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
]. 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
]. 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
]. 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
From a gender perspective, the interaction between migrants and the representatives of health care systems (e.g., health care providers) can be a challenging task for both sides. The gender of patients and physicians has been shown to influence doctor-patient interaction [17
], and cross-cultural interactions have been described as demanding by patients and health care professionals (HCPs) [20
]. The exchange of health-related information is a central aspect of the treatment situation [21
]. In this regard, the ability to handle health-related information is an important factor—an ability neatly tied to the concept of health literacy.
Health literacy, a term first coined in the 1970s [22
], has since been defined in numerous ways [23
]. In 2012, Sørensen et al., proposed an integrated conceptual model of health literacy, reconciling 17 definitions and 12 models of health literacy [24
]. Drawing on this integrated model, health literacy is defined as “the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively” [24
]. Importantly, the model describes health literacy as a social-relational concept with societal, environmental, situational and personal determinants influencing a person’s health literacy. Gender can be understood (and is described by Sørensen et al.,) as a personal determinant for health literacy [24
] with numerous societal, environmental and situational connotations that go far beyond biological sex differences. Migration can also be integrated into the model in several ways: Having a migrant background as a personal determinant, the migration process as a situational factor, both also connecting to societal and environmental aspects that may differ between host countries.
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
]. 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
] 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.
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
]. 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
]. 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
]. 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
], 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 HCP did not report on the needs for specifically solving gender-specific challenges. Instead, they almost unanimously addressed the needs for more time and for cultural and language mediators/interpreters. This suggests that the HCP see the processing step of understanding health-related information as the key health literacy element in the context of migration. Importantly, in most cases understanding was described as a mutual process—understanding the patient as well as making oneself understood by the patient. Meeting the need for more time may be to the benefit of migrant patients and to that of the whole population; doctors giving more time to the individuals instead of doing “five minutes of medicine”, as one physician put it in an FGD, would serve the HCP as well as the patients [74
]. The shortage of HCPs in Germany is a widely discussed situation [76
] which still does not seem to improve substantially [78
]. Our research is in line with these observations. In the context of ongoing migration, the effects of this problem are particularly evident.
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
]. 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
]. 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.
Regarding the health literacy model by Sørensen et al. [24
] the allocation of statements to the processing steps was never a clear-cut decision, as these steps may overlap and interact. Our study partly questions the sequential nature of accessing, understanding, appraising and applying health-related information as proposed by Sørensen et al. [24
]. From the perspective of the HCP, the negative appraisal of psychotherapy especially by migrant men prevented them from accessing information about this way of treatment. This is consistent with psychological research, which has shown the interrelatedness of perception and appraisal on multiple occasions [89
]. Mutual understanding, improved by involving an interpreter, can eliminate false assumptions as in the case of the erroneously assumed role of a husband as a gatekeeper (see 3.2.1). This case also shows that understanding can also enable access. Furthermore, the health literacy of the HCP interacted with that of their migrant patients. A good example for this interaction is the processing step of understanding health information: By far the most statements in this regard were directed at reciprocal understanding. The ability to understand the patients and the ability of the patients to understand the HCP are mutually dependent. This emphasizes the social-relational nature of health literacy as well as its process character that already has been called “doing health literacy” [91
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
] shaped some of their statements as well. With anti-immigration and anti-Islamic movements rising all over Europe [94
], 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.