Introduction

Worldwide, Indigenous and ethnic minority women encounter disparities in their exposure to social determinants of health, as well as access to high quality healthcare [1,2]. While these distinct groups are highly diverse (i.e., language, culture, migration status, origin, etc.), they share common challenges such as higher levels of poverty, lack of access to social services, gaps in social protection coverage and higher inequalities in healthcare outcomes [3]. Europe is home to over 100 ethnic minority groups [4], which form many of Europe’s “stateless nations” [5], and are distinguished from other minorities in their claim for self-determination [6]. The Basque Country, which is administratively divided in two nation-states (Spain and France) [7] or Sápmi which is divided in four nation-states (Finland, Norway, Sweden and Russia) [8] are examples of many stateless nations in Europe. Both the Basque and Sámi people have endured centuries of systemic oppression, marked by forced assimilation policies. These measures included taxation, legal restrictions, and religious regulations, alongside efforts to suppress their languages through the education system [9,10].

In the Basque Country, the healthcare system continues to reflect the historical imposition on the Basque language, with a shortage of bilingual professionals who speak Basque [11,12]. The Basque population’s legal right to access healthcare services in their language depends on the varying legal status of the Basque language across different administrative regions within the Basque Country. As a result, patients often struggle to communicate in their preferred language [13], which can hinder their ability to fully understand medical options and make informed healthcare decisions.

The Sámi people are entitled to healthcare services under both national and international legal frameworks. In Norway, their rights are protected by general legislation, such as the Patients’ Rights Act, and international agreements like the UN Declaration on the Rights of Indigenous Peoples and the International Covenant on Civil and Political Rights, which have been incorporated into Norwegian law through the Human Rights Act [9]. Despite these legal protections, research suggests that the Sámi report lower satisfaction with healthcare services compared to the majority population [14,15]. However, their health challenges differ from those faced by Indigenous groups in Canada, the United States, Russia, and Greenland. In Norway, Sámi and non-Sámi individuals have comparable life expectancies and similar mortality rates for specific health conditions [9]. Nevertheless, certain groups within the Sámi population, such as reindeer herders, appear to experience higher levels of depression and anxiety than the majority population in the same regions [16].

Research indicates that while all Indigenous, and ethnic minority groups experience communication/language problems, cultural and religious differences, and discrimination during healthcare encounters this problem is even more pronounced in women within these groups [17–19]. A woman´s origin, culture, geographic background, and access to healthcare can impact their experiences [20]. Consequently, minority women have a unique perspective of women´s healthcare issues that are not adopted by other groups, which can create isolation and could function as an impediment to social action or health behaviors considered acceptable by the majority of women [21].

Many minority language speakers and non-hegemonic cultures are denied access to quality healthcare services due to the power differentials that exist between the minority and dominant cultures. According to Roche [22], language oppression, as a form of domination, is comparable to oppression related to race, color, national origin, or ethnicity. While many European countries have multiple official languages and more than 50% of Europeans can communicate in more than one language—exposing them to diverse cultures and worldviews—the continent is also home to numerous regional and ancestral languages. However, studies on the impact of culture and language in healthcare remain scarce [23]. Aside from studies performed on the Catalans, Sámi, and Swedish community in Norway that address healthcare service issues in bilingual settings, other European studies regarding language and healthcare have mainly focused on immigrant populations and lack of standardized tools for other groups [23].

The concept of cultural safety has been promoted by Mãori nurses working in Aotearoa within a colonial context, and other Indigenous, and ethnic minority communities in Australia and Canada [24]. Few studies regarding cultural safety have been conducted in Europe [23]. According to Curtis et al. [1], in addition to the power differential arising from language and culture, other contributing factors include an overall lack of awareness and training of healthcare workers regarding the importance of culture and language associated with a particular group within the healthcare delivery system. In these situations, therapeutic relationships between a healthcare worker and a patient are particularly at risk of intended or unintended bias. For safe and quality care to be implemented, healthcare workers need to work towards both cultural safety and critical consciousness. The role of health workers and healthcare systems in generating and sustaining these inequities is progressively undergoing scrutiny [1].

Cultural safety is the concept of proactively and consciously considering social, economic and political situations, and power relations in healthcare, acknowledging that culturally unsafe healthcare practices can intensify institutional discrimination and replicate traumatic experiences in historically oppressed populations [25]. Cultural safety addresses the power imbalances between practitioners and patients through the process of reflexivity. That is, health care providers, and health systems, must acknowledge and address their own cultural biases and recognize that each individual’s dignity must be valued. Cultural safety is a concept that derives from critical social theory and asserts that established methods such as, ‘cultural awareness’ or ‘cultural competence’, which are often applied in healthcare, neglect to address power relationships, which are historically unbalanced between migrant and/or Indigenous, and ethnic minority groups and healthcare providers and services [26]. As such, Indigenous, and ethnic minority groups are often perceived as the ‘other,’ rather than as an ally whose knowledge and values can positively contribute to the patient-provider relationship or improve healthcare services. Culturally safe practice, on the other hand, focuses on relationships of both mutual and reciprocal trust and respect [26]. Healthcare organizations and authorities must also be held accountable for delivering culturally safe health care that meets the needs of individuals and their communities [1].

Despite global attempts to increase patient safety and care quality, improving safety for Indigenous and ethnic minority populations has lacked sufficient attention and thus, remains an under researched area. As argued by Chauhan [27], patients from Indigenous, and ethnic minority groups continue to feel unsafe, experience discrimination, lack appropriate interpreting services and have inadequate knowledge of the healthcare settings/systems during healthcare encounters [27]. Therefore, the purpose of this scoping review is to analyze and summarize the available literature related to experiences with culturally safe care among Indigenous and ethnic minority women (IEMW) in Europe.

Materials and methods

Eligibility criteria

This review included studies involving IEMW from all European countries and stateless nations. Studies addressing the health care experiences of IEMW who self-identify as Indigenous or as members of an ethnic minority group have been included. Excluded were studies where the participant was not the recipient of the healthcare service, or if the study focused only on the experience of the healthcare professional [30]. No publication date restrictions were applied. Inclusion and exclusion criteria are shown in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Scoping review inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pone.0325847.t001

For this study we defined culturally safe care as safe, quality care as defined by the participant and/or their community [30]. Studies that did not focus on core tenets of cultural safety—such as community relationships, cultural identity, and power relations [30] or that did not use a cultural safety framework or explicitly engage with its core principles were excluded. Due to the diverse use and overall lack of consensus with regards to the concepts of cultural safety and related terms, studies which also address concepts such as cultural competency, cultural humility have been considered if previously defined inclusion criteria was met [1].

Results

Selection of sources of evidence

Following the scoping review framework outlined above, multiple databases and reference lists were searched to produce a broad list of relevant studies (Fig 1). The primary search resulted in a total of 860 articles found in the following databases: PubMed (n = 227); CINAHL (n = 89); Embase (n = 28); Web of Science (n = 521) and Epistemonikos (n = 0). An additional 8 articles were retrieved from additional sources, such as reference lists and broad web-based searches conducted prior to this review, increasing the total to 868 articles. Subsequently, 124 duplicates were identified by using the Zotero and Covidence software. Therefore, the remaining 744 articles were scanned to review the title and abstract for possible inclusion. Title and abstract screening resulted in the removal of 680 (91%) articles, which produced the retrieval of 64 (9%) articles. After reading in full the 64 remaining articles, additional exclusions were conducted for studies that did not address cultural safety or core tenets thereof, such as relationship of community, cultural identity and power relations (n = 53; 83%), studies that were not conducted in Europe (n = 2; 3%), did not include healthcare experiences of participants (n = 2; 3%), or only addressed the experiences of healthcare providers (n = 3; 5%). Ultimately, 4 articles were retained for this scoping review.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Flow diagram of evidence search.

https://doi.org/10.1371/journal.pone.0325847.g001

Samples

Sample size of participants varied from eleven [14] to forty eight [36] (Table 2). Two articles [14,15] include Sámi participants in Norway. Olaniyan and Hayes [36] incorporated 48 Black British (n = 32) and South Asian-British (n = 16) students from racial and ethnic minority backgrounds living in the United Kingdom, who were attending a higher education institution. Thirteen participants had a current professional diagnosis of depression (n = 8), anxiety (n = 4) or bipolar disorder (n = 1), 21 had self-defined mental health problems and 25 had prior help-seeking experiences. Del Pino, et al. [37] included 16 adult Romani women (RW) aged between 23 and 62 who had contact with the public health system. Samples were obtained through purposeful, convenience and snowball sampling.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Characteristics of sources of evidence.

https://doi.org/10.1371/journal.pone.0325847.t002

Design and methodology

Qualitative methodologies were used in all four studies (Table 3). A constructivist grounded theory (CGT) approach was used in two studies [15,36], and interpretive phenomenology (IP) was used in another study [37]. Mehus et al. [14] conducted a qualitative explorative descriptive study. Semi-structured qualitative interviews were conducted in all four studies followed by data coding and thematic analysis.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Aims, methods, and key findings of sources of evidence.

https://doi.org/10.1371/journal.pone.0325847.t003

Discussion

This review identified 4 sources related to experiences with culturally safe care among adult IEMW in Europe. The limited number of articles included highlights a significant gap in research utilizing cultural safety as a framework to address the experiences of Indigenous and ethnic minority individuals within Europe. All articles were peer-reviewed and published in English in international journals. Although all of the articles included women as participants, only one article was exclusively exploring the experiences of ethnic minority women [37], and none of the articles addressed the experiences of gender non-normative individuals.

In terms of sampling, all articles were published within the last 6 years, indicating the innovative standing of the implementation of cultural safety in health care. It also detects the scarcity of research addressing cultural safety within the European context. The samples varied in size, demographic characteristics of participants, and cultural backgrounds. This variety supports previous research encouraging the implementation of cultural safety interculturally [38].

Most articles in this review emphasized the necessity for implementation of cultural safety to close the gap of health disparities in Indigenous and ethnic minority populations. Participants in the reviewed studies referred feeling diminished, demeaned, and disempowered, which are considered the 3D´s of culturally unsafe practice [39]. Proposed measures to implement culturally safe healthcare in the studied settings included addressing the health disparities, power relations, and cultural aspects within the healthcare system. These findings coincide with research highlighting the importance of emphasizing the differences between healthcare workers and patients that influence care, and work to reduce any aggression on the patient’s cultural identity as a way to implement culturally safe healthcare [1].

Most of the proposed measures focused on healthcare provider training or reflexivity. However, few measures addressed the institutional responsibility for the implementation of the proposed measures and policies. This conflicts, to some degree, with studies that highlight the need to embed cultural safety at both individual and institutional levels [14,40], to avoid the risk of ignoring contexts by avoiding to draw from critical theoretical perspectives [38].

Most findings present ethnic matching or cultural and language concordance as an important aspect to improve cultural safety during the healthcare encounter. However, reviewed studies address that this is not as beneficial if cultural and historical contexts are disengaged. This matches research highlighting the significance of maintaining focus on providing a safe environment for Indigenous and ethnic minority patients, as defined by the community, during the healthcare encounter, which is one of the essential origins of cultural safety [41].

Overall, the reviewed studies acknowledge the lack of culturally safe care in distinct Indigenous and ethnic minority communities within Europe. There is also agreement in the lack of consensus with the use of cultural safety and related terms such as cultural competence, cultural awareness, cultural sensitivity, and culturally appropriate care [1,36], as well as risks of oversimplifying the concept by depriving it from critical theoretical perspective [40]. Despite the limited research on culturally safe care in the European context and the need to advance its implementation, universities in Norway have been engaged in an ongoing initiative since 2019 focused on developing learning outcomes to better meet the needs of Sámi patients. In addition, a Sámi nursing education program has been established to enhance culturally safe healthcare services [42]. The implementation of these programs could serve as valuable models for integrating culturally safe practices in healthcare settings serving other Indigenous and ethnic minority populations across Europe.

Limitations

Although several databases were systematically searched, it is possible that data from unpublished studies, such as dissertations, were inadvertently overlooked in this scoping review. Our primary objective was to examine the use of cultural safety as a framework within the European context, and the strict inclusion criteria we applied consequently limited the number of articles included. This finding highlights that there is significant room for growth in this area. Furthermore, the lack of studies specifically focusing on Indigenous, Ethnic, and Migrant Women (IEMW) further constrained our ability to explore gender disparities and inequalities in relation to culturally safe healthcare.

Conclusions

This scoping review shows that Indigenous and ethnic minority populations in Europe experience discrimination and receive suboptimal healthcare services. This appears to be related to power relations within the healthcare encounter and the healthcare system. There are limited data on the implementation of cultural safety in Europe, potentially indicating a lack of awareness regarding the concept of cultural safety or its core tenets, as well as regarding the importance of culture, racism and biases in healthcare related to ethnic minority populations. Overall, this scoping review reiterates the necessity for further studies to promote the implementation of cultural safety in Indigenous and ethnic minority in the European context.

Supporting information