Hultin et al. BMC Public Health(2024) 24:1257
https://doi.org/10.1186/s12889-024-18711-7

BMC Public HealthOpen Access

RESEARCH

A qualitative study on diverse experiencesof medication safety among foreign-born
persons living in Sweden
Lisa Hultin1*, Ulrika Pöder1, Mariann Hedström1, Anna Ekman1,2 and Katarina Hjelm1
Abstract
Background The ongoing global migration has led to multicultural societies, with many migrants who do not speak
the official language in the host country. This could contribute to communication problems with staff in healthcare
and a risk to patient safety. Research on patient safety in medication use in migrants is an under-researched area. The
aim was to explore diverse foreign-born people’s experiences and perceptions of self-management of medication anddetermine if home-based practice patterns have implications on medication safety, and what factors may support
safe medication use.
Methods A qualitative explorative study, with individual semi-structured interviews and participant observations in
the patients’ home. Qualitative content analysis was applied.
Results A purposeful sample of 15 foreign-born persons identified by healthcare staff as having language difficulties
in Swedish that may pose a safety risk in connection with medication use at home, was selected. Three categories
were identified. The first category showed respondents being dependent on another person, having experiencesof not receiving information about their medications due to language barriers, having difficulties getting accessto the healthcare centre and feeling distrusted/misunderstood. The second category showed respondents being
independent and self-motivated Although they struggled, they managed to get access/contact with the healthcare
centre themselves and felt understood/listened to by the staff. The last category concerned factors that facilitating
medication use; such as having a medication list in the respondents’ own language and offering a choice of languageon the answering machine at the healthcare centre. Although they knew it was impossible to get an interpreter at thepharmacy, they felt safe knowing there was always a solution for receiving understandable information.
Conclusion The findings highlighted that language barriers can complicate the communication between migrants
and the healthcare, which can affect the medication safety. Understanding of this group is essential to improve thecooperation between patients and staff, leading to culturally congruent care. This knowledge should be used inhealthcare to understand the gap in communication to increase patient safety. Further research from other angles,
e.g. pharmacy/healthcare staff and relatives is needed to identify and evaluate facilitation to improve the outcome of
the intended medication treatment.

*Correspondence:
Lisa Hultin
lisa.hultin@pubcare.uu.se
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.

Hultin et al. BMC Public Health(2024) 24:1257

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Keywords Communication barriers, Medication safety, Migrants, Patient safety, Primary health care, Qualitative
research, Self care

Background
Migration is increasing worldwide. Approximately
281 million persons are migrants globally, and the number is predicted to increase in the future [1]. With thisongoing global migration and globalisation, many societies have become multicultural, with many migrants(immigrants and refugees) who do not speak the official
language of the host country. This could contribute to
a communication problem with the healthcare system,
inappropriate treatment, and insufficient medication
safety [2–4]. Good communication is essential to ensure
patient safety, in terms of use of medication by patients[5]. A recent systematic review [6] on safety of healthcare for ethnic minority patients (some migrant groups
included) concluded that there has been limited focus
on improving safety for ethnic minority populations,which remains an under-researched area. People of ethnic minority backgrounds and migrants might experience inequity in the safety of care and are at a higher riskof patient safety incidents and have, for example, higher
rates of adverse drug events and dosing errors comparedto the population of origin [6]. Another review of ethnic
minority patients (limited number of migrants) in the
UK aimed to establish types of and possible medicationrelated problems experienced [7]: cultural and religious
beliefs, different expectations, language and communication barriers, lack of knowledge of the healthcare
services, and underestimating patients’ desire for information were discussed as factors related to problems oftaking medications as advised, concern for side effects,
risk of adverse drug reactions, and problems accessing healthcare services. However, only two out of fifteen studies included were performed in the patients’home, and none had made observations of patient’s selfadministration. It was concluded that further research isneeded and designed to identify and address the needs
and perspectives of these groups, particularly as little evidence exists on what influences medication-related problems among migrants.
For migrants, it can be difficult to navigate in, and to
get access to, healthcare, within the often complicatedand exchangeable systems and models in the organisationof healthcare [3, 4]. This can be explained by language
difficulties but also cultural dissimilarities in beliefs
about health and illness and knowledge about the existing healthcare organisation [4, 8–10]. Lack of social support and other socioeconomic factors might contributeto migrants having more difficulties in searching for care[4]. In general, migrants have poorer health and shorter
life expectancy than the population of origin [11, 12].

In Sweden, the number of migrants has increased from
11% of the registered population in 2000 to approximately 20% in 2022 [13]. People who have migrated toSweden come from a variety of countries, at different
times, and with different reasons for migration. The pattern of migration changed in the mid 1980s into nonEuropean refugees (mainly from the Middle East andAfrica) from labour migrants from Scandinavian andEuropean countries dominating during the industrialisation from the post-war era. In 2015, an unusually highnumber of migrants from Afghanistan, North Africa, andSyria applied for asylum to nearly all European countries.
The third largest recipient country was Sweden [14]. The
foreign-born population is therefore characterised bygreat diversity. The group of persons born outside Europe
who have spent 0–9 years in Sweden are characterised
largely by the refugee migration that took place in recent
years. However, many migrants have spent a long time in
Sweden [15].
Using medications is a complex process, and language
difficulties can play a role in the patient’s adherence toprescribed medications [16]. Transcultural care emphasises the need to provide care based on the individual’sor group’s culturalhealth beliefs, practice, and values.
This determines health-related behaviour, including selfmanagement of medications, and thus affects health.
Thus, the primary goal of healthcare should be to provide culturally congruent care. The health care needs tobe designed in a partnership between the individual andhealthcare staff and an integrated care based on a combination of holistic, generic, and professional care knowledge, and in multi-professional collaboration, to achieve
the goal of health and to prevent illness [17].
How migrants experience medication management athome has been studied to a very limited extent; however,no studies have been found that have been performedin patients’ home, including observations on use of andhandling of medications. Little evidence exists on what
influences medication-related problems among ethnic minorities, particularly migrants, despite increased
diversification of populations in countries throughout theworld as well as what support is needed to optimise theuse of medications [6, 7].
Therefore, this study explores diverse foreign-bornpeople’s experiences and perceptions of self-managementof medication and determine if there are implications ofhome-based practice patterns on medication safety, andwhat factors may support safe medication use.

Hultin et al. BMC Public Health(2024) 24:1257

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Methods

Data collection instruments

DesignA semi-structured interview guide and an observation
scheme were developed based on a literature review,peer-review with experts, and standardised/validated
instruments [21]. Both were based on the patient’s selfreported use of medication, and observation items
within domains known to be relevant to safe medication
management, including adherence, knowledge, polypharmacy, attitudes, physical and cognitive ability, andlifestyle [22, 23]. The semi-structured interview guideincluded standardised questions on demographic dataand questions on four areas: usage of medication, acquisition of medication, facilitation of medication, and conformity with prescribed medication. Probing questions
were posed when appropriate, such as what kind, where,
and why. Focus areas in the observation scheme were:
how the person takes their medication, preparations of
medication, time, hygiene, use of medication list, andsupport in taking/handling medication.
A pilot study was conducted with two persons to test
the interview guide for content, understanding and tocheck the consistency and the observation scheme. As
the interviews and observations turned out well, all thematerial was included in the study.

A qualitative explorative study design with individual
semi-structured interviews and participant observations was used to collect data, as it provides new insights
and increases understanding in an area that has previously been investigated to a limited extent. Semi-structured interviews allowed the respondents to discuss thecontent within a given frame of questions and aimed toreach a nuanced and deeper understanding of the perceptions and experiences of self-management of medications [18]. Semi-structured interviews may be favourable
when studying experiences and perceptions. These often
take into account gender and cultural variations, whilst
acknowledging there is something fundamental regardless of these factors [19]. Participant observations basedon an observation scheme facilitate collection of data
concerning practical procedures and provide complementary information [18]. The purpose of the observations was to study first-hand what was going on rather
than simply assuming what we know. Direct observation of patient care has been used as a reliable qualitative
research method to measure errors and adverse eventsin healthcare [20]. This method provides insight into theunspoken elements and connects the researcher moreclosely to the basic human experience [18].
Setting/inclusion sites

Respondents were asked for participation by staff at a
primary healthcare centre and a voluntary organisation(a cooperation with the municipality and the church)
in an immigration dense area in Sweden. The voluntaryorganisation organises courses and gatherings for immigrants to promote the integration process.
Study population and inclusion criteria

A purposeful sampling strategy [18] was applied. Foreign-born people identified by healthcare professionals as having language difficulties in Swedish that may
pose a safety risk in connection with medication use athome were invited to participate. Excluded were individuals < 18 years old or having language problems due tomental or somatic disease or known current drug abuse.
Individuals were asked by staff at the healthcare centre
and at the voluntary organisation, and they replied by filing in a reply coupon or answered directly to the question; thereafter, a registered nurse (LH) contacted themto set a time and place for the interview. When the person agreed to participate, the medication list from the
medical record was collected (with consent from theinformant) from the healthcare centre where the patient
was registered, as a support when discussing handling of
medication.

Data collection/process

Data were collected between May 2022 and January 2023.
The interviews and observations were conducted in the
respondents’ homes (n = 9) or at the voluntary organisation (n = 6). A female registered nurse with extensive
experiences of caring for patients in home care (LH) collected all the data. She was not involved in the medication management of the study respondents and was notaffiliated with the healthcare centre or the voluntaryorganisation. An authorised interpreter of the same sex
and who spoke the same language as the respondent wasused.
To enable a comparison between the medication profileand the prescribed medications during the observationand interview with the respondents, the nurse used the
respondents’ medication list from the medical record.
The nurse conducted individual interviews and observations of the participants (noted on an observation
scheme) in the respondents’ home or in a quiet separate
room at the voluntary organisation while the respondent
prepared and took their medication. The observation
scheme was filled in by the nurse. Occasionally, the nurse
asked the respondent for clarification regarding theirexperiences; otherwise, the observer was quiet. In cases
where the observations were conducted at the voluntarily
organisation, information regarding the home environment and storage of medications was only requested verbally. The individual interviews were held directly after
the observations.

Hultin et al. BMC Public Health(2024) 24:1257

If a discrepancy was noted between the patients’ selfreported use of medication and the medication prescribed, then provided that the respondent consented, acertain contact person (registered nurse) at the healthcare centre was contacted, with the goal of informing thephysician responsible for the patient (n = 1).
The interviews and the observations lasted between
0.5 and 2 h (median 33 min). The interviews were audiotaped, and field notes that were both descriptive andreflective were taken.
Data analysis

Data were analysed by inductive, qualitative content
analysis to identify recurrent and overarching categories[18]. Interviews were transcribed verbatim by a professional transcription service. The unit of analysis consistedof both interview transcripts and observations schemes.
Data collection and analysis proceeded simultaneously,
and the analysis was based on openness for variation in
the data and a search for patterns, regularities, and contradictions by comparing the statements from the different respondents. Sampling was continued until the
researchers agreed that informational redundancy wasachieved, that is, the point at which no new information or themes emerge from the data. First, the transcriptfrom the interviews and the notes from observations
schemes were read through thoroughly several times to
get a sense of the whole. Meaning-bearing units, that signify the parts of sentences/phrases that carry a meaning
were identified and coded as close to the text as possible.
Thereafter, they were sorted and compared to identify
similarities and differences to find patterns; finally, they
were grouped into sub-categories and categories.
In order to increase the trustworthiness of the results,
investigator triangulation was used to validate the findings [18]. The first author conducted the initial analysis and then discussed the codes with the co-authors inorder to compare them and verify their categorisation. If
needed, the results were discussed among the researchers until consensus was reached. To increase the credibility, the analysis proceeded to the point when no new
information appeared in order to achieve maximum ofvariation. Careful descriptions of the method are given
to ensure dependability. Confirmability was reached byillustrating the content of the categories by illuminating
quotations.

Results
Characteristics of the study population

The study included 15 foreign-born persons, all except
one female, aged between 42 and 72, most with an educational level below primary school (n = 8), and reporting
no or limited ability to speak Swedish (n = 15). All persons
were identified by staff as having language difficulties

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Table 1 Characteristics of the respondents
Variable
GenderAge (years) 1
Time of residence in Sweden (years) 1
Educational level
No education/illiterate
Public school < 6 years
Primary school < 9 years
Secondary school ≤ 12 years
University < 2 years
University ≥ 2 years
Reason for migration
Refugee
Employment
Relative
Living conditions
Alone
Living together with the family
Self-reported fluency in the Swedish language
Completely
Lack of
LimitedNot at all
Contacts with healthcare (homecare)
Medications/Nature cure remedies from homecountry
Fasting once a year
1

Women = 14,
Men = 166.5(42–72)
11(4–46)
2
2
4
4
3
11
4
1
14
4
7
4
0
0
12

Median (range)

Table 2 Country of birth of the study population
Country
Syria
Afghanistan
Kurdistan
Iran
JordanBangladesh
Eritrea
Somalia

n
7
2
1
1
1
1
1
1

in Swedish posing a safety risk in connection with their
medication use at home. Medications treating depression, hypertension, migraine, anxiety and diabetes werecommonly used. All but one lived together with theirfamily (Table 1). The respondents were mainly refugees
originating from countries in the Middle East and witha median time of residence in Sweden of 11 years (4–46
years) (Table 2).
Approximately half of the respondents reported being
dependent on government support for their medication
costs (n = 8). The others thought the cost of medication
was too expensive (n = 3) or manageable (n = 4), as theSwedish system allows for a maximum yearly medication

Hultin et al. BMC Public Health(2024) 24:1257

cost; thereafter, the medication is free. Half of the
respondents answered that they were willing to accept ageneric medication if needed. Furthermore, almost all the
respondents (n = 12/15) stated in the interviews that they
fasted every year for a month; hence, every day during
this period, they do not eat between sunrise and sunset.
They either took their medication before sunrise, aftersunset, or took half of the medication before sunrise andhalf after the sunset. If anyone was ill, became ill or too
old, they did not need to fast.
Categories and sub-categories

Three categories were identified in the analysis of theinterviews and observations; “Dependent on anotherperson”, “Independent and self-motivated” and “Factorsthat can facilitate medication use” (Table 3), (P = quotefrom individual interview and respondent/person = eventfrom observation, P1 and person 1 correspond to thesame person).
Dependent on another person

This category captures the experiences of the respondents who described not being informed about their
medication or not understanding the information given.
They thought it was difficult to access the primary healthcare centre and felt misunderstood and distrusted. Thus,
they became dependent on support from others in handling their medications.
Not receiving information about medication because oflanguage problems

The respondents felt that they did not receive enoughor any information from the doctor about their medication or comprehend the information if it was given. They
would have liked to receive information about why (theindication), when and how they should take the medication and the potential side effects. Even though the
respondents expressed there is always an interpreter ora family member available during the visit at the healthcare centre, they still did not feel that they received
this information. This led to them stopping to take theTable 3 Categories and sub-categories from the analysis
Categories
Dependent on anotherpersonIndependent andself-motivatedFactors that can facilitate
medication use

Sub-categories- Not receiving information about medication because of language problems- Difficulties getting in touch- Feeling distrusted and misunderstoodby the healthcare- Managing to reach out and contact thehealthcare centre- Feeling understood and listened to- Possibilities to translation- There’s always a solution at the pharmacy to receive understandable information

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medication, taking incorrect dosage and/or not daring totake medications:
The doctors said that according to the tests, the doseof Levaxin should be changed, but I don’t even know
how they would change it and what it would be. He/
she hasn’t said anything since. (P3)This was also confirmed during observation of Respondent 1: “The person starts to eat breakfast and explainsthat he/she always take the medication during breakfast
time, shows various boxes with pills and insulin. Showsa box with insulin that is unopened and explains that he/she does not understand why and when to take the insulin, and why it has not been opened. When comparedagainst the medication list, it turns out that it is insulin,with long-term effect that has not been taken due to lackof information”.
Some respondents expressed that they take their medication but without knowing on what indication and somealso described being scared to take them because of thelack of information leading to a lack of understanding.
Problems were also reported related to not receiving
information on test results from blood or x-ray. During
the observation of Respondent 3: ‘The person reaches
inside a plastic bag in which boxes of medication are
stored. Takes out one box with pills and explains that it’s
not possible to read on the box or the medication list as it
is in Swedish; therefore, it’s difficult to understand when
to take them and when to contact the doctor again. The
person shrugged his/her shoulders and head, resigned
and expressed that “this is impossible to understand”’:
No, no. No one is helping me with that. I would liketo know if there are side effects from the medications,what is it used for…, they have side effects on the kidneys, maybe or the liver or something. But nobody
tells me about this. (P12)

Difficulties getting in touch with staff in healthcare

Respondents experienced that it was difficult to get intouch with the healthcare centre due to language problems. They did not understand the Swedish-speaking answering machine when calling the healthcare
centre, and they were unable to speak with the nurse at
the healthcare centre in case they got through the different choices with the answering machine. They weretotally dependent on another person who contacted
the centre to make an appointment. Since they could
not manage to book an appointment themselves, they
were often late with follow-ups, sometimes days, weeks
or even more. Some of them expressed that they went
to the hospital’s emergency department instead, sinceHultin et al. BMC Public Health(2024) 24:1257

it was impossible for them to reach the healthcare centre. During the observation of Respondent 5: ‘The person searches for the correct box when the daughter who
is there for the visit helps to find the correct box and
explains that her mother got sick and could not reachthe healthcare centre to get a prescription for her medication. Thus could not get the correct medication at thepharmacy; therefore, the mother went to the emergency
department, since the daughter was out of town andcould not help’:
I got the syringe and the tablets. And then he told me“you have to contact your doctor at the health centre”, but I don’t know how, I can’t do it (answeringmachine). (P5)
Yes. Yes, it is always the children who help. Unfortunately, that’s the way it is; roles are reversed in Sweden, so it’s the parents… it’s the children who have totake care of the parents in terms of language. (P14)

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that they could discuss different treatment alternatives
with their doctor.
Managing to reach out and contact the healthcare centre

Some of the respondents experienced that they could
manage the language well. They could call the healthcare
centres, managed the answering machine with different
choices, talked to the registered nurse who called back,and booked an appointment. Sometimes they had to calla few times before they could get an appointment; however, they were not dependent on another person to assist
them. They felt trust in that they could get in contact
with the healthcare centre if they, for example, needed toadjust the dosage of a medication:
My doctor usually gives me an appointment every
three or six months. But in the meantime, if something comes up and I need to contact the doctor, I
have numbers for the counsellor and the coordinator. So I can contact them and they can talk to thedoctor and arrange a doctor’s visit if necessary. (P22)

Feeling distrusted and misunderstood by staff in thehealthcare

Respondents felt that the doctor and the registerednurses did not listen to them when they tried to communicate, regardless of whether an interpreter was present.
Every time they got in contact with the healthcare centre, they could not get an appointment at all, or were told
they had to wait or were in line for an appointment thatthey never got. They felt distrusted and expressed thatthey often met a new doctor and could not build a trusting relationship and had no continuity in care. Therefore,
they tried to find the solution using “google”, which could
end up with an adverse event due to wrong dosage:
For example, I say that Sertraline is not good, that I
can’t sleep when I take it. And then the doctor usually prescribes it again; so despite that, even though
I’ve said it’s of no use, the doctor e prescribes thesame thing. (P3)
I got very angry. I was really sick, and I needed to beon sick leave for a week or two, just to be able to get
my energy back, to start to get better. But the doctor said “no, you have to learn the language”. Don’t
you understand? I’m telling you I’m not well and I’msick. It’s not that I don’t want to learn the language,
but right now I’m not feeling well. And then I said,“when you can’t understand, I don’t want to comehere. And I don’t even want to be treated”. (P3)

Independent and self-motivatedThis category describes the experiences of the respondents who understood the information provided and felt

Feeling understood and listened toSome respondents felt that they could discuss with thedoctor what medication they had, on what indications, aswell as how and what time they should take them. They
could also read and understand a medication list. During
the observation of respondent 8: ‘The person shows all
the boxes of medication, explains how to check the dateof expiration on each box, and what time and on whatindication to take the medication. After this, the person
also shows the medication list and explains that this iswhere to double check all of the medications and if they
don’t, or he/she doesn’t, understand the text, the doctor
or the daughters make a translation so he/she can use it
anyhow’.
The respondents felt trust in that they could manage
either with an interpreter or without. They might want tohave an interpreter if they saw a doctor, but not when visiting a physiotherapist; it was up to them to decide. Someof the respondents expressed that there were doctors or
nurses who could speak their language at the healthcare
centre. They felt trust that there was always someone
who could give them information about the medication if
they did not understand everything.
If there is medicine where the prescription needs tobe renewed, then the doctor does that. Like Gabapentin, in the beginning I had three, but when the
doctor saw that I was getting worse and worse, thedoctor increased the dose to three in the morning;the doctor listens. (P17)Hultin et al. BMC Public Health(2024) 24:1257

Factors that can facilitate medication use

This category encompasses factors perceived to facilitate medication use, related to translation possibilities,
and a sense that there was always a solution for receiving
understandable information at the pharmacy.
Possibilities to translation

Most respondents did not have a wish or a suggestion
about what could facilitate adherence to prescribed
medication. However, when different suggestions were
proposed, they were positive. Everyone expressed that aninterpreter is the most important factor for facilitation.
Almost all were positive about receiving a medication listin their own language. They expressed that it could facilitate their adherence to their medication, especially since
many of them did not understand the information thatthe doctor gave them. During the observation of respondent 1: ‘The person had taken the insulin injection and
was about to take the pills when reaching for the medication list in a plastic bag and gave it to the observer andexpressed “I got that from the doctor, but I can’t read it so
you can have it”. Another suggestion that the respondents
were positive towards having was language selection on
the telephone answering machine at the healthcare centre. The respondents felt that this service, available ate.g. the Swedish Social Insurance Agency and the Swedish Public Employment Service would make it easier forthem to get in contact with the health care centre. If that
opportunity were to be available, the participants would
know that they could manage to reach out themselves
and thus feel more secure:
I can’t express myself in Swedish. At the Swedish
Social Insurance Agency and the Swedish Public
Employment Service, there, you can choose the language. But in healthcare, you can’t. That’s weird.
(P17)

There’s always a solution at the pharmacy to receive
understandable information

Most of the respondents expressed that it was not possible to get an interpreter at the pharmacy. However,everyone was satisfied with the service at the pharmacy.
They could usually find someone that could speak theirlanguage; also, many pharmacists were bilingual. Even
if no one spoke their language, they always managed to
explain in some way with hand signs or google translate.
It did not matter if the person could not speak any Swedish at all. They always felt secure that they would receive
information at the pharmacy. The respondents expressedthat the pharmacist was very meticulous; often, theywrote information on the boxes in their language, such as
the indication for the medication and what time to take

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the medication. During the observation of respondent 8:‘The person shows the observer two of their medication
boxes where the bilingual pharmacists have written theinformation in the respondent’s own language’:
A person who works there, hi´s/she’s from X-land.
So, when I collect the medicine, he/she helps me andwrites, for example, like this. Hi/she wrote “I take itfor high blood pressure”. So he/she helps. (P1)
When they talk and tell me, I understand quite well.
So for me, it has never been a problem to get medicine or understand what they are saying at the pharmacy. I understand. (P22)

Discussion
This study is unique as it, through interviews and observations, explores diverse foreign-born people’s experiences and perceptions of self-management of medication,and if home-based practice patterns have implications
on medication safety, and what factors may support safe
medication. It adds new knowledge on migrants’ experiences of reaching their healthcare centre, facilitation in
medication and communication at the pharmacy. The
main findings showed that the two first categories represent different patterns among the respondents. One
group where the respondents struggled and were dependent on another person to get information about medications, had difficulties in accessing the healthcare centre
and felt that the staff did not trust them. The other groupof respondents were independent and self-motivatedin reaching out to the healthcare centre and in managing their medication. Having a medication list in the
respondent’s own language and the option to choose
their own language on the answering machine at thehealthcare centre were perceived as factors that would
facilitate their use/handling of medications. Although it
was known that it was impossible to get an interpreterat the pharmacy, they felt there was always a solution forreceiving understandable information, which made themfeel safe. Notably, this study identified positive practices
within pharmacies that contribute to preventing medication-related problems. The broader healthcare system
can learn from these practices by incorporating workgroups that include multilingual and multicultural staff,
providing lists with contact numbers for staff who speak
different languages to facilitate communication and,most importantly, fostering a positive attitude towards
patients and work tasks. These initiatives aim to findsolutions and deliver high-quality services, thereby positively impacting medication safety for persons speaking
different languages.
Is it possible that depending on the year and what kindof reception the respondents received when arriving inHultin et al. BMC Public Health(2024) 24:1257

Sweden, affected their ability as migrants to get control
over their own self-care and medication? In Sweden,
the national law on activities for getting established for
newly arrived migrants [24] was passed in 2010 under the
Ministry of Employment. Newly settled migrants who
have received a residence permit in Sweden are offeredan Introduction programme, including a civic orientation
course. This programme is intended to facilitate access to
the labour market and promote integration. It has beenfound [25] that the Introduction programme provides
an opportunity to develop knowledge and skills to gain
more control over one’s life and participate in the Swedish society. However, this kind of programme has beendifferent over the years in Sweden. Due to the high number of incoming refugees in 2015, referred to as the “refugee crisis” [26], it is not certain that everyone was offered
the Introduction programme. Therefore, this could haveaffected the respondents’ opportunity to learn about thehealthcare system. Thus, depending on what year they
arrived in Sweden, this could have influenced their ability to gain control over their self-care and medication
management. The findings of this study suggest that theestablishment programme could be expanded to include
more education in the Swedish language and information
about the healthcare system, e.g. purchasing medications.
The majority of respondents in the present study experienced they could not reach/access the healthcare centre. Apart from language problems, it has been shownthat lack of social support and other socioeconomic factors might also contribute to migrants having more difficulties in seeking care [4, 8–10]. An integrated careconsiders both lay and professional beliefs, aiming to provide individualised care that is thus, culturally congruent
care [17]. The results of this study show that the healthcare centre is not completely accessible for this group ofpatients, namely migrants. Thus, the healthcare centre
needs to be developed to be accessible for all patients,
irrespective of background. As previously shown [17], thestaff need to be trained to have adequate skills in identifying patients’ individual beliefs, practise and values. Thereis a need to design care in partnership between patientsand staff. Together, they should develop an integrated
care, including both professional and lay beliefs, practiseand values to achieve the goal of good health and prevent
illness. Therefore, the healthcare centre needs to develop
and have a strategy/routine to identify these vulnerable
patients to prevent adverse events and patient suffering.
This study indicates the need for implementing structures, such as staff education and assessments tools to
assist healthcare providers in identifying patient’s needs
and those who are vulnerable. Especially since healthpromotion of migrants in the early post-migration stage
and communication is considered to be an importantarea for patient safety [27, 28]. Communication barriers

Page 8 of 11

or different cultural backgrounds increase the risks topatient safety [29]. The results show that there is a needto improve safety for migrant patients, and that this is
still an under researched area as stated in a systematic
review focusing on ethnic minority patients, although
there were some migrants included [6].
With few exceptions, the majority of respondents inthe present study claimed they fasted and changed their
medication accordingly. This could be a medication
safety risk and has been noted in diabetes care [30]. The
recommendation is for the patient and the responsible
physician to have a dialogue about suitability and risks
that can arise from not taking the medication before thefasting begins. It is important to be aware of this and tounderstand that medication reviews can be a general way
to avoid medication errors and to contribute to medication safety. Religious practices, such as fasting, can have anegative impact on health [30]. There may be differences
between individual perceptions and the healthcare staff
where the organisation’s rules and norms prevail [31, 32].
It is important to be observant of the risk of clashes incase of differing perceptions and, thus, always assess theindividual’s perceptions.
The respondents in this study reported no or limited ability to speak Swedish, and one category that was
identified was “dependent on another person ”. Theyexperienced that they did not receive information about
medication because of the language problems. Moreover,they had difficulties getting access to staff in healthcare
and being able to communicate with them, and they felt
distrusted and misunderstood. This is in line with previous studies [2–4], which have shown that it can be difficult for migrants to navigate and to access healthcare andthat communication problems with staff at the healthcare
centre can lead to inappropriate treatment. In fact, many
adult migrants do not have appropriate health information and often face difficulties in managing health issues[33]. Good communication is essential to ensure patient
safety, in terms of use of medication by patients [5].
A pictogram is a graphic symbol conveying specificmeanings, which were not mentioned in our results.
However, could their inclusion be a suggestion forsituations where foreign-born do not understand thelanguage? Previous use of pictograms has shown to contribute to patient safety/adherence if used in combination
with good communication [34].
The findings in this study show that having an interpreter present is the best means to facilitate understanding and safe medication use. According to theManagement Act [35], in Sweden, there is a right to use
an interpreter in contact with all public authorities for
persons who cannot speak Swedish, and the responsibility for calling upon the interpreter service and obtaining
the provision of an interpreter lies with the healthcare

Hultin et al. BMC Public Health(2024) 24:1257

service [36, 37]. However, there is a problem, since thepharmacies are not deemed to be a public authority anddo not receive financial support for interpreters. Therefore, they do not use them. Good cooperation between
healthcare and the interpreter service has been shown tocontribute to high-quality healthcare for patients in needof interpreters to be able to communicate in healthcare[38]. A scoping review [39] shows that this is important
for a relationship between the migrant and the healthcare professionals in order to promote adequate information about medications. A trusting relationship with thepharmacist leads to increased reliable information being
shared about medications, a bridge to the cultural divide,
and an understanding for their patient and, subsequently,
their compassion and care being improved.
The findings in this study showed that half of the
respondents received government support for their
medication. Households in the Nordic countries areamong the wealthiest in the world. However, in Sweden,
the income inequality has increased at a fast pace during the past few decades. It is well established that economic inequality might lead to poverty and increased
health inequalities [40]. In a systematic review [41], it isshown that socio-economic factors, including language
proficiency, level of education, financial burdens, werecommon themes for non-adherence to medication, compromising patient safety. These findings might be a resultof increasing inequalities.
Limitations

We aimed to interview and observe all respondents intheir homes; however, due to recruitment problem the
majority, nine out of 15, were interviewed in their home
and the rest in an environment that was consideredfamiliar and a safe zone for the interviewees. Althoughpatients were asked to participate at the healthcare
centre, many turned down the offer. Certain groups ofpatients are difficult for researchers to access becauseof their social or physical location or vulnerability. This
group of patients are vulnerable, not least due to theirexperiences related to migration (most were refugees),
and therefore, deemed challenging to recruit for research[42]. While the observation contexts differed, the impact
is considered negligible as the same data collection
instruments/methods were used, with only storage andhome environment differing in observations made at thevoluntary organisation, where the majority were conducted at home.
The use of an interpreter was essential for communicating with respondents. To reduce the influence of interpreters, we minimised the number of interpreters andonly used gender-matched professionally authorised persons [43].

Page 9 of 11

The purposeful sampling strategy aimed to include
information-rich cases to deepen our understanding of
the studied area [18] and, therefore, explanations cannot
be draw from it.
All but one of the respondents were females, which isa limitation. It cannot be ruled out that the results could
have been different with an increased number of male
respondents. However, carefully collected, analysed anddescribed results are transferable to groups and contexts
similar in characteristics [18].
Potential limitations related to the sampling procedurethat could affect the results within the studied group, e.g.
education level and time of residency in Sweden, may
introduce sampling bias. However, this was considered in
the analysis, and no such differences were found regarding educational level or time of residency in Sweden
within sub-groups. However, due to the qualitative study
design, such relationships cannot be excluded. The study
design made it possible to explore different perceptions
and experiences to get a deeper understanding of thestudied phenomenon, albeit not to seek explanations.
Relevance for clinical practiceThe study highlights the importance of identifying individual experiences and perceptions of self-management
and medication to visualise aspects that can be improved
to promote health and well-being.

Conclusion
In conclusion, this exploratory study highlights that
language barriers in healthcare can affect medication
safety. Two groups with different patterns were identified: one that struggled and was always dependent onanother person to access and communicate with staff in
the healthcare centre. The other group struggled too, butthey were able to get access to and communicate with thehealthcare staff on their own. Being aware of migrants
with communication barriers is essential to design andimplement future facilitation of medication. Thus, having a medication list in the patient’s own language or
the option to choose one’s language on the answeringmachine in clinical practice could improve the communication between the patient and the staff. Furthermore,
it could lead to culturally congruent care based on theindividual’s beliefs, practise and values However, manyof the respondents felt that, at the pharmacy, there wasalways a solution for receiving information about medications that was understandable. This new knowledge on
migrants’ experiences of being able to access the healthcare centre, facilitation in medication and communication at the pharmacy should be used to understandthe gap in communication barriers in order to increase
patient safety. It is important to promote equality. The
findings in this study show one picture of a problem, andHultin et al. BMC Public Health(2024) 24:1257

it is important to explore the problem from other angles,
e.g. perspectives from staff in pharmacies/healthcare aswell as inputs from relatives. Therefore, further studies
are needed in this area.
Acknowledgements
We are grateful to the staff at the healthcare centre and the voluntaryorganisation for migrants for their support in recruiting respondents. This
work was supported by grants from Vetenskapsrådet (The Swedish ResearchCouncil), Sweden, reference number: 2021–06415.
Author contributions
A.E., K.H., M.H., and U.P., wrote study design; L.H., data collection; L.H., M.H., U.P.,
data analysis; L.H., drafting the manuscript with critical revisions to the paper
for important intellectual content by all authors. K.H., A.E., M.H., U.P., obtaining
funding. All authors read and approved the final version of the manuscript.
Funding
This work was supported by grants from Vetenskapsrådet (The Swedish
Research Council), Sweden, reference number: 2021–06415.
Open access funding provided by Uppsala University.
Data availability
The datasets generated and/or analysed during the current study are
not publicly available in order to protect the integrity, anonymity, andconfidentiality of the respondents, with the exception that anonymised
quotations supporting the data in the results section in the manuscript are
shown. These are available from the corresponding author upon reasonable
request.

Declarations
Ethics approval and consent to participate
The study was implemented in accordance with the Helsinki Declaration(World Medical Association, 2013), and all study procedures were approved by
the Swedish Ethical Review Authority (#2020 − 00842).
Written informed consent was obtained from the respondents. Prior to theinterviews, plans were made for the respondent to get contact with staff fromthe healthcare centre or a social welfare officer in case of negative reactions in
the interview situation. However, no such reactions occurred.

Page 10 of 11

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

15.

16.
17.
18.

Consent for publication
Not applicable. No identifiable participant data have been included.

19.

Competing interests
The authors declare no competing interests.

20.
21.

Author details
1
Department of Public Health and Caring Sciences, Uppsala University,
IFV, Husargatan 3, Box 564, Uppsala 751 23, Sweden
2
Primary Care and Health, Uppsala County Council, Uppsala, Sweden

22.

Received: 9 October 2023 / Accepted: 24 April 2024

23.
24.

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Page 11 of 11

Lisa Hultin has a PhD in medical science, focusing on Caring Sciences.
The focus of her thesis was patient safety and patient participation. She is a
specialist nurse in elderly care. International studies on patient safety havebeen conducted in collaboration with the University of Leeds.
Ulrika Pöder is an Associate Professor in Caring Sciences, and a seniorlecturer at the Department of Public Health and Caring Science at
Uppsala University, Sweden. She is a specialist nurse in intensive care andneurosurgery, with a PhD in Medical Sciences. Her field of interest is patient
safety, patient participation and person-centred care. Her research includes
populations from diverse ages and health conditions, from paediatric toolder persons. Research settings are municipalities, healthcare centres, as wellas in-hospital care. To improve patient safety, her work also concerns work
satisfaction and nursing education.
Mariann Hedström is an Associate Professor, and a senior lecturer at the
Department of Public Health and Caring Science at Uppsala University. She
is a registered nurse with a PhD in Medical Sciences. Her research interest
includes patient safety issues, particularly care of older people in different carefacilities and their use of medications.
Anna Ekman is a Clinical Pharmacist at Primary Care and Health, UppsalaCounty Council, with vast experience of medication in elderly with multiple
chronic diseases and patient safety issues in the field of medication use.
She is involved in creating and updating guidelines of medication use, both
locally in Uppsala and in collaboration with other parts of Sweden. Her field ofinterest is optimizing medication use, prescription and communication, and inminimizing harm caused by medication use.
Katarina Hjelm is a Professor in Caring Sciences at the Department of Public
Health and Caring Science at Uppsala University, Sweden. She is a diabetes
specialist nurse and nurse tutor with a PhD in Community Medicine. She has
vast experience in research on migration and health, management of chronic
diseases, and international health, and has a particular interest in beliefs about
health and illness and the influence on self-care and how to best organisecare for foreign-born persons, particularly with diabetes. As a scientificleader, projects have been run on e.g. chronic disease management, healthdevelopment in migrants, care of migrants in psychiatry and emergency
care, culturally adapted elderly care of migrants, communication and use ofinterpreters in healthcare, evaluations of walk-in centres for migrants, anduse of medications at home among foreign-born persons with language
difficulties. International studies on chronic disease management have been
conducted in collaboration with researchers from the UK, Zimbabwe, Uganda,
China, and Oman.