Health workers and Sub Saharan African women’s understanding of equal access to healthcare in Norway

This article describes and analyzes conceptions of equal access to healthcare by health workers and Sub Saharan African women living in Norway. The main objective of the study was to find out if there is equal access to healthcare as understood by both the provider and receiver side of healthcare. The two sides have different positions from where to observe and judge the services given, which can give a broader understanding of the healthcare system. Do Sub Saharan African women find healthcare services unjust and discriminating? Do health workers share conceptions of access held by these women? This study used a qualitative fieldwork research design. One hundred interviews were done with health workers and 55 interviews were done with Somali, Gambian and Eritrean women who all had experienced female genital mutilation/cutting (FGM/C). The study found a mismatch in the conceptions of access to healthcare between health workers and the women. Health workers did not believe there was equal access to healthcare and were critical of how the system functioned, whereas the women trusted the system and believed there was equal access. However, both sides had corresponding views on the following challenges facing the healthcare system: little time available to identify symptoms, difficulties in navigating the system, difficulties in getting referrals, and some negative adjudication by some health workers. Bourdieu’s concepts of field, habitus and hysteresis, and candidacy theory were used to analyze the collected data. It was concluded that health workers and the women based their experiences of healthcare on differing cultural frames and expectations. The women seemed to base their assessments of healthcare on previous experiences from their home country, while health workers based their understanding from experiences within the system.

Dear Editor in PLOS ONE.

January 2021
Earlier this year I submitted an article that was published in your journal: Lien/Hertzberg: A system analyses of the mental health services in Norway and its availability to women with female genital mutilation. It was publish the 4 th of November 2020: https://doi.org/10.1371/journal.pone.0241194 In addition, I have written a new article describing how health workers and SSA-women in Norway understand equal access to health care. This article I will submit today is a follow up on the previous article. It contains information about equal access from both sides: the supply and the demand side of health care. Pierre Bourdieu's theory of practice is used to understand the mismatch and gaps that was found in the assessments of access between the two sides. Candidacy theory is also used at the lower level to understand what is implied within the dimensions described in this theory of candidacy as a joint negotiation of health care.
The article has 8937 words I hope your journal will find the article interesting and thereby will be willing to publish it.
I have suggested several reviewers for this paper.
Best regards from Inger-Lise Lien shown that a general lack of trust in a society can impact the use of healthcare [6,7], thereby other hand, studies also show differences in the use of emergency services (ER) and the GP [9].

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Immigrants from Somalia use ER services more often than Ethiopean, Eritrean and Gambian 87 immigrants [9,10,11]. Naess [12] argue that there is a lack of trust among the Somalis and argue 88 that "cramped timeslots and a cut-to the case attitude among doctors" can be a poor foundation 89 for trust", thereby placing reasons for distrust into the way that the services are organized.

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This study found a split in attitudes between health care workers and the SSA-women 91 that will be presented and analyzed in this article. At the practical level, however, there were 92 agreements between the two parts about the functioning of the system. There were match and 93 mismatch in the attitudes that require appropriate theoretical analytical tools in order to be needs and vertical equity that requires that individuals with different needs receive different 117 amounts and levels of services.

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In a study from Italy, Glorioso and Subramanian [18] found inequity in health service 119 utilization even though the country practices universal and egalitarian healthcare in principle.

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There was a significant amount of pro-rich inequity in the utilization of specialist services, but 121 the use of primary care was found to be inequitable in favor of the less wealthy. Glorioso and 122 Subramanian [18] argue that the benefits of prevention and early diagnosis are unequally 123 distributed in favor of the wealthy. When health status is perceived as good, poorer groups tend 124 to hold back their use of expensive or inefficient health services; that is, they limit their use of 125 preventive care and postpone their access to curative care, creating the conditions for future 126 worsening of their health status.

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There are two sides to equal access of healthcare, namely a supply side and a demand 128 side, and access to healthcare has mostly been studied from the supply side [17]. Ruger [19] 129 focuses on the barriers that may reduce equal access to healthcare and chose a health capability 130 perspective that focuses on users' resources. He argues that user groups must increase their 131 knowledge so they can profit from the healthcare system. This way of thinking has been 132 strengthened by others who are concerned with empowerment strategies and the degree of fit 133 between the demand and supply sides. 134 Macintyre et al. [20] are concerned with the need for a systemic analysis that can 135 inform policymakers about the "fit" between needs for healthcare and the receipt of healthcare.

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Within this connection, the researchers argue for several dimensions of healthcare, such as 137 availability, affordability, and acceptability: are taken into account" [20:190]. This focus on "fit" and "gaps" between the provider and the 141 receiver has led to an increasing interest in more closely examining the receiver side of 142 healthcare, not only individually, but also from cultural and symbolic angles. shows that there is an asymmetry in power and an enforcement of dominant values onto service 173 users. They also found a rich experience of barriers to accessing and negotiating medical health 174 services for their patient group, and the greatest problem during negotiation was language.

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Koehn [24] used the candidacy framework in a study of ethnic minority seniors' access to 176 healthcare in Canada. According to Koehn, the first six dimensions in the theory deal with 177 negotiation, but she argues that the seventh dimension represents the environmental context in 178 which the negotiation occurs; thus, this dimension lies outside of negotiation [24].

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The habitus concept has been criticized for being deterministic, and not sufficiently  do not receive it. They argued that the medical system is hierarchical and bureaucratic and meets 290 clients on its own terms rather than on those of the patient. The system is to blame for being rigid 291 and not giving patients enough time, competence, and understanding. Some participants said that workers' "ideas about SSA-women's habitus".

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The morality within the biomedical habitus of health workers seems to be based on a human 325 rights conception, and health workers often complained that SSA-women did not know their 326 human rights and therefore did not claim their rights. underestimation, stigma and rejection as interpreted by the health workers themselves, and when 339 it comes to permeability there is resistance towards referrals of these women in the system.

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When health workers discuss the substantive content of the navigation dimension of the SSA-341 women's habitus, they fill it with weak system competence, incorrect use of the system, weak 342 networks and not knowing their rights so that they can make adequate health care claims. This

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indicates that the health workers can assess the hysteresis that Bourdieu has described, when 344 16 there is a mismatch between the habitus and the requirements of the field. The overall conclusion 345 of the health workers is that there is not equal access to healthcare because of these system 346 factors, the mismatch between health workers' ways of thinking, and the SSA-women's ways of 347 acting and thinking -their habitus.

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As an example of how good the Norwegian healthcare system is and how generous the 358 GPs are, a Gambian woman explained that when she divorced her husband, the GP even came to 359 her home, talked with her for a long time, and helped her to apply for social security money, and 360 she got sick leave for many weeks. She said that she loved the GP. Others said, "The Norwegian

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There was a general attitude among the Eritrean, Gambian, and Somali women that they 384 found the health system to be fair and good. This goes for all the three ethnic groups. However, 385 they found that doctors were sometimes insecure about their own competence, consulted with 386 books or the internet, and asked the patients questions, so the patients thought the doctors did not 387 have sufficient knowledge. The women's understanding and assessment of the healthcare 388 system also seem to be based on the fact that they compared the system in Norway not against 389 ideologically based principles about rights grounded in policy documents and moral principles, 390 but rather against the system in their original homeland, and they all concluded that the 391 Norwegian system is better. In this way their biomedical habitusbased in the home country, is 392 used as a baseline to assess the biomedical system in Norway. The women do not prefer the

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(S2 Table 2) 404 Among the most mentioned complaints is that the women are not understood when it 405 comes to FGM/C and that FGM/C is not mentioned. "The experience with the healthcare system 406 has been good but lacking in regards to conversations around FGM/C. It seems as a taboo here as   Out of 53 women who discussed their pain during the interviews, 36 women said that 432 they suffer from pain and illnesses. The pains are often around the reproductive area as well as in 433 the legs, back, and stomach. Eleven women suffered from pain that had received a diagnosis.

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Twenty-five women said that they suffered from pain that was undiagnosed and unexplained by

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The Somalis also seek healthcare within their religion, and they distinguished between 468 going to the imam, a religious healer, and then going to an Islamic conference outside the 469 country. Different imams and/or healers are believed to have more ability to cure than others. when they feel that the biomedical system does not provide a sufficient cure when they have pain 484 and when they are not referred further.

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According to Kleinman [36], physicians have a narrow focus on diagnosis and treatment 486 (disease), which leads them to exclude the patient's experience (illness) from their consideration. The SSA-women have an external position from which they seek access to the system. At 513 the principal level, the SSA-women seem to trust the overall system when it comes to its will to 514 diagnose, refer, treat, and care for their health. They seem not to have an expectation based on 515 the formulation of rights from where they measure their achievements to healthcare, making 516 them disappointed with what they receive. In fact, they seem to think that the system and the  The hysteresis apparent in the conceptions of equal access to healthcare between the two sides 546 has mostly been analyzed in terms of Bourdieu's concepts of habitus and field. In addition,

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Dixon Woods' theory of candidacy has been presented in which she uses "joint negotiation" to 548 explain the driving forces of access to healthcare. issues at the table in order to obtain and negotiate their aim in rational and argumentative ways.

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In the candidacy theory the negotiation process includes events and happenings, which took 554 place long before the first meeting with health professionals. In this way, the concept of 555 negotiation transgresses into the reality of the habitus of the patient groups, on the supply side.

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By doing so, it touches upon very relevant factors within the habitus, but without being able to 557 frame it analytically through a coherent structure of internalized codes, understandings, and 558 values obtained both consciously and unconsciously within a long socialization process. These 559 frames, in this study called "habitus" can be diverse due to the different people and fields, and groups, but to a lesser degree frame a coherent habitus.

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Through the use of the negotiation conception with all seven elements included, the 564 importance of the demand side in order to get access seems to outweigh the importance of the 565 supply side. In reality, it is the adjudication done by the health workers that in the end provides 566 the ultimate power to define the tipping points for the candidates' entry. This is what interviews 567 with health workers in our study stressed. These workers have been aware of their power as well 568 as the SSA-women's lack of power and knowledge about rights. In the candidacy theory, the 569 blame for unequal access to healthcare is to a great extent put on the demand side even though 570 responsibility is theoretically thought to lie in the middle as a "joint negotiation." access; thereby, they may also be able to observe the hysteresis that exists between different 578 habitus and the habitus of the medical field. This observation is based from within and is a 579 benefit for assessing equal access to healthcare that the patients who try to obtain access do not 580 necessarily have.

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In recent years there has been a development in the medical sector away from paternalism 582 towards a more democratic healthcare approach. There is an expectation that most patients have 583 a high level of education and knowledge about health issues-so much so that they are welcome 584 to have a say when it comes to medication and healthcare.

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Complaints from the SSA-women directed towards the health care system has dealt with 586 structural and organizational matters. In addition SSA-women have focused on the lack of 587 competence when it comes to FGM/C. Many of them suffer from unexplained pain that needs to 588 be cured. Not only should SSA-women get an offer for reproductive and sexual counselling, but 589 they should also get an offer for pain management and treatment.

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In a situation where new patient groups have less schooling and scientific knowledge 591 about health issues and less knowledge about the system and their rights, the biomedical field is, 592 to a greater extent than before, in the way it is organized and functions, in hysteresis with the