Gender differences in beliefs about health: a comparative qualitative study with Ghanaian and Indian migrants living in the United Kingdom

The United Kingdom is a major destination for international migration [1]; between 1993 and 2011 the foreign-born population in the UK almost doubled from 3.8 million to around 7.0 million. There is a well-established association between migration to high income countries and health status, with some groups reporting poorer health outcomes over time than the host population [2, 3]. However, the relationship between migration and health is dependent upon a number of factors including ethnicity, migration status (voluntary or involuntary migration), age and gender [4]. Other factors such as long hours of work, unemployment, poorer quality housing, stress and poor command of the host country’s primary language can have detrimental impacts on migrant health outcomes [5]. Furthermore, migration influences lifestyle choices and health behaviours, with evidence of changes in dietary pattern due to challenges incorporating traditional foods as well as increased consumption of processed food [6]. As a consequence, we see an increase in chronic diseases among migrant populations, for example cardiovascular disease, stroke and Type 2 diabetes are more prevalent among people of South Asian ethnicity (e.g. Indian, Pakistani and the Bangladesh) in the UK [7, 8]. Furthermore, migrants from African countries are at a higher risk of developing chronic diseases than those that do not migrate [9]. People of African descent living in Europe have high incidence rates of stroke, diabetes and hypertension [10] and this may be attributed to differences in individual health behaviors or the socioeconomic circumstances of migrants [11].

Understanding how individuals make sense of health, and empowering communities to adopt healthy practices to prevent chronic illnesses, is an important first step to developing practical interventions to improve health outcomes among migrant populations. However, studies that have examined health beliefs and health behaviours have tended to aggregate findings from migrants across different countries of origin or have examined single groups from specific countries of origin, or ethnicities, in isolation. However, aggregation at this level does not recognize heterogeneity in beliefs and behaviours [12]. There may be the assumption that there are inter, but not intra, sharing of common beliefs and behaviours across minority ethnic groups. Africa has been described as culturally complex [13] and yet there are shared common beliefs and cultural values that center around the equal status of spiritual and physical aspects of the body in health, a strong respect for the role of elders within families and society and the role of extended kinship bonds (e.g. grandparents, aunts, uncles, cousins) in the influencing of important health-related decisions [14]. Within Ghana an estimated 70% of the population depend on complementary or alternative medicine for their healthcare [15]. Conversely, within India it is common to attribute and explain illness in terms of chance-related factors, fate or karma [16]. Furthermore, there has shown to be a reluctance to accept a diagnosis of emotional illness because it can impact on the chances of other members of the family getting married which can impact on decisions to seek help [17]. More research is needed to explore differences across cultural groups in terms of beliefs about health and health-related behaviours.

Processes that influence health behaviours and health outcomes across minority ethnic groups are complex; a range of factors influence or drive health behaviours. The patterning of such factors may, or may not, depend upon ethnicity-based groupings, and although people might be classified as the same ethnic grouping, culture ascribes specific gender roles for men and women, which can further influence perspectives of health [5]. For example, women, as a consequence of being “genetic housekeepers” or information holders within families [18],are more likely than men to cite hereditable factors as causes of conditions such as breast cancer, heart disease and arthritis [19]. Furthermore, it is increasingly recognized that it is important to understand how men “do” health and illness. It is proposed that men perceive social pressure to conform to dominant masculine gender role norms and that deviation from these norms may lead to gender role conflict [20]. However, masculine gender role ideals exist with contextual factors, such as age, class, culture and these also influence health behaviour [21]. To date much of the research in this field has been conducted with Western populations and more work is needed to understand the role of gender in moderating cultural diversity in beliefs about health. The aim of this study was to undertake a comparative exploration of beliefs of health among male and female Ghanaian and Indian migrants and White British participants residing in an urban area within the UK.

Ethical approval for the study was obtained from a the University of Birmingham Research Ethics Committee. The consolidated criteria for reporting qualitative studies (COREQ) [22] were adhered to.

The aim of this study was to undertake a comparative exploration of beliefs of health among male and female Ghanaian and Indian migrants and White British participants residing in an urban area within the UK. Differences in beliefs and health behaviour practices were apparent across participants from the different countries of origin and the persistence of culturally based beliefs following migration would account to some extent for observed differences in beliefs and health practices between a host population and new migrants [5]. However, established gender differences were also apparent and women were more proactive around issues concerning their weight than men [26] which is in line with previous research reporting that women commonly opt for portion controlled or lower calorie foods [27–31] and are likely to avoid fat and consume higher amounts of fiber than men [26]. Conversely, maintaining good health is not seen to be a motivation for men’s food choice.

The analysis demonstrated a clear position that men are more likely to report that they are well because of how they attribute signs of good health. Men’s beliefs about health are shaped by societal prescription of their role and “being masculine” may involve being able to withstand challenges, conceal emotion and not disclose distress, which in turn could shape behavioral responses such as help-seeking [32, 33]. Men in our study attributed good health to the avoidance of healthcare services or not having a major illness and evidence suggests that in general men in Britain are less likely to visit their GP compared to women [34]. In Ghana it has been shown that men are three times more likely to use complementary or alternative medicine than females [35]. A recent review on delays in medical and psychological help seeking in men showed that men often delayed seeking help as they misinterpreted a symptom as insignificant and therefore not requiring professional support [36] The same review also highlighted that conformity to masculine gender role norms was an important barrier to men’s help-seeking whereby men considered medical help-seeking behaviour to be a feminine activity.

This study demonstrated that participants from Ghana and India were less likely to speak about engaging with pharmacists or healthcare providers for common symptoms. Attributing being healthy to not having a “serious condition” or to not needing to access healthcare services might reflect differing previous experiences of healthcare systems utilization. Although in the UK each person is registered with a general practitioner in their geographical area, the experiences of migrants from Ghana and India may be explained by the differences in access to health services in their respective home countries. For instance, India has a large private healthcare system although it is estimated that three quarters of the population live below the poverty line and are unable to access private healthcare; the public sector health services within India primarily focus on preventative health approaches and as such low and middle income citizens may be precluded from accessing services offered by private healthcare providers [37]. In contrast, Ghana, has a National Health Insurance System that was introduced in 2009 to provide universal access to healthcare, with each individual required to make a yearly qualifying contribution [38]. Prior to this, access to and utilisation of high quality health care was selective—graded by economic status. Coupled with a low doctor-patient ratio, this made it increasingly difficult to obtain an appointment with a doctor [39]. Recent evidence from Ghana [40] indicated an increase in preferences for alternative remedies (including traditional and faith based remedies) for treating illnesses rather than seeking an appointment with a health professional. Furthermore, minority groups in high income countries may use channels other than primary healthcare facilities (e.g. self-medication) because of minimal previous exposure to healthcare services [41]. Other issues around accessibility of healthcare services for migrant populations included inadequate knowledge of health risks, minimal understanding of public health messages and cultural and language barriers [42].

The findings should be interpreted within the limitations of this study. Firstly, the study utilized a small sample of migrants, most of whom were younger and included only two country of origin groups, which may limited the range of stories provided. Furthermore, the sample recruited into this study was highly educated and may not reflect the experiences of migrants with differing socioeconomic and immigration status. In addition, participants were recruited through community settings, including Christian churches, which may have introduced bias in the sample around the role of religion in health. Finally although the results provide novel data around the experiences of migrants in the UK, it may not possible to generalize findings to other migrant groups within other UK cities.

This study is important in that it is the first study to undertake a comparison of the perceptions of health among migrants from different countries of origin (India and Ghana) living in the UK. This study adds to the existing literature indicating that migrants’ perceptions of health and engagement in health behaviours are influenced by not only cultural prescriptions formed from their home country environment but also personal and societal expectations of gender-based behaviour. Future research could consider the role of migration on perceptions of health and illness and how this impacts on help-seeking and utilization of healthcare services, which emerged during this analysis as an area likely to be impacted by beliefs about what it means to be healthy. Furthermore, cultural definitions of what it is to be healthy are essential in supporting the co-design of interventions for minority populations and the results of this study add to the call for culturally sensitive community-based interventions, which may increase engagement and lead to better health outcomes for migrant populations.