Tolerance and acculturation
Authors: Goth Ursula Småland 
Published: December 2014

Background: Since the 1970s, Norway has experienced a significant increase in population diversity. In 2001, a patient-list system, also referred to as the General Practitioner (GP) Scheme (Norwegian: Fastlegeordning), was introduced to ensure access to primary health care for the entire population. At the time of its introduction, the scheme, which was designed for a homogenous population, was intended to improve the quality of GP services. By facilitating stability and continuity in the doctor-patient relationship, the scheme aimed to ensure equitable access to, and use of, secondary health care. Despite the intention to facilitate stable doctor-patient relationships, employees in health care facilities report that many immigrants use the emergency room rather than GP services. Equity in health care is the absence of systematic disparities in health care. Since the provision of equitable health services is a priority in Norway, this study aimed to investigate the possible motives for immigrants’ choice of service provider and to propose measures to increase the uptake of GP services by this group.Purpose and approach: The aim of the article is to examine newly arrived immigrants' experiences with primary health care. The article attempts to shed light on why immigrants seek medical help at the emergency room and not from their assigned GPs in non-life-threatening situations.Methods and materials: We adopted an exploratory approach in order to investigate both the motives and experiences of diverse groups of immigrants. Semi-structured interviews were conducted with 12 Oslo GPs and 13 immigrant representatives, all living in Oslo. To illustrate patterns on a large scale, we adopted a quantitative approach based on data from health authorities’ registers of consultations. 1,935,000 primary health care consultations conducted in the Greater Oslo area over a two-year period were included in the regression analyses.Results and interpretation: The study shows a varied pattern of use of GP services among the diverse groups of foreign-born residents. Results suggest that immigrants are more likely to use emergency-room services during the first few years after arrival. Results also indicate that information about the patient-list system does not always reach newly arrived immigrants. Contrary to general understanding, non-visible immigrants (when considering factors such as skin color and clothing) diverge the most from the pattern of the majority. Immigrants originating from European countries, such as Sweden and Poland, use the emergency room most frequently. From the qualitative aspects of the study, we have also found that primary health care services are not perceived as equitable.Conclusion: Recently arrived immigrants’ utilization of primary health care services shows an unfavorable pattern. The choice of primary health care service providers is dependent on the individual’s preferences, expectations, experiences and/or actual obstacles. The observed utilization of services provided at emergency rooms is one more reason for monitoring and increasing tolerance and cultural sensitivity in primary health care.