Responsabilidad del Sr Silvestre-Holms como administrador de la empresa

This section includes themes that emerged from the participants’ discussions about the cultural characteristics and customs of immigrants that posed problems in the clinical encounter. According to some respondents’, these features were common across specific groups of immigrants, although personal idiosyncratic habits and attitudes play an important role in the outcome of the interaction between professionals and patients. The data from the interviews indicated that almost all informants believed that immigrant populations have special cultural characteristics that influence their perceptions towards health, disease, medicine and care. These cultural differences were perceived to shape the clinical encounter.

10.3.1. Gender issues

Several informants, mainly female staff, recognised the disadvantageous position of women among groups of immigrant populations. Features of inequality between genders in domestic, social and educational issues were mentioned by some participants. The inferior status of female immigrants, as it was perceived by health staff, was reported to affect the provision of health care by creating obstacles in the access to health services and impeding clinical interaction:

‘… some immigrant women can visit the doctor only if they have cared to finish or arrange their responsibilities at home. … among immigrant populations, women are usually less educated which results in a less privileged position for the comprehension of medical instructions.’ [P10, nurse (male), 32 years old]

‘It is clearly obvious (during a conversation with the couple) that the husband has the upper hand. … he talks to the doctor on behalf of his wife. Even when I ask about strictly feminine issues, such as the woman’s period, it is the man who replies as if he knows everything about her …’ [P15, consultant doctor (female), 56 years old]

As such, there was a widely held view that female immigrants suffer a double oppression both in wider society and within the immigrants’ community specifically. This situation was felt to have a significant negative impact on their physical and mental health:

‘… I am opposed to the imposition of the strict religious clothing of women which obliges (them) to cover almost all parts of the body. It is an unhealthy and abusive practice … which serves no purpose other than the degradation of the woman's personality. But this is the least. Even more important is the fact that women of some Muslim populations do not have the same access to education and professional development, thereby being disadvantaged at social level … and economically dependent on their husbands.’ [P12, consultant doctor (female), 39 years old]

Several informants mentioned that Muslim women often want, either out of personal desire or after their husband’s intervention, to be examined only by female doctors and some have also refused care by male nurses. This attitude was reported to cause problems in the operation of health services:

‘In my department there are only male surgeons and the examination requires almost always the removal of a part of clothing. So the desire to be

examined by a woman is impossible, in fact.’ [P13, nurse (female), 42 years old]

‘There is a command by the (hospital’s) administration to provide a woman to serve (women who ask for a female doctor) … . We try, then, to find … a woman doctor, even in clinics that are not on duty. Many times this is a waste of time and a source of conflict among staff.’ [P20, midwife (female), 43 years old]

In addition, a few female participants mentioned the dominant role of some male immigrants which may be expressed through adverse reactions when interacting with female health staff. A female doctor attributed this phenomenon to underlying prejudice by some male immigrants towards the professional role of working women.

10.3.2. Health behaviour

It was reported by some participants that certain immigrant groups do not give the necessary attention to behaviours that are consistent with the concepts of public health, including prevention, screening and early diagnosis of diseases. It was also argued by some non-medically qualified participants that immigrants have a wrong perception that only doctors are competent for consultation in health issues. In this way, the roles of nurses and the other non-medical health staff were felt to be disregarded:

‘… many times … I have a hard time to convince them about the value of … the interventions of preventive medicine as well as the importance of my role as a health professional, just because I am not a doctor.’ [P06, health visitor (female), 40 years old]

In addition, several participants stated that amongst some immigrant groups there were people who had a low perception for the value of personal hygiene to preserve and promote health. Some participants claimed that this attitude was a cause of morbidity that acts independently of and additionally to immigrants’ poorer socio-economic conditions:

‘… I have noticed … that many people shave or wash together, sometimes using the same stuff, … you know what I mean, razors, sponges … . I often see immigrants who are sloppy, without clean clothes and behave in a totally unhealthy manner.’ [P04, nurse (female), 32 years old]

‘Refugees have other ideas about the neonate’s care as well as about cleanliness and personal hygiene. They do not give the same importance as we do. That is why they are not interested … in health education.’ [P16, midwife (female), 48 years old]

Again, these statements may derive from stereotypical impressions prevailing in health services or in society in general, although this was clearly denied by the participants when such a suggestion was implied by the interviewer.

10.3.3. Religious customs and philosophical views

A special cultural characteristic that was widely mentioned during the interviews was associated with the religious practices of Muslim patients during Ramadan. Indeed, it was supported that the strict application of Ramadan rules can negatively affect the compliance of patients with dietary guidelines and medical instructions:

‘There are patients that (besides food) do not even want to take medicines during … Ramadan. Previously, the department had a Muslim trainee doctor who achieved in some cases, … not often, to convince them for the necessity of … (following) therapeutic guidelines during Ramadan. The rest of us have a … greater problem.’ [P07, nurse (female), 45 years old] ‘They follow the nutrition that is imposed by their religion even during pregnancy. … . Especially for the pregnant women, this can affect the development of the foetus.’ [P20, midwife (female), 43 years old]

Other habits, such as the avoidance of pork meat by Muslim patients, were felt to cause only slight problems during hospitalisation because special arrangements for feeding them had to be made. Furthermore, according to the responses of some informants, various immigrant groups lacked any confidence in the value of Western medicine or

were unfamiliar with the environment and practices within health services in the Western world. A different approach, respectful of their ideas, was supported by some respondents to be required for the care of these patients.

It is noted that some participants, especially doctors, highlighted the need for tolerance of such cultural differences even when they are expressed through inappropriate behaviours. The scientific ability and the professional role of health personnel were considered valuable tools for the mitigation of cultural gaps and, in turn, the provision of suitable care to patients from different cultural backgrounds:

‘Health professionals … have to explain to each immigrant that health care is not associated with religious, cultural or national issues. … they must understand that medical care aims only at protecting their health and does not stem from bigotries. Unfortunately, not all will understand it or even if they will, some will not agree and will not comply. However, we should respect … such peculiarities of immigrants, without, of course, making concessions to the quality of service.’ [P01, consultant doctor (male), 63 years old]

‘… the (cultural) characteristics do not cause problems in clinical interaction with any patient as long as there is mutual respect and understanding. … . When the health of the patient is in risk … , usually there is a mutual understanding … due to the importance of the situation.’ [P02, resident doctor (male), 36 years old]

Importantly, one doctor expressly stated that respect for an individual’s personality as well as composure and patience towards personal behaviours should be applied not only in health staff’s interaction with immigrants but also in their dealings with the indigenous population.