Dismissed and unheard: Arab immigrant women’s experiences seeking pelvic pain care in Norway

Abstract

Objective:

Immigrant women face unique challenges accessing appropriate gynaecological health care. This study investigates how Arabic-speaking women perceive and respond to pelvic pain while navigating Norwegian health care.

Methods:

Interpretative Phenomenological Analysis (IPA) was employed to examine the lived experiences of nine Arab women through interviews conducted in Arabic, facilitating both in-depth individual case analysis and cross-case comparative examination.

Results:

Four themes emerged: (1) Symptom Dismissal and Erosion of Trust in Healthcare; (2) Cultural Stereotyping and Communication Challenges; (3) The Intersection of Pain, Identity, and Daily Life; and (4) Navigating Healthcare Systems and Treatment. These themes reveal challenges in provider relationships, impacts on daily functioning, and complexities of cross-cultural health care experiences.

Conclusion:

Findings highlight the need for improved cultural competency and better recognition of immigrant women’s health concerns. Health care providers should consider cultural backgrounds and previous health care experiences when treating Arab immigrant women, ensuring more effective and culturally sensitive care delivery.

Plain language summary

Immigrant women with pelvic pain struggle to receive appropriate health care in Norway

Pelvic pain affects one in five women globally, significantly impacting daily life. This study examined how Arab women in Norway experience and manage pelvic pain within the Norwegian health care system. We interviewed nine Arab women living in Norway for 7 to 20 years, conducting interviews in Arabic for comfort. Our findings highlighted four main challenges. First, seven of nine women reported health care providers dismissing their pain as normal or inadequately investigating symptoms, eroding trust and discouraging future care-seeking. One doctor even suggested a woman was imagining her problems. Second, cultural stereotyping and communication barriers were prevalent. Despite interpreter services, medical terminology was confusing, and some doctors made inappropriate ethnic assumptions. Women with Arabic-speaking doctors had better experiences. Third, pelvic pain severely affected daily life, hindering childcare, employment, and relationships, leading to isolation for some. Fourth, women faced long waiting times and struggled with the Norwegian health care system’s emphasis on patient autonomy, contrasting with the directive approach in their home countries. These findings indicate that the Norwegian health care system inadequately serves immigrant women with pelvic pain. Health care providers need enhanced cultural competency training to avoid stereotypes and respect diverse backgrounds. Crucially, providers must believe women’s pain reports and conduct thorough investigations. Taking immigrant women’s concerns seriously and providing culturally sensitive care will enable access to appropriate treatment, maintain trust, and support Norway’s goal of equal health care for all.

Introduction

Female chronic pelvic pain (CPP) is persistent pain perceived in pelvic structures, often associated with negative cognitive, behavioural, sexual, and emotional consequences. It may present with symptoms suggesting dysfunction of the lower urinary tract, sexual function, bowel, pelvic floor, or any of the pelvic organs. ¹ Globally, CPP conditions affect 15%–24% of women, representing a significant public health concern that extends beyond physical symptoms to impact mental health, social relationships, and overall quality of life.^2–4 What complicates the condition further is the multifactorial aetiology, with rarely or no involvement of ongoing tissue trauma, inflammation, or infection. ¹ Thus, management includes a holistic approach where patient involvement is fundamental.

While CPP poses challenges for all women, immigrant women face additional and unique barriers in accessing and receiving appropriate health care. These barriers are shaped by culture, which in this study refers to more than language alone. Following Griffith et al., ⁵ we understand culture as encompassing shared beliefs about health and illness, norms for expressing and discussing pain, expectations about patient-provider interactions, and values regarding family involvement in health care decisions. Women from Arabic-speaking countries span diverse nations across the Middle East and North Africa, including Syria, Somalia, and Iraq. Despite this diversity, women from Arabic-speaking countries often share overlapping cultural frameworks that influence how they experience and navigate health care.^6–10

Focusing on the Norwegian context, women from Arabic-speaking countries represent a growing demographic navigating this health care system that differs markedly from the one in their countries of origin. ¹¹ For health care personnel in Norway, challenges in communication, family involvement, and religious and cultural diversity create additional obstacles in pain management and treatment adherence when caring for Arab women. ¹² Research focusing specifically on Arab women’s health care experiences has identified significant cultural competency gaps in health care delivery ¹³ and persistent communication challenges, despite the availability of interpreter services. ¹⁴ A growing body of research emphasizes the need for cultural competency in the treatment of ethnically diverse populations, including health care providers’ awareness of their own biases and the adoption of cultural humility, defined as an openness to learning from patients’ cultural perspectives.^15,16 The Norwegian health care system presents a unique context for understanding these challenges. Characterised by its strong emphasis on primary care, the system is designed to provide universal access to health care services. ¹⁷ Furthermore, the inclusion of patient and user rights in legislation is essential, as it requires health care professionals to involve patients in decision-making and encourages their active participation. This approach reflects a wider shift towards patient autonomy, empowerment, and self-management, in line with modern management recommendations for women with CPP. ¹ However, a systematic review by Altun et al. ¹⁸ identified several key themes in immigrant women’s health care experiences, including difficulties in expressing pain symptoms across cultural and linguistic barriers, challenges in understanding Western medical approaches as opposed to less autonomous health care systems, and feelings of dismissal by health care providers. These challenges may undermine the intended goals of patient-centred care and limit immigrant women’s ability to fully engage with health care services, despite the system’s structural emphasis on equity, participation, and empowerment.

Despite growing research on immigrant health experiences, there remains limited understanding of how Arab women specifically navigate and interpret their experiences with CPP within the Norwegian health care system. ¹⁹ The Health Belief Model (HBM) provides a theoretical framework ²⁰ for understanding how women from Arab countries perceive, interpret, and respond to their pelvic pain in Norway. The model’s core component – perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy – illuminates the complex decision-making processes in health care–seeking behaviours. This study, rooted in the framework of HBM, aimed to investigate how women from Arab countries perceive, interpret, and respond to their pelvic pain while navigating the Norwegian health care system. The study is guided by the following research question: How do women from Arabic-speaking countries experience, understand, and manage their pelvic pain within the Norwegian health care system?

Materials and methods

Study design

This qualitative study employed Interpretative Phenomenological Analysis (IPA) to explore and understand the lived experiences of immigrant women from Arabic-speaking countries seeking health care for CPP in Norway. IPA was chosen as the methodological framework due to its capacity to capture the depth and richness of individual experiences while acknowledging the interpretative nature of the research process. ²¹ This approach aligns with the aim to investigate how women from Arab countries perceive, interpret, and respond to their pelvic pain while navigating the Norwegian health care system. ²² This study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) ²³ guidelines to ensure comprehensive and transparent reporting of the qualitative research methodology and findings. The COREQ checklist was followed throughout the research process to maintain methodological rigour and enhance the credibility of the qualitative research.

Data sampling

Participants were recruited through social media posts, written in Arabic, with information about the study and contact information to an Arabic-speaking member of the research team. Forty women made contact after the initial post, of whom 25 women confirmed their interest in participation. In alignment with methodological principles from IPA, this study deliberately limited participation to 9 individuals from the available pool of 25, as this sample size facilitated the requisite depth of analytical engagement while achieving theoretical saturation – evidenced by the recurrence of thematic patterns and the richness of experiential accounts that emerged during the iterative analysis process. ²⁴ The sampling strategy aimed to capture diverse experiences while maintaining homogeneity in terms of the core phenomenon under investigation. Selection was guided by the participants satisfying the inclusion criteria: (1) a woman aged 18 and above; (2) experiencing CPP pain; (3) born in an Arabic-speaking country; and (4) currently residing in Norway. Nine Arab women participated in this study, representing various backgrounds (Table 1).

Table 1.

Overview of the nine included Arab women participants.

Code	Age range	Years resident in Norway	Educational level	Marital status	Urban or rural
Participant A	30–40	11	Primary school	Married, children	Rural
Participant B	20–30	10	High school	Married, children	Rural
Participant C	30–40	7	University	Married, children	Urban
Participant D	30–40	9	High school	Unmarried, child	Rural
Participant E	40–50	20	University	Married, children	Urban
Participant F	40–50	9	Primary school	Married, children	Urban
Participant G	30–40	14	University	Married, children	Urban
Participant H	50–60	13	University	Married, children	Urban
Participant I	20–30	13	University	Married, no children	Urban

The final sample consisted of women between 20 and 60 (mean age 39.5 years) with different lengths of residence in Norway (ranging from 7 to 20 years). Participants represented diverse educational backgrounds, from primary school to university level, and predominantly lived in urban areas (six out of nine participants) in Norway. All but two of the participants were married with children, offering insights into how family dynamics intersect with health care experiences.

Data collection and analysis

The data were collected by two research assistants, of whom both with higher education within public health sciences and extensive experience working with migrant women both nationally but also internationally. The first is fluent in Norwegian and English, and the second assistant is trilingual Arabic/Norwegian/English; this second research assistant shared the participants’ cultural background and served as an interpreter. A rigorous translation protocol ensured accuracy through multistage validation by the principal investigators (MT, MKT) and research assistants, followed by a supervisory review by SCG and consensus discussion of any discrepancies.

From an initial sample of 25 participants with CPP, 9 were Arab-speaking immigrant women who met our inclusion criteria and form the basis for this analysis. The remaining participants were from Somalia and included in a separate study. These nine Arab-speaking participants were selected to ensure diversity in age, duration of residence in Norway, marital status, educational attainment, and CPP symptom duration.

Prior to the interviews, the interview guide was pilot-tested among one migrant woman experiencing CPP of Somali origin. Minor corrections were performed after the pilot testing, mainly related to the phrasing of the questions (Supplemental Material 1). Subsequently, a comprehensive review of the interview guide was conducted involving the research team and research assistants to ensure that the questions were conceptually appropriate, culturally sensitive, and aligned with the study objectives.

The nine participants were selected following the IPA principles of purposive homogeneity, with theoretical saturation reached through voluntary participation by the interested women. After obtaining written and verbal consent, semi-structured interviews were recorded and store using Nettskjema Dictaphone, a secure digital recording application, during September-December 2024. Interviews were conducted in Arabic using a non-professional interpreter and lasted from 22 to 38 min. The recordings were manually transcribed from Arabic to Norwegian and subsequently translated into English.

The analysis followed the IPA guidelines ²¹ through four systematic steps:

• Multiple close readings of the transcripts were conducted with detailed exploratory notes focusing on descriptive, linguistic, and conceptual elements of participants’ experiences with pelvic pain in Norwegian health care.

• Exploratory notes were transformed into experiential statements capturing essential meanings, while maintaining connection to original narratives.

• Patterns and relationships between experiential statements were identified, clustering similar experiences while preserving individual contexts.

• A comprehensive table of personal themes was developed to capture both individual experiences and shared patterns across participants (Table 2).

The analysis process, illustrated in Table 2, demonstrates the progression from raw experiential data to refined thematic understanding, preserving both the authenticity of the individual narrative and the cross-participant patterns that illuminate the complexity of immigrant women’s health care experiences in Norway.

Table 2.

Detailed phenomenological analysis of Arab women’s health care experiences.

Superordinate theme	Subtheme	Experiential statement	Linguistic elements	Supportive quotes	Interpretative notes
Cultural and Communication Barriers in Patient-Provider Trust	Trust and Credibility	Feeling dismissed and invalidated	Use of passive voice, emotional language	The doctor didn’t take me seriously . . . (P-B)	Reflects power dynamics in health care relationships
		Barriers to changing providers	Expression of helplessness	I wanted to change my GP, but . . . it was embarrassing. (P-C)	Reflects power dynamics in health care relationships
	Cultural Communication	Impact of language barrier	Direct reporting of challenges	My GP speaks Arabic, so I don’t have any problems. (P-A)	Language as facilitator or barrier to care
The Intersection of Pain, Identity, and Daily Life	Physical Limitations	Restricted mobility and function	Detailed description of limitations	I can’t work now; I can’t vacuum either. . . (P-D)	Impact on independence and self-sufficiency
	Social Isolation	Withdrawal from social activities	Use of absolute terms	I have no social life; I have cut contact with everyone. (P-F)	Social consequences of pelvic pain conditions
Navigating Healthcare Systems and Treatment Journey	Treatment Approaches	Comparing health care systems	Comparative language	Here in Norway, they are careful with medication, the opposite of [the system in] my home country. (P-H)	Cultural expectations influence treatment perception
	Patient Education	Unmet information needs	Expression of uncertainty	When you don’t get enough information . . . you become less motivated . . . (P-I)	Impact of communication on treatment adherence

The analytical process was strengthened by the research team’s interdisciplinary expertise spanning multiple relevant fields: XX (deleted for review) with a background in public health and social sciences; XX (deleted for review) with a background in psychology, social sciences, and education; and XX (deleted for review) with a background in women’s health, CPP research, and public health with extensive clinical experience working with migrant women. This combination of public health, psychology, and social sciences facilitated a comprehensive analysis that captured both the health care and psychosocial dimensions of participants’ experiences.

Ethics approval and consent to participate

The Norwegian National Research Ethics Committee’s initial assessment of this project (date: 05 February 2024) concluded that it did not require further evaluation (reference no. 709515) and that it only needed approval from the Norwegian Centre for Research Data due to the personal information collected (date: 09 April 2023, reference no. 258827).

Results

The analysis revealed four distinct themes:

1. Symptom Dismissal and Erosion of Trust in Healthcare explores how immigrant women’s pain experiences are minimised, dismissed, or inadequately investigated by health care providers, leading to erosion of trust and reluctance to seek future care.

2. Cultural Stereotyping and Communication Challenges demonstrates how cultural assumptions, language barriers, and communication difficulties create additional barriers to effective health care, despite the availability of interpretation services.

3. The Intersection of Pain, Identity, and Daily Life highlights how pelvic pain significantly impacts women’s family responsibilities, social relationships, and daily activities.

4. Navigating Healthcare Systems and Treatment Pathways explores the participants’ experiences navigating Norwegian health care, contrasting these with the treatment approaches in their countries of origin.

Symptom dismissal and erosion of trust in health care

Seven of the nine participants described situations where their symptoms were not properly investigated and subsequently minimised or attributed to common conditions. Participants in this study described how their immigrant status, language barriers, and cultural background compounded these experiences, creating additional layers of vulnerability in clinical encounters. For instance, Participant A, believing she had a serious medical issue, detailed the pain she was experiencing to a health professional; her symptoms, however, were dismissed as normal, leading her to believe she had no choice but to endure the pain:

Since the health personnel said it was normal, I just have to endure it.

This dismissal affected her future health care–seeking behaviour by eroding her trust in the health care system and creating reluctance to seek care for subsequent symptoms, as she internalised the message that her pain experiences would not be taken seriously or properly investigated.

The experience of not being believed by medical professionals emerges as a significant concern among participants. Another participant described her interaction with her family doctor, who similarly dismissed her symptoms:

The doctor didn’t take me seriously; he said I just think I have problems, but actually I don’t. (Participant B)

This dismissal not only invalidated her subjective experience of pain but also positioned her as an unreliable narrator of her own physical symptoms. For Participant B, experiencing this dismissal in an unfamiliar language and health care system intensified her sense of powerlessness. Without sufficient linguistic resources, she was unable to effectively advocate for further investigation of her symptoms.

Some participants described particularly challenging encounters that affected their trust in the health care system. One participant shared a distressing experience relating to pain during intercourse:

She [her GP] refused to examine me, was dismissive, and I was suppressed. I wanted to change my GP, but I had a male contact person in the municipality, and it was embarrassing to talk about my challenges [the pain during intercourse]. (Participant C)

This experience highlights how negative interactions with medical providers intersect with culturally shaped barriers to create compounded obstacles to seeking health care. These barriers include gendered norms around discussing intimate health concerns, as well as unfamiliarity with patient rights within the Norwegian system.

Cultural stereotyping and communication challenges

Beyond outright dismissal, participants also encountered cultural insensitivity that compounded their health care challenges. Participant G described two problematic interactions; the first one was regarding her ongoing pelvic pain:

The doctor said to me that my uterus is down due to childbirth [referring to uterine prolapse] . . . it is uncomfortable, especially during menstruation. (Participant G)

The second interaction occurred during pregnancy:

A doctor told me ‘. . . you have difficulties [during childbirth] because you who come from the Middle East are shorter than us [‘white’ Europeans], therefore you don’t have enough space for the baby’. (Participant G)

This interaction demonstrates how cultural stereotyping, and assumptions about ethnicity, can become embedded in medical explanations, further marginalising immigrant women’s health care experiences.

Communication barriers further complicated understanding of medical conditions, as illustrated by another participant’s confusion over medical terminology:

They [healthcare personnel] say the disease is sleeping [sic; the intended medical meaning was ‘in remission’] . . . is the disease ‘sleeping’?! I have never heard of that, yet I have all these symptoms. (Participant H)

The importance of clear communication and patient autonomy was emphasised:

I feel a bit uncertain. I got medical help, but an explanation or sufficient information was not quite there. When you don’t get enough information, you become less motivated to engage with the healthcare process. (Participant I)

However, not all interactions were negative. Despite the challenges faced by some participants with health care professionals, positive experiences were also reported, particularly when language barriers were addressed. One participant emphasised her positive experience with a doctor who spoke her native language:

Yes, but you can get an interpreter who can help. My GP speaks Arabic, so I don’t have any problems communicating with him. (Participant A)

This highlights how linguistic accessibility can fundamentally transform patient-provider relationships and health care outcomes.

The intersection of pain, identity, and daily life

The impact of pelvic pain on daily life emerged as a significant theme, with participants describing how their conditions affected their ability to maintain normal activities and fulfil basic tasks. The pain and discomfort significantly impacted their quality of life and often impinged on their family responsibilities, described vividly by Participant E:

I can’t do anything when I get these pains. One day my daughter had an appointment at the health clinic, and suddenly the pains came. I couldn’t go to the appointment. (Participant E)

This shows how the unpredictable nature of their conditions interfered with childcare responsibilities.

Another participant D described the extensive impact of pelvic pain, which she bore on top of a pre-existing condition:

It’s in the joints and nerves. I can’t work now; I can’t vacuum either. The condition [an autoinflammatory disease] has really developed. I can’t hold the phone for more than 10 minutes, and I can’t drive for more than an hour. Showering is the biggest challenge, especially one week before menstruation starts . . . (Participant D)

This detailed description illustrates how these conditions affect every aspect of daily life.

One Participant F explained the social isolation she felt resulting from the pelvic pain:

I have no social life, I cut contact with everyone. My quality of life has become very poor after I came to Norway, due to the pain in my body. (Participant F)

This statement reveals how painful conditions can lead to social withdrawal and a deterioration in the quality of life.

Navigating health care systems and treatment pathways

Participants frequently compared their health care experiences in Norway with those in their home countries, revealing different expectations and approaches to treatment, expressing challenges of adjusting to a different health care system. Several participants expressed frustration with the long waiting times in Norway:

Here in Norway, they are careful with medication, the opposite of my home country. In Norway, you either die or get better [she said with a smile] while waiting for the appointment. What’s not good is the long waiting time. (Participant E)

The complexity of managing pelvic pain across different health care systems became further apparent through the participants’ experiences. One participant experienced unexpected side effects following medical intervention in Norway:

In my home country, I used to take medicines, and I didn’t have any adverse reactions to them. I developed them [side-effects from medication] after my last operation in Norway. (Participant F)

This highlights the need for better patient education and shared decision-making in treatment plans within the Norwegian health care context.

Discussion

The application of the HBM reveals how the participants’ perceived barriers to health care access are influenced by their dual framework of health care expectations, developed through experiences in both their countries of origin and Norway. The model elucidates why participants might choose to endure symptoms rather than seeking further medical attention, highlighting how cultural beliefs about pain tolerance, previous health care system experiences, and perceived treatment effectiveness collectively influence health care decisions.

The theoretical framework further recognises that immigrant women’s health care experiences are shaped by their perceived barriers. These barriers reflect the experiences of dismissal of symptoms leading to reduced trust that they could receive help for their problems, language barriers and lack of information leading to lack of motivation to pursue further health care and, as a result, loss of autonomy. Within this framework, the concept of cultural capital becomes relevant, as participants navigate between their inherited health knowledge systems and the Norwegian health care context, often experiencing dissonance when their cultural expressions of pain are not recognised or validated by health care providers. The HBM’s emphasis on self-efficacy is particularly pertinent in this study, as participants’ confidence in managing their health conditions is significantly influenced by their ability to communicate effectively with providers and receive culturally responsive care. ²⁰ Understanding these theoretical underpinnings helps to illuminate the importance of individually targeted interventions with strong emphasis on building trust and improve patient autonomy for addressing the complex needs of Arab immigrant women with pelvic pain conditions in Norway.

The erosion of trust documented in our findings aligns with recent research on immigrant health care experiences in Scandinavian contexts.^7,25 However, our analysis reveals that trust operates as more than an interpersonal dynamic; it functions as a critically modifying factor affecting all HBM constructs. When health care providers dismiss symptoms as normal, they fundamentally alter women’s frameworks for understanding legitimate suffering, a process that Ahmadinia et al. ⁹ identify as particularly acute among Middle Eastern immigrants in Nordic countries. It is important to acknowledge that symptom dismissal and communication difficulties are well-documented challenges for women with CPP irrespective of ethnic background.^2,3 However, for Arab immigrant women, these experiences are compounded by language barriers, unfamiliarity with health care system navigation, cultural differences in expressing and discussing pain, and potential provider biases related to ethnicity and immigration status. Thus, while the core experience of dismissal may be shared, the mechanisms through which it occurs, and its downstream consequences are shaped by the intersection of gender, culture, and immigrant status. This normalisation represents a form of epistemic invalidation where biomedical authority overrides embodied knowledge, fundamentally altering self-efficacy – a crucial HBM component that determines whether individuals believe they can successfully navigate health care systems. ¹⁷

The cultural dissonance between Arab and Norwegian health care approaches extends beyond communication barriers to fundamental philosophical differences in conceptualising health and treatment. As Katoue et al. ²⁶ note, Middle Eastern health care systems often emphasise immediate pharmaceutical intervention with less patient involvement, contrasting sharply with the Norwegian regulations including patient autonomy, empowerment, and self-management in modern health care. ¹⁷ This divergence creates challenges for immigrant women from Arab countries who, Alkhaibari et al. ²⁷ demonstrate, may interpret patient-centred care and shared decision-making as provider disengagement rather than as empowerment.

Our findings support Webair’s ²⁸ observation that the absence of patient-centred care traditions in Arab context creates expectations for more directive medical authority, leading to confusion when Norwegian providers emphasise patient autonomy. This misalignment is further complicated by what Attum et al. ¹⁰ identify as cultural preferences for gender-concordant care and family involvement in medical decisions, preferences often unmet in Norwegian health care settings.

The intersection of pain, identity, and social isolation revealed in our findings resonates with Hawkey et al.’s ³ work on the impact of pelvic pain on daily life, but takes on additional dimensions for immigrant women. The social consequences of unfulfilled family obligations due to pain create what Landmark et al. ⁴ describe as ‘cascading psychosocial effects’; for these Arab women, however, these effects are amplified by the cultural expectations of women’s roles as family caregivers. This aligns with Demirtaş et al.’s ¹⁹ findings that immigrant women experience compounded quality of life impacts from pelvic pain due to additional acculturative stressors. The resulting isolation is particularly concerning given Jouanny et al.’s ¹¹ evidence that stigmatised pelvic conditions already create significant impediments to seeking help, barriers that are magnified when combined with cultural taboos around discussing intimate health concerns.^12,13

Language obstacles, while partially addressed through interpreter services, remain inadequately resolved in practice. Our findings support Kwan et al.’s ¹⁴ systematic review showing that professional interpretation alone does not ensure effective communication, as cultural concepts of health and illness require translation beyond linguistic conversion. Recent research on Arabic-speaking immigrant women demonstrates that culturally tailored health education tools can significantly improve health literacy and communication, highlighting the importance of culturally specific interventions. ³⁰ The positive experiences with Arabic-speaking providers in our study align with Al Shamsi et al.’s ²⁹ meta-analysis demonstrating significantly improved health outcomes when language concordance exists. However, as Khorshidi Organi et al. ³⁰ and Taylan and Weber ³¹ argue, effective cross-cultural health care communication requires both shared language and shared conceptual frameworks for understanding illness experiences. This is particularly relevant for conditions like pelvic pain, where Altun et al.’s ¹⁸ systematic review found that immigrant women often lack culturally appropriate vocabulary to describe symptoms, leading to misdiagnosis or delayed treatment. Drawing on Fricker’s ³² concept of epistemic injustice, we can understand these communication barriers as contributing to testimonial injustice, whereby immigrant women’s pain accounts are given deflated credibility due to identity-based prejudices related to language, culture, and immigration status. This epistemic invalidation means that their experiential knowledge of their own bodies and symptoms is systematically undervalued in clinical encounters.

The structural dimensions of health care access revealed in our study extend beyond individual encounters, encompassing systemic issues within the Norwegian health care model. Norway practises a gatekeeping system in which patients must first consult their assigned GP before accessing specialist care. While this system ensures resource efficiency, it creates what Darebo et al. ⁶ identify as compound barriers for immigrant women unfamiliar with navigation strategies developed by majority populations. These findings support the systematic review by Pérez-Sánchez et al., ⁷ which shows that immigrant women face delays in accessing sexual and reproductive health services. This is particularly problematic for chronic conditions requiring ongoing management. The extended waiting times that participants found particularly distressing reflect what Khosravi et al. ³³ documented as a barrier to health care utilisation, in which inefficient service delivery can discourage women from seeking medical care.

These findings have important implications for health care policy and practice in increasingly diverse societies. Health care provider cultural competency training must move beyond stereotypical cultural traits. Instead, adopting a framework of cultural humility, which emphasizes ongoing self-reflection, recognition of power imbalances, and lifelong learning, can better address unconscious bias and power dynamics in clinical encounters.^16,34,35 This approach recognizes that cultural understanding is not a finite skill to be mastered but an ongoing process of self-critique and respectful engagement with patients’ lived experiences. Health care systems need flexible approaches that accommodate diverse expectations while maintaining clinical standards, including improved access to gender-concordant providers when culturally important, ⁹ in order to promote equitable and culturally responsive care. This is particularly crucial for conditions like CPP requiring intimate examinations and discussions. One participant’s experience that she wanted to change her health care provider but had a male contact person in the municipality, making it ‘embarrassing to talk about my [her]challenges’. This demonstrates how referral and contact person systems can inadvertently create barriers. These systems are designed to facilitate coordination but may not consider cultural preferences for gender concordance in sensitive matters. Research on immigrant and ethnic minority women demonstrates that multiple intersecting barriers exist when accessing health care services, requiring comprehensive, multi-level interventions.^36,37 The development of ‘cultural health mediators’ or ‘intercultural mediators’, as suggested by recent European models and WHO, could bridge different health care paradigms while supporting system navigation.^38,39 Ultimately, achieving equitable pelvic pain care for women from Arabic-speaking countries requires recognising that their experiences reflect not only individual struggles but also systematic failures, requiring institutional-level interventions that value diverse ways of understanding and experiencing health.

Strengths and limitations

This study offers valuable insights using IPA for rich, detailed data; conducting interviews in Arabic for authentic expression; and recruiting a diverse sample with varied residence lengths (7–20 years), educational backgrounds, and geographical locations. Thus, we believe our study holds adequate information power based on a narrow study aim, HBM as a theoretical framework, a strong interview dialog between the researcher and the participant, and the analysis of each participant’s narratives using IPA. ⁴⁰

Several limitations warrant consideration. While pilot testing strengthened the interview guide, it was conducted with a Somali woman rather than an Arabic-speaking participant, which represents a limitation. Cultural and linguistic differences between these groups may have influenced how certain questions were interpreted. It should also be noted that Arabic-speaking populations are not a homogeneous group, encompassing considerable linguistic and cultural variation. Consequently, some language- or culture-specific nuances may not have been fully captured, even had pilot testing been conducted within an Arabic-speaking community. However, subsequent discussions within the research team and ongoing reflexive engagement during data collection helped mitigate this limitation. Another limitation is the multi-stage translation process (Arabic to Norwegian to facilitate joint understanding and discussion within the research group, and later from Arabic to English for publication purposes). Another limitation was the use of a non-professional interpreter that may have affected precision, particularly for culturally specific pain expressions. The average 29-min interview duration potentially limited deeper exploration of complex experiences and emotional responses. The sample predominantly consisted of married mothers (8/9 participants) and urban residents (6/9), possibly limiting insights into single, childless, or rural women’s experiences. Additionally, findings may not transfer directly to other immigrant groups or health care contexts beyond Norway.

Despite these limitations, the study provides valuable insights into Arabic-speaking women’s pelvic pain experiences in Western health care. The cultural concordance in research methodology enhanced participant comfort and data authenticity.

Conclusion

These findings show that immigrant women from Arabic-speaking countries living in Norway face significant challenges related to CPP. Cultural barriers, language difficulties, and a health care system that does not always take their special needs into account can lead to alienation and result in the medical problem being overlooked. Ensuring that all women receive equal health care in the universalist Norwegian health care system requires the implementation of measures that properly recognise and meet these women’s unique health challenges, as well as strengthening trust between immigrant women and health personnel.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261444190 – Supplemental material for Dismissed and unheard: Arab immigrant women’s experiences seeking pelvic pain care in Norway

Supplemental material, sj-docx-1-whe-10.1177_17455057261444190 for Dismissed and unheard: Arab immigrant women’s experiences seeking pelvic pain care in Norway by Miroslava Tokovska, Simen Christensen Grøgaard and Merete Kolberg Tennfjord in Women's Health