them reporting positive results, which is in line with studies focusing on the effectiveness of interpreter services [ 79, 80, 81]. Although being a general solution, this could also help with gender-specific aspects of language barriers. Regarding the processing step of appraisal, the gender-specific solution women as pioneers for the acceptance of psychotherapy seems especially remarkable in several ways, as it is (a) a solution coming from the migrants themselves and (b) an example for the (self-) empowerment of women being advantageous to men as well.

The three concepts gender, migrant background and health literacy can be understood very differently [ 82, 83, 84]. Within the FGD, participants addressed gender using the man-woman dichotomy with a strong emphasis on gender roles. The usage of the term migrant background was slightly different from the definition introduced by the moderators, because the participants usually referred to first generation migrants (as opposed to first- and second-generation migrants). In some respects it can be justified to examine the diversity of migrants in Germany as a group instead of focusing on certain subgroups. This is the case when it comes to phenomena associated with transnational migration in general, such as the need to find orientation in an unfamiliar health care system or to communicate in a new language. Looking at migrants in general can also reveal aspects that are special to the host countries instead of ascribing differences between migrants and non-migrants to culture, religion or other attributes of a certain migrant group. In contrast, the term migrant background, which is very common in German administration and research, covers people with and without a direct migration experience and is therefore known to be a controversial concept [ 85]. As the HCPs in the FGD used it almost exclusively for first generation migrants, the term seems dispensable at least for the purpose of this study. Furthermore, the HCPs often focused on patients of Turkish or Arabic descent. Most migrants living in Germany are of Turkish origin, and refugees from Syria and Iraq came to Germany in large numbers in recent years [ 86]. Although there are more people of Polish origin in Cologne than there are people of Iraqi, Syrian, Algerian, Moroccan, Libyan and Lebanese origin combined [ 87], not a single statement referred to persons of Polish origin. Migrants from Russia were only mentioned in connection with female health care representatives feeling rejected by male patients. It may be the case that the HCPs had only few encounters with patients of Polish origin, but this may also pose the question who is regarded as having a migrant background at all [ 88]. Additionally, only one of the HCPs was of Eastern European origin, but eight HCPs had roots in Turkey and Arab countries and reported to dealing with many patients from these regions, which may have contributed to focusing on these migrant groups during the FGD. Unsurprisingly, the term health literacy was rarely mentioned literally. Health literacy is a very broad concept; in real-life situations its determinants and processing steps may be observed rather than health literacy as a whole.

By mapping real-life situations from the perspectives of HCPs to the integrated model of health literacy by Sørensen et al. [ 24], our research contributes to a deeper understanding of cross-cultural health care situations. Our findings suggest that challenges regarding the appraisal of health-related information may be connected to needs and solutions directed at a different processing step, namely understanding. To our knowledge, this is the first study exploring gender-specific aspects of health literacy of migrants from the perspective of HCP. A specific strength of our research lies in the application of the health literacy model by Sørensen et al. [ 24] to qualitative data with a concrete assignment of statements to the respective steps of health information processing. As far as we know, this has not yet been explored and can help to understand the complex relationships between systemic factors and gender aspects in the context of migration. Furthermore, our findings contribute to the further development of the concept of health literacy by (a) emphasizing the social-relational character of health literacy and (b) describing its processing steps as iterative rather than sequential elements. Another advantage of this research lies in the composition of the FGD. The participants were HCP from different professions, covering a wide range of ages and including first- and second-generation migrants as well as non-migrants.

There are several limitations to this study. First, it might be the case that the research question provoked generalizations about the diverse group of migrants. Asking the participants to refer to specific situations was aimed at preventing this. This may not have worked in every case, as relating to specific situations can mislead in regarding them as typical or representative for the migrant group mentioned. Second, the observations reported in this study may evoke stereotypes about persons of Islamic faith, a matter we intensely discussed within the research team. Although the participants of the FGD spoke with great empathy for migrants and more than 50% of them were first or second generation migrants themselves, it cannot be ruled out that stereotypes about persons of Islamic faith, for example about male Muslims [ 92, 93] shaped some of their statements as well. With anti-immigration and anti-Islamic movements rising all over Europe [ 94, 95], this is a delicate ethical matter, especially for researchers positioning themselves as favoring openness and equity. It is crucial not to see possible biases in their perceptions as personal deficits of the HCP. Stereotypes belong to the cognitive toolbox of all persons [ 96]. Overcoming them is especially difficult when acting under time pressure as it is the case in health care. The HCPs reported situations in which migrant women experienced serious health care disadvantages the HCP related to gender roles. We think these findings are important and should be reported. There may be situations that demand that HCPs act against perceived gender taboos in order to ensure adequate health care, especially for women, and there may be cases when doing so would do more harm than good. These difficult decisions have to be made by the HCP in every single case, and they clearly stated they need support in doing so. They strongly called for measures to improve mutual understanding with migrants. This indicates that they saw incomprehension and misunderstandings on both sides as the main causes of the challenges they perceived in interacting with migrants. Third, qualitative research is not aimed at representativeness [ 97]. This is also true for this study, as neither the participants are a representative selection of HCPs, nor the situations they described can be considered representative for the interaction with migrants. In most cases, gender-specific observations made by the HCP were limited to migrants from Turkey and Arab countries. Finally, it has to be mentioned that the FGD were held in the German language and translated into English. That may lead to a loss of information and/or bias in the meaning of the translated statements as they are presented in this manuscript.

Exploring the challenges, needs and applied solutions with regard to achieving optimal health care within different subpopulations of migrant men and women by letting them state their own perspective was outside the scope of this project. From our view, this would be the logical next step for further research in order to gain a more complete picture about gender-related aspects of health literacy in interactions with migrant patients.

5. Conclusions

Our research provides insights into the special role of gender in health literacy as perceived by HCPs when interacting with migrant patients mainly from Turkey and Arab countries. These results only represent the possibly biased or assumption-based perspectives of health care professionals on their migrant patients. From the HCPs' point of view, gender-specific challenges can result in consequences for the way in which health-related information is accessed, understood, and appraised in cross-cultural health care situations. It also shows that meeting these challenges by reducing time pressure and providing resources for improving communication may help HCPs to better understand the individual needs of their patients and prevent them from using heuristics that can be associated with stereotyping. This may be to the benefit of all actors within the health care sector-HCPs as well as persons of all genders and countries of origin. The results of our study can sensitize HCPs and policy makers to gender-specific challenges in the cross-cultural health care settings and show possible starting points for their solutions, especially at the level of mutual understanding of HCPs and migrants. Further research should focus on the perspective of the migrants themselves, considering the specific situations of different groups from different countries of origin.

Chakraverty D, Baumeister A, Aldin A, Jakob T, Seven ÜS, Woopen C, Skoetz N, Kalbe E. Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany. International Journal of Environmental Research and Public Health. 2020; 17(7):2189. https://doi.org/10.3390/ijerph17072189

Chicago/Turabian Style

Chakraverty, Digo, Annika Baumeister, Angela Aldin, Tina Jakob, Ümran Sema Seven, Christiane Woopen, Nicole Skoetz, and Elke Kalbe. 2020. "Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany" International Journal of Environmental Research and Public Health 17, no. 7: 2189. https://doi.org/10.3390/ijerph17072189

# data[].attributes.attachment_link.title
Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany

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Health literacy can be described as a complex process shaped by individual resources and preferences and by the nature and quality of health-related information people encounter. The main objective of this study was to explore the views of health care professionals on how gender as a personal determinant of health literacy affected their interactions with migrant patients.

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AFGHANI REFUGEES PRINCIPAL HEALTH ISSUES:

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AFGHANI REFUGEES PRINCIPAL HEALTH ISSUES:

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In Australia, refugees from Afghanistan face various health issues, like diabetes, mental health disorders, and because of differences in culture accessing the healthcare becomes quite harder for them. Most of them are suffering from some sort of trauma. The National Multicultural Health Policy in Australia emphasize on tackling the disparities in health for migrants, improve health literacy, and provision of care that is culturally competent(FECCA,2021). When the nurses in Australia understand these unique needs, they will be able to provide care to the Afghan people in a more competent way.

Reference:

The Federation of Ethnic Communities’ Councils of Australia, Chand, M., & Geronimo, M. A. (n.d.). Health and wellbeing in multicultural Australia. In Submission to the Multicultural Framework Review.https://www.homeaffairs.gov.au/reports-and-pubs/PDFs/multicultural-framework-review-public-anonymous-submissions/a-c/australian-multicultural-health-collaborative.PDF

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Because of its shared cultural heritage, Afghanistan's cuisine is inspired by Persian, Central Asian, and Indian cuisines. The food is halal and mostly consists of rice and Afghan bread paired with mutton, beef, chicken, and fish. Common vegetables, dairy products (milk, yogurt, whey, etc.) and dried and fresh fruits (apples, apricots, grapes, bananas, oranges, plums, pomegranates, sweet melons, raisins) go well with these. The majority of Afghans eat  rice dishes, usually served with some kind of naan. Tea is a fundamental component of hospitality and is typically eaten in considerable quantities every day. The nation's diverse ethnic and geographic makeup is reflected in its culinary delicacies(Wikipedia contributors, 2024b).

Reference:

Wikipedia contributors. (2024, August 11). Afghan cuisine. Wikipedia. https://en.wikipedia.org/wiki/Afghan_cuisine

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My main aim is to identify and tackle the distinctive disparities in health faced by migrants and refugees from Afghan culture as a nurse practitioner according to domain 1 (Clinical Expert)(Migrant & Refugee Women's Health Partnership, 2019). From this domain, the competency focused is 1.3 that emphasize on the importance of understanding ethno-specific variations. It has been acknowledged by me that Afghani people face various challenges from the health perspective that are related to socio-economic, linguistic, and cultural factors. That is why my goal is to deliver clinically and culturally appropriate care(Munnings et al., 2019b).

Reference:

Munnings, K., Laidler, L., Ramsay Health Care Australia, O’Donovan, K., Patetsos, M., Federation of Ethnic Communities’ Councils of Australia, Phillips, C., Philp, A., Australian Government Department of Health, Schreiber, J., Sdrinis, S., Ward, K., Wright, M., Australian College of Nursing, Abbasova, G., & Sarafian, C. (2019). Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds. In L. Martinez & O. Dandash (Eds.), COMPETENCY STANDARDS FRAMEWORK FOR CLINICIANS. https://culturaldiversityhealth.org.au/wp-content/uploads/2019/02/Culturally-responsive-clinical-practice-Working-with-people-from-migrant-and-refugee-backgrounds-Jan2019.pdf