European Journal of Physiotherapy
ISSN: 2167-9169 (Print) 2167-9177 (Online) Journal homepage: https://www.tandfonline.com/loi/iejp20
A qualitative study among women immigrants
from Somalia – experiences from primary health
care multimodal pain rehabilitation in Sweden
Bruno Semedo, Britt-Marie Stålnacke & Gunilla Stenberg
To cite this article: Bruno Semedo, Britt-Marie Stålnacke & Gunilla Stenberg (2020) A qualitative
study among women immigrants from Somalia – experiences from primary health care multimodal
pain rehabilitation in Sweden, European Journal of Physiotherapy, 22:4, 197-205, DOI:
10.1080/21679169.2019.1571101
To link to this article: https://doi.org/10.1080/21679169.2019.1571101
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EUROPEAN JOURNAL OF PHYSIOTHERAPY
2020, VOL. 22, NO. 4, 197–205
https://doi.org/10.1080/21679169.2019.1571101
ORIGINAL ARTICLE
A qualitative study among women immigrants from Somalia – experiences from
primary health care multimodal pain rehabilitation in Sweden
Bruno Semedoa
, Britt-Marie Stålnackeb and Gunilla Stenberga
a
Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden; bCommunity Medicine and Rehabilitation,
Rehabilitation Medicine, Umeå University, Umeå, Sweden
ABSTRACT
ARTICLE HISTORY
Background: Immigrants often experience difficulties with acculturation and post migratory stress
after arrival in a host country and studies report poor health, chronic pain and depression. This is a
challenge for primary health care and interventions need to be evaluated.
Objectives: To explore the experiences of a group of women from Somalia who took part in a multimodal pain rehabilitation programme in primary healthcare in Northern Sweden.
Methods: Seven individual interviews a few months after participation, and a focus group discussion
one year after the programme were conducted and analysed with Grounded theory.
Results: A core category regained life emerged from the data. This was described as a process in two
categories: panic and connection. The participants experienced that the programme was helpful and
that the pain was reduced. They became more open-minded; got new ideas and knowledge; were
helped to improve their societal adaptation and integration; experienced that they were not alone;
and learned that there is benefits when a group of people share experiences and feelings.
Conclusions: Multimodal pain rehabilitation can be helpful for women immigrants from Somalia. The
programme triggered positive changes in their lives and they received knowledge about how to manage pain and improved their self-confidence and health.
Received 3 August 2018
Revised 7 January 2019
Accepted 12 January 2019
Published online 15 February
2019
KEYWORDS
Primary healthcare; group
treatment; team treatment;
chronic pain;
musculoskeletal pain
Abbreviation: MMR: multimodal rehabilitation
Introduction
Chronic pain is one of the most disabling and costly afflictions in the developed world, but its burden is equally or
more important in the developing world [1–3].
Approximately, 20% of the world’s population suffers from
chronic pain [3]. In Sweden, chronic pain is more common
among women than men and among immigrants [4].
According to Statistics Sweden, approximately 53,987 emigrants came to Sweden from Somalia between 2000 and
2014 [5] and around 7200 Somalis received Swedish citizenship between 2000 and 2011 [6]. These immigrants are passing or have passed through a process called acculturation.
Acculturation is the changes that occur as a result of contact
with culturally different people, groups and social influences
[7], even if these changes occur as a result of intercultural
contact [8]. Migrants (immigrants, refugees and asylum
seekers) often experience difficulties with acculturation and
post migratory stress after arrival in a host country. This
stress may be related to language barriers, unemployment,
cultural differences, lack of social support, and experiences of
discrimination, xenophobia or racism [9,10]. These factors
place migrants at risk for physical and mental disorders [11].
Some migrants report their health to be good or very
good before moving to the host country [12]. However, this
CONTACT Gunilla Stenberg
gunilla.stenberg@umu.se
can change completely after migration, with subsequent
reports of poor health and feelings of depression and loneliness [12]. Moreover, migrants report poorer health when
compared with local inhabitants [11].
If gender is taken in consideration during the migrant’s
acculturation, women tend to be at a higher disadvantage
when compared to men. The disadvantage makes female
migrants even more prone to depression or feelings of loneliness [12,13]. One reason for this may be a lack of higher
education which makes it more difficult for women to compete with men in the labour market [12,13]. In addition, having chronic pain further complicates the situation and leads
to loss of control [14,15]. Healthcare does not always support
immigrant women in finding a way forward, but rather holds
them back [15].
According to International Association for the Study of Pain
[16], ‘pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage’. Pain syndromes are distinguished on the basis of duration, site and pattern [17,18].
Chronic pain is not transitory like acute pain, and persists
more than three to six months [18]. Manifestations of plastic
and biological changes, which may be permanent, are responsible for pain transmission to the neural pathways and other
tissues, and will be partly responsible for that pain became
Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå 90187, Sweden
ß 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.
0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in
any way.
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B. SEMEDO ET AL.
Table 1. Background data for the participants.
Settings
Participant Age (years) Number of children Individual interview Focus group
P1
P2
P3
P4
P5
P6
P7
38
51
44
51
39
43
51
2
1
1
1
3
1
6
冑
冑
冑
冑
冑
冑
冑
冑
x
冑
冑
x
冑
冑
冑: present; x: not present.
chronic [17,19]. However, psychological factors (such as
depression, anxiety, fear, lack of self-confidence, and inability
to handle different negative situations or events) also play an
important role in pain experience [17,20] and chronic pain
negatively affects quality of life when about 1/3 of those who
suffer from chronic pain are less able or unable to maintain
an independent lifestyle [21]. Therefore, it is important to
determine appropriate treatment, focussing on the original
cause of the pain and taking into consideration all the other
factors that contribute to perpetuation of the pain.
Scientific evidence shows that multimodal rehabilitation
(MMR) can be more effective than separate interventions to
reduce pain, increase return to work, give a more active life,
and shorten sick leave [17]. Since 2011, national guidelines in
Sweden for selection criteria are available to support assessment of patients with chronic pain, and thereby offer MMR
on the appropriate level (specialist vs. primary healthcare)
[22]. MMR programmes typically consist of psychological
interventions combined with physical therapy, exercise or
activity. MMR is based on a biopsychosocial model [23] that
assumes that successful treatment must take in consideration
somatic, psychosocial, environmental and personality factors.
MMR involves interventions that proceed from a holistic perspective, combining behavioural psychological approaches
and physical activity or relaxation exercises. MMR involves
several methods to manage pain, as well as education about
pain and physical activity. MMR is a process, and consists of
well-planned and coordinated actions led by a team of professionals with a common goal [24]. The professionals who
may be involved in the multimodal team include a medical
doctor, nurse, physiotherapist, occupational therapist, social
worker and psychologist.
There is a need to examine chronic pain, together with
psychosocial points of view, especially with regard to immigrants and refugees who suffer from chronic pain and usually have more difficulty accessing healthcare [13]. These
groups have not been included in previous studies of MMR
and it is important to let the patients’ voices be heard.
Therefore, we performed a qualitative study that aimed to
explore the experiences of a group of women from Somalia
who took part in a multimodal pain rehabilitation programme in primary healthcare in Northern Sweden.
Methods
A qualitative approach with emergent design was used with
individual interviews and one focus group discussion.
Grounded theory [25] was used for the data analysis.
A group of Somalian women underwent an MMR programme with a biopsychosocial approach in a healthcare
centre in Northern Sweden. The programme took place during the autumn of 2013. Women with some type of chronic
musculoskeletal pain (mostly joint and muscle pain) were
invited to take part in the programme. Eight women participated. The programme consisted of six weekly group sessions. Each session lasted up to two hours. There were one
nurse, two physiotherapists, and one medical doctor involved
in the programme. One of the physiotherapists had further
education in cognitive behavioural therapy. The MMR programme consisted of physical activities like outdoor group
walks and swimming lessons, and theoretical interventions
like counselling about diet, body awareness, how to cope
with pain, and women’s health.
Study participants were originally from Somalia. Somalia
has suffered from many internal problems since its authoritarian socialist regime collapsed in 1991 and resulted in
many refugees. Participants reported that they were active in
Somalia and did not have pain or difficultly performing their
normal activities when they lived there. The age of the participants varied from 34 to 52 years old (Table 1) and they
lived in Sweden. Five participants were married but only two
lived with their husbands. All the participants had children
and lived with their children. Five were searching for a job,
one was on sick leave, and one was a student. Four had
never worked in Somalia. Three had 3–10 years of education,
and the rest had not frequented school before they emigrated to Sweden.
Data collection
The inclusion criterion was patients who participated in an
MMR programme for women from Somalia. They were
informed about the study and asked to participate by one of
the professionals in the MMR team. If they answered, they
received an invitation letter by the first author at the beginning of 2014. The letter was written in two languages,
Swedish and Somali. Seven participants were included and
one declined to participate. The individual interviews took
place during February to April 2014.
An interview guide with open ended questions was created for the individual interviews by the research team. The
questions were open-ended and mainly about the participant’s experiences from the programme, e.g. if and what
help they got from the MMR programme, and what could
have been done to have a better programme. The first question was always ‘How do you feel being part of
the programme?’
All individual interviews were conducted in the meeting
room at the healthcare centre where the MMR programme
took place. Three people were present during the interviews,
the participant, the interviewer (BS) and an interpreter. Three
different interpreters were used; one woman interpreted for
five of the individual interviews and the focus group discussion. The interpreter was asked to be as explanatory as
EUROPEAN JOURNAL OF PHYSIOTHERAPY
199
Figure 1. The model describes the process experienced by the participants. On the top is the core category that resulted from the whole process. The large circles
represent the categories, and the smaller circles the subcategories. Both large circles are connected by the MMR programme which triggered the process
of change.
possible when translating the questions. The reason for this
was to promote a clear understanding of the questions for
the participant. The interpreter was also asked to interpret
the answers word by word, as nearly as possible to the original, so that loss of the original information would be kept
to a minimum. The length of the interviews was from 15
to 60 minutes.
As a second step to deepen the analysis, a focus group
discussion was carried out. All women who participated in
the MMR-programme were asked to participate in a focus
group discussion at a one year follow-up. A new invitation
letter was sent and a new interview guide was created to fit
the focus group discussion. The questions in the interview
guide related to how the programme affected participants
during the past year. Five participants gathered for the focus
group discussion in November 2014 in the conference room
at the same primary health care centre as before. The first
author (BS) led the group discussion. One particular team
member (the nurse) was asked to be present. She was present during all of the MMR sessions and therefore had an
important role during the MMR project. The participants
were acquainted with her, and thought to be more at ease
to interact during the discussion. Another member of the
research team (GS) was present at the focus group discussion
to help with the moderation if needed. All the participants
sat around an oval table, and the focus group was held for
an hour and 20 minutes.
Data analyses
The interviews and focus group discussion were recorded
using an MP3 recorder and transcribed using verbatim transcription. Analyses of the transcribed data were done using
Open Code version 4.01 [26]. The analysis was done in several steps, starting with open coding, then focussed coding,
and selective coding [25,27]. After these steps, subcategories
started to emerge, followed by categories and the main category. Triangulation of the data was made by three persons
(BS, GS, MR). The analyses were made independently and
then negotiated in the research team to increase the credibility and validity of the results. Finally, a model was created
to illustrate the process (Figure 1).
Ethical considerations
During the course of this study, general ethical principles
regarding research were followed and the study was
approved by the ethics committee of the Medical Faculty of
Umeå University (document number 2013-192-31 M).
The letters of invitation clearly stated the objectives of
the study and informed the participants that participation in
the study would be completely voluntary. The participants
were informed that possible future treatments at the healthcare centre would not be influenced by their participation
(or lack of participation) in the study. All written information
was explained verbally before the individual interviews and
focus group discussion. It was also explained that their
answers would be confidential, and that there would be no
right or wrong answers. After being ensured of the study
intentions, the participants signed an informed consent.
Results
One core category regained life emerged from the interviews
and the focus group. The core category represents a process
that positively influenced participants’ lives. This process was
experienced from the beginning of the MMR programme
and continued one year after the end (Figure 1). The main
result from the whole process was that participants became
more open-minded. They acquired new ideas and knowledge, obtained help to improve their adaptation and
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B. SEMEDO ET AL.
Table 2. Core category, categories, subcategories and examples of open codes.
Core category
Categories
Subcategories
Open codes
Regained life
Panic
Life crisis
Big shock in the body
Life suddenly became different
Unemployment creates chaos
Was always in the bed
Isolation makes us sicker
Felt almost imprisoned
Had pain in the whole body
Was very tired
Not possible to walk
Whole musculature was tense
Thought that I had a serious disease
Searched for medical help weekly
Got a lot of treatments
Expensive healthcare before the programme
Good experiences in the programme
Interesting and useful programme
Programme encourages and gives a lot
Programme gives more in the group
Group promoted interaction
We learn from each other
We participated together in the activities
We got a lot of useful information
Learned how to perform activities better
Learned how to exercise, train and walk
Learned the consequences of inactivity
Got to understand better how our bodies work
Know that is important to take care of the body
Made us handle (things) without the doctor
We got to know how to help ourselves
Forward the information to others
Can help to promote the programme to others
Tried to help others
I got my health again
Feel better and healthier after the programme
Pain became easier to handle
I feel younger
Isolation
Experienced poor health
Constant search for medical help
Connection
Positive experiences in the programme
Good interaction as a group
Attained knowledge
Self-management and self confidence
Willingness to share
Improved health
integration in the society, realised that they were not alone
with their problems, and recognised that there was something to gain if a group of people share their experiences
and feelings.
When the participants described their experiences before
the programme, they often used the word I, defining the
participants as individual entities. These individual entities
changed to we (the group of participants) when they
described their experiences during and after the programme.
Two categories were associated with the core category:
panic and connection. Four subcategories were associated
with the category panic, and six subcategories with the category connection (Table 2). The core category, categories,
subcategories and examples of codes are presented in
Table 2.
The relations between the theme, categories and subcategories are presented in Figure 1. Explanations of each category are presented in the text below. Subcategories are
marked in italics. Quotations from the participants are presented, indented in the text.
Panic
The category panic was related to participant experiences
and feelings before attending the programme.
The subcategory life crisis was related to experiences and
feelings that participants had in their personal life before the
start of the MMR programme. The differences between
Somalia and Sweden (e.g. culture, language, food, weather)
made it difficult for participants to be acquainted with
Swedish settings.
It is a great change when moving from one’s own country to
another completely different (one). It feels like a shock in the
body and it takes time to gain roots. It takes several years for
one to understand how to survive. (P2)
The participants felt as if they had lost their identities when
they came to Sweden. Some reported that they were used to
interacting with other people in Somalia but since they moved
to Sweden, they were not able to interact with the local inhabitants because of language barriers. This led to difficulties in
finding a job and being self-sufficient. Unemployment and the
barriers to being active in Swedish society led to what the participants expressed as troubles in their lives.
… it’s the unemployment that is the worst and therefore creates
chaos. (P4)
Weather differences between Somalia and Sweden were
negative in the participants’ lives. They reported missing the
sunny and warm climate of Somalia, and felt that the short
and cold winter days in Sweden made them feel depressed.
… we were used to be in a sunny country and suddenly we
came to a country that hardly has sun during the winter, and it
causes the body to be in shock. (P3)
The participants experienced isolation and felt loneliness.
They sometimes felt like they were imprisoned, alone and
EUROPEAN JOURNAL OF PHYSIOTHERAPY
misplaced. Some even had feelings of hopelessness. This
lead to feelings of fear, stress, anxiety and depression, and
these contributed to poorer reported health. This was further
intensified if the participants had children to care for. Over
time, these feelings resulted in a vicious spiral.
More fear, stress and anxiety led to isolation and desire to
only stay in bed.
It’s not good to be isolated and to be alone. One becomes more
ill. (P6)
Participants experienced poor health in general before the
MMR programme. Some participants also reported fatigue.
This was permanent, and sometimes on such a large scale
that it impeded performance of being active and their normal daily activities.
I had pain in the whole body and a lot of tiredness during that
time, indeed. (P2)
Some participants reported stomach pain. They related
the pain and poor health to stress and poor eating habits
that they acquired when they came to Sweden. This was
because of difficulty in accessing fresh and familiar foods, as
well as the high price of food (especially fresh food) in
Sweden compared to Somalia. Stomach pain and musculoskeletal pain made some of the participants feel desperate.
I had pain and was so tense that I thought that I had a serious
disease. (P2)
Participants stated that their health started to deteriorate
significantly when they moved to Sweden.
The subcategory constant search for medical care represented experiences the participants had in their search and
need for healthcare. Before the start of the MMR programme,
the participants searched for medical help at their local
healthcare centre. The participants stated that the medical
staff could not find any relevant problems with them. Even if
the medical staff tried to explain that there was nothing
wrong with the participants’ bodies, the staff prescribed
medicines for the pain. The permanence and worsening of
symptoms, and lack of answers for the patient’s problems
led to feelings of frustration and insecurity.
… . I almost thought that I had something broken, and visited
the doctor so many times. (P1)
According to the participants, the situation was like an
endless loop. They only searched for medical help more frequently, and in some cases, they ‘visited the doctor once
a week’.
Another reported aspect was the expense of the medical
care and prescribed medicines. Even though Sweden has a
state-delimited annual limit for healthcare expenses, these
were an extra burden on their limited incomes. The participants stated that before coming to Sweden they rarely
searched for medical help.
Connection
The category ‘connection’ was related to participant experiences and feelings during and after the programme.
201
Participants had positive experiences regarding the MMR
programme that they expressed as interesting, useful and
helpful. The most valued were judged to be the diet classes
and physical activities. All parts of the programme stimulated, motivated and encouraged the participants to be
active. This was something that had not happened since
they moved from Somalia. For example, the group walks
were a fun, efficient and inexpensive way for them to be
active. Contact with the water during swimming classes was
especially appreciated.
Some of the participants claimed that they could ‘go further with their lives’, and that the programme experiences
helped them to ‘get their lives back again’.
What is good is that everything that I got here has helped me to
live today. (P1)
Participants were unanimous about the programme being
very good and useful. However, there were some topics
raised that were said could be improved, such as too few
swimming lessons, and problems with being together with
participants who already knew how to swim. Some participants wanted further development of the programme, and
asked for a continuation (like a Step 2).
Good interaction as a group was another subcategory that
emerged. The participants reported being pleased with the
experiences they had in the group created for the programme. The opportunity to share their experiences, opinions, ideas, knowledge and feelings with the rest of the
group and the staff promoted an important interaction that
would be impossible if the programme was held only on an
individual level. They stated that training in group was not
only therapeutic, but also fun. The fact that the participants
shared a similar cultural background, language and problems, was also pointed out as positive. These common factors promoted an easier and better interaction.
One learns and gets a lot from each other. One learns about
experiences and opinions. It provides much more if there are
many (people) compared to just one. (P2)
Attained knowledge represented the general knowledge
that the participants obtained from the programme. This
knowledge was related to several aspects, such as information about diet, different training options, pain, body awareness and women’s health.
All the information that I got here has helped me to live
today. (P1)
Information about diet was commended by all participants. They improved and adapted their diet, learned how to
access and prepare food, how to combine different foods,
and about the need to ingest dietary sources of vitamin D.
They talked about food with us … it was good to be there and
to learn how to eat properly. (P4)
Information about exercise and physical activity as a way
to reduce pain symptoms and maintain good health was
also appreciated. Participants reported that walking was an
activity that they often performed in their home country.
However, they had become less physical active since they
moved to Sweden. Interval training instructions were
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B. SEMEDO ET AL.
experienced as fun, and helped them to be more active.
Participants liked learning to swim and especially having
contact with water since it is relaxing and fun. They appreciated the opportunity to swim indoors during the cold and
dark winter months. Participants reported having to learn
about training in the gym as a way to be physical active and
to improve their health. Gym training was something new
for some of the women. They assessed gym training as a
good alternative, especially during the winter months, since
it becomes challenging and difficult to train and be
active outdoors.
It was also clear that participants were willing to share
their knowledge with other people who might be in the
same situation they were before the programme. The participants emphasised a strong willingness to promote the programme and provided some ideas about how to do it. They
even presented the possibility of being available to talk
about their experiences to anyone who wanted information
about the programme and might be interested in
participating.
I started to go to the gym, and that was something that I didn’t
care about or wanted to do before. (P2)
… . we are ready, and prove that they will become healthier with
the program. (P3)
Discussions of body awareness were also an appreciated
topic. The participants reported that they started to feel their
bodies in a different way, started to realise that their pain
was not related to serious disease, and that the pain could
be manageable. Some participants reported that they were
afraid of exhaustion before the programme, since they
thought that a rapid heartbeat could result in major heart
problems or even death. During the programme, they
learned that higher heart beats and becoming tired are due
to poor physical condition, and this was something that
could be improved.
Improved health. This subcategory represented the participant’s own assessed state of health after the MMR programme. Participants generally reported that their pain was
reduced, reduced to some extent, or completely resolved
after the programme.
I learned that if the heart beats fast and I become breathless it is
not something serious, it is just bad physical condition. (P3)
The subcategory self-management and self-confidence
showed how the participants acquired ability to take care of
themselves and their own health, and they started to be
more confident. The knowledge attained helped them realise
that they did not need to visit the doctor every time a little
problem occurred. They learned that they could reduce their
need and search for medical help.
I visited the doctor once a week before … .Nowadays, I haven’t
come here for almost a year. We (participant and healthcare staff)
haven’t met because of this program. (P1)
This confidence led the participants to perform their daily
activities more effectively. The association of factors like
understanding of their bodies, less need and search for medical help, and better ability to perform the daily activities,
influenced the willingness and motivation to participate in
activities, meet other people, get a job, integrate into society, and reach their goals.
… . we can continue with our lives! (P2)
Directly after the MMR programme, some participants
asked questions about problems in finding a place to be
physically active after the end of the programme. At one
year follow up, the participants enthusiastically said that they
had solved this themselves by renting a place where they
could have dancing lessons together, and also bring
other friends.
Willingness to share represented the willingness of participants to share their programme experiences and knowledge
with others. In some cases, the participants stated that they
had influenced others, e.g. family and friends, to be
more active.
We have learned interval training. I started to do that with my
husband. (P3)
My pain is completely gone, thanks to the program. (P7)
The participants generally reported that their health was
improved and some participants reported that they felt
younger and even had regained their health. The state of
health that participants referred to was the one they had in
their home country, before the war, and before coming
to Sweden.
I got my health again! (P1)
However, there were also exceptions. One participant said
that her main disease had already been treated with specific
medical help before the MMR programme, and therefore did
not notice any changes in her health with the
MMR programme.
Discussion
This qualitative study provides insights into the feelings and
experiences that a group of women immigrants with chronic
pain expressed in connection with a multimodal pain
rehabilitation programme. The programme triggered a process that changed the participants and their lives in a positive way when they attained knowledge about pain, diet and
how to exercise, became capable to taking care of themselves, and improved their self-confidence. Most participants
improved their health as well. The participants expressed this
as they regained life.
Before the programme started, the participants reported
that their lives were in crisis and chaos, and that they were
mostly isolated from the rest of the society. These results are
in accordance with previous research [12,14,15,28,29], in
which female immigrant pain patients reported loss of their
identities and social network. They developed emotional distress, were depressed, and lost their ability to carry out the
daily activities that they were used to performing. The participants in our study experienced their health as poor before
the MMR programme. Many immigrants experience their
health as poor or very poor when they come to a host country, and report physical disabilities due to pain which
EUROPEAN JOURNAL OF PHYSIOTHERAPY
includes persistent suffering, fatigue, limited endurance
[12,13,28–30] and mental ill-health [14,15]. This often led to
healthcare visits. Constant or frequent searches for help and
health care before the MMR programme was a topic raised
by the participants in our study. Other studies also describe
this behaviour [14,15,28,29,31].
In the current study, the participants were unanimous
about the usefulness of knowledge attained from the MMR
programme. Ekhammar et al. report factors such as coping
with pain or understanding their bodies and their respective
limitations or problems as useful knowledge acquired from
MMR programmes [31]. The programme also led to improvement in their health. These results are supported by other
studies of MMR, which show long-term positive effects on
pain and disability [31,32].
The MMR programme trigged a change that led to a new
course in the participants’ lives. In their own words, as they
‘got their life back’. This is in agreement with another study
where MMR led to feelings of empowerment and regained
hope [31]. Other long-term effects on depression and several
domains of life satisfaction are seen after MMR [32].
The increase in self-management was another topic raised
by participants. Some studies support this, in that participants report having more confidence in themselves, and better strategies for coping with pain [28,32]. Another important
result was the lesser need and search for healthcare after the
programme. In another study, MMR programme participants
had fewer negative beliefs about recovery, and were therefore less frequently referred back to primary health care for
follow-up compared to participants of an individual rehabilitation programme [32].
Patients participating in MMR programmes are commonly
included in a group. According to our participants, it was
beneficial and this is also described in other studies of MMR
[32,33]. Patients in group rehabilitation reported reduced
anxiety and depression, and improved body image [28].
However, others report no differences when group rehabilitation is compared to individual rehabilitation [34].
Similar to other studies, the immigrant women felt isolated and missed the social interaction from their host country [14,29]. As our MMR group was adapted so that
participants shared a similar language, background and culture, they had the opportunity to express themselves and
share their own experiences with the group. The interaction
between group members resulted in them becoming we
instead of I. This may have contributed to the programme’s
positive results.
After the MMR programme, participants reported a willingness to share their acquired knowledge from the MMR
programme with others like their family and friends. There
are studies about patients who started to socialise more, and
had more willingness to interact with the surrounding society after MMR. For example, they interacted more with their
families or searched for a job [31,32]. Even if the results from
these studies do not precisely support our study results, they
are similar in the way the participants were willing to interact more with others after the MMR programmes.
203
Participants reported that they liked their lives in Somalia
even if there were problems there, and they would not want
to emigrate if it wasn’t for the war. The participants pointed
out that when they lived in Somalia, they had a job, a house,
a family, a social network, fresh food on the table, good weather, and most importantly, good health and no signs of
depression. These topics are in accordance with those
already documented in the literature [12,29], where immigrants reported having good health, no signs of depression,
and no feelings of loneliness before moving to the
host country.
Some participants expressed difficulties in finding a place
to do physical activities after the programme. Even if they
participated in the programme and had positive results, they
need to have proper stimulation to continue to have an
active life. This is important to be aware of since physical
activity has a positive long-term influence on many diseases [35].
In a study by Stenberg et al., some health care professionals doubted the appropriateness of group rehabilitation for
immigrants due to the need for an interpreter and different
cultural views on pain [36,37]. In this study, immigrants
found MMR to be beneficial even if an interpreter was used.
Norrefalk et al. found that interdisciplinary rehabilitation in
an 8-week programme for patients with chronic pain was
beneficial to the same extent for immigrants as for native
Swedes in terms of return-to-work [36]. However, it has been
reported that the healthcare ‘one size fits all system’ does
not work for our multicultural society [7]. Our healthcare systems and healthcare providers have to evolve and adapt to
the different situations that arise when those that search for
help have very different backgrounds and cultures [15]. This
study can serve as an encouragement to set up MMR programmes for immigrants with chronic pain in primary health
care. However, there is a need to further study the rehabilitation process among both women and men immigrated from
different parts of the world.
Methodological discussion
Individual interviews are good for participants who are not
talkative, because they can take their time in answering
[38,39]. In this study, the participants had no problems
criticising the least good aspects of the programme. Even
the less talkative participants had enough time to express
their experiences and thoughts. Some of the participants
were a little apprehensive about expressing their feelings
and opinions to someone they did not know, especially at
the beginning of the interviews. This could also be because
the interviewer was a man. It is possible that a woman
would get the answers more promptly. To overcome these
difficulties, and since some of the interviews were short, we
decided to add a focus group interview. A focus group interview is useful to perform explorative studies in a new field
because the lively collective interaction can generate spontaneous, expressive and emotional perceptions on a higher
scale than the individual interview [39]. In that way, focus
group worked very well in this study. However, the
204
B. SEMEDO ET AL.
participants did not report any negative experiences of programme like they sometimes did during individual interviews.
Some difficulties of using a man as interviewer were
noticed during the focus group discussion. Even when there
was a lot of positive energy from the group, the answers
and questions posed by the participants were usually
directed to other MMR group members, to the woman member of the MMR team, or the woman member of the
research team, and not to the interviewer.
The interviews and focus group discussion were held in
Swedish because the interviewer was unable to speak
Somali. The participants had very limited knowledge of
Swedish and an interpreter had to be used. The way in
which the experiences and ideas were formulated and
expressed could have been affected to a greater or lesser
extent. Some sentences had to be paraphrased in the transcriptions to make them more fluent. All the coding was
then directly written into English for the final paper. There is
a risk for translation bias when translating from Somali to
Swedish and then to English. This is a challenging problem
and not new to this study [35]. However, it was not possible
to find an interpreter that could translate from Somali direct
to English.
The first author has a physiotherapy degree as clinical
background and academic training in qualitative research. He
also has his own experiences of moving from one country
and culture to another. This was a positive experience when
talking about relevant topics to be included in the interview
guide, and also led to sensitivity when conducting the interviews. There may be a risk of taking one’s own experiences
into the analysis, if one is being subjected to the same phenomena that is under study. The first author was aware and
reflected on this during the research process. To enhance
trustworthiness, triangulation was used with several researchers involved in the analysis and negotiating the result. The
second author (BMS) has extensive experience in the specialty care of chronic pain patients. The third author (GS) has
clinical experience in primary health care. Both second and
third authors have academic experience in qualitative research.
The participants’ mainly positive experiences in this study
could be due to cognitive dissonance [40]. This phenomenon
suggests that one seeks psychological consistency between
personal expectations and reality. Even if the participants did
not seem to have difficulties expressing their opinions, they
may have accepted some lesser attractive approaches/ideas
during the programme’s course in order to find the necessary psychological consistency. This acceptance may have
been further exacerbated since the programme was held in
a group, as one is more prone to accept something less
pleasant if others also accept it [40].
Conclusions
This study provides insight into the experiences that a group
of immigrant women had as participants in a MMR programme. The participants pointed out that their experiences
were very positive, and the programme triggered positive
changes in their lives. They learned about pain, diet and how
to exercise, became capable of taking care of themselves,
and improved their self-confidence, health and reduced
their pain.
Acknowledgements
The authors would like to thank the participants for sharing their stories.
Thanks to Marta Ramos (MR) who assisted with the triangulation
and analysis.
Disclosure statement
The authors report no declarations of interest.
Funding
This work is supported
Agency, REHSAM.
by
the
Swedish
Social
Insurance
ORCID
Bruno Semedo
Gunilla Stenberg
http://orcid.org/0000-0002-2916-0628
http://orcid.org/0000-0002-9231-3594
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in
Europe: prevalence, impact on daily life, and treatment. Eur J
Pain. 2006;10:287.
Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute
and chronic diseases and injuries in 188 countries, 1990–2013: a
systematic analysis for the Global Burden of Disease Study 2013.
Lancet. 2015;386:743–800.
World Health Organization (WHO). World Health Organization
supports global effort to relieve chronic pain; 2004 [cited 2018
Aug 01]. Available from: http://www.who.int/mediacentre/news/
releases/2004/pr70/en/
€m P, Ho
€gstro
€m K, et al. Chronic musculoskelBergman S, Herrstro
etal pain, prevalence rates, and sociodemographic associations in
a Swedish population study. J Rheumatol. 2001;28:1369–1377.
€r
Myndigheten
fo
samh€allsbeskydd
och
beredskap.
S€akerhetspolitik. Sverige och Somalia. [Security. Sweden and
Somalia]; 2014 [cited 2018 Aug 01]. Available from: http://www.
sakerhetspolitik.se/Konflikter/Somalia/
Sweden Statistics. Invandringar och utvandringar efter
€delseland och ko
€n. År 2000–2015 [Immigration and emigrations
fo
by country of birth and gender 2000–2015]; [cited 2018 Aug 01].
Available from: http://www.statistikdatabasen.scb.se/pxweb/sv/
ssd/START__BE__BE0101__BE0101J/ImmiEmiFod/?rxid¼2c9b596406f9-4f54-b24c-40378c39010a
Gibson MA. Immigrant adaptation and patterns of acculturation.
Hum Dev. 2001;44:19–23.
Arnett JJ. The psychology of globalization. Am Psychol. 2002;57:
774.
^te D. Intercultural communication in health care: challenges
Co
and solutions in work rehabilitation practices and training: a comprehensive review. Disabil Rehabil. 2013;35:153–163.
Schwartz SJ, Unger JB, Zamboanga BL, et al. Rethinking the concept of acculturation: implications for theory and research. Am
Psychol. 2010;65:237.
EUROPEAN JOURNAL OF PHYSIOTHERAPY
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
Beiser M. The health of immigrants and refugees in Canada. Can
J Public Health/Rev Can Sante’e Publiq. 2005;96:S30–S44.
Sethi B. Service delivery on rusty health care wheels: implications
for visible minority women. J Evid Based Soc Work. 2013;10:
522–532.
Sethi B. Newcomers health in Brantford and the counties of
Brant, Haldimand and Norfolk: perspectives of newcomers and
service providers. J Immigrant Minority Health. 2013;15:925–931.
M€
ullersdorf M, Zander V, Eriksson H. The magnitude of reciprocity
in chronic pain management: experiences of dispersed ethnic
populations of Muslim women. Scand J Caring Sci. 2011;25:
637–645.
Zander V, M€
ullersdorf M, Christensson K, et al. Struggling for
sense of control: everyday life with chronic pain for women of
the Iraqi diaspora in Sweden. Scand J Public Health. 2013;41:
799–807.
International Association for the Study of Pain (IASP) taxonomy;
2017; [cited 2018 Aug 01]. Available from: https://www.iasp-pain.
org/Education/Content.aspx?ItemNumber¼1698&navItemNumber
¼576#Pain
Ahlberg M, Axelsson S, Eckerlund I, et al. Rehabilitering vid
€versikt. Stockholm: SBUlångvarig sm€arta: En systematisk litterturo
€r medicinisk utv€ardering; 2010.
Statens beredning fo
Merksey H, Bogduk N. Classification of chronic pain. 2nd ed.
Seattle: IASP Press; 1994. p. 59–71.
Woolf CJ. Central sensitization: implications for the diagnosis and
treatment of pain. Pain. 2011;152:S2–S15.
Demyttenaere K, Bruffaerts R, Lee S, et al. Mental disorders
among persons with chronic back or neck pain: results from the
World Mental Health Surveys. Pain. 2007;129:332–342.
Harstall C, Ospina M. How prevalent is chronic pain. Pain Clin
Updates. 2003;11:1–4.
Swedish Association of Local Authorities and Regions (SALAR).
€r multimodal rehabilitering vid långvarig sm€arta
Indikationer fo
[National Medical Indications 2011. Indications for multimodal
rehabilitation for patients with chronic pain]; 2011 [cited 2018
Aug 01] Available from: https://www.socialstyrelsen.se/Site
CollectionDocuments/nationella-indikationer-multimodal-rehabilit
ering.pdf
Gatchel RJ, Peng YB, Peters ML, et al. The biopsychosocial
approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581.
Gatchel RJ, McGeary DD, McGeary CA, et al. Interdisciplinary
chronic pain management: past, present, and future. Am Psychol.
2014;69:119–130.
Charmaz K. Constructing grounded theory: a practical guide
through qualitative analysis. London: SAGE; 2006.
ICT Services and System Development and Division of
Epidemiology and Global Health. OpenCode 3.4. Umeå: Umeå
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
205
University; 2013; [cited 2018 Oct]. Available from: http://www.
phmed.umu.se/english/units/epidemiology/research/open-code/
Dahlgren L, Emmelin M, Winkvist A, et al. Umeå universitet.
€r folkh€alsa och klinisk medicin. Epidemiologi.
Institutionen fo
Qualitative methodology for international public health. 2nd ed.
Umeå: Epidemiology and Public Health Sciences, Department
of Public Health and Clinical Medicine, Umeå University; 2007.
218 pp.
Michae€lis C, Kristiansen M, Norredam M. Quality of life and coping strategies among immigrant women living with pain in
Denmark: a qualitative study. BMJ Open. 2015;5:e008075.
Nyen S, Tveit B. Symptoms without disease: exploring experiences of non-Western immigrant women living with chronic pain.
Health Care Women Int. 2018;39:322–342.
Nortvedt L, Hansen HP, Kumar BN, et al. Caught in suffering
bodies: a qualitative study of immigrant women on long-term
sick leave in Norway. J Clin Nurs. 2015;24:3266–3275.
Ekhammar A, Melin L, Thorn J, et al. A sense of increased living
space after participating in multimodal rehabilitation. Disabil
Rehabil. 2016;38:2445–2454.
Merrick D, Sundelin G, Stålnacke B-M. One-year follow-up of two
different rehabilitation strategies for patients with chronic pain. J
Rehabil Med. 2012;44:764–773.
Pietil€a EH, Stålnacke B-M, Enthoven P, et al. "The acceptance" of
living with chronic pain—an ongoing process: a qualitative study
of patient experiences of multimodal rehabilitation in primary
care. J Rehabil Med. 2018;50:73–79.
Dufour N, Thamsborg G, Oefeldt A, et al. Treatment of chronic
low back pain: a randomized, clinical trial comparing groupbased multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises. Spine. 2010;35:469–476.
Reiner M, Niermann C, Jekauc D, et al. Long-term health benefits
of physical activity – a systematic review of longitudinal studies.
BMC Public Health. 2013;13:813.
Norrefalk J-R, Ekholm K, Linder J, et al. Evaluation of a multiprofessional rehabilitation programme for persistent musculoskeletal-related pain: economic benefits of return to work. J Rehabil
Med. 2008;40:15–22.
Stenberg G, Pietil€a Holmner E, Stålnacke B-M, et al. Healthcare
professional experiences with patients who participate in multimodal pain rehabilitation in primary care – a qualitative study.
Disabil Rehabil. 2016;38:2085–2094.
King N. Horrocks C. Interviews in qualitative research. London:
Sage; 2010.
Wibeck V. Fokusgrupper: om fokuserade gruppintervjuer som
€kningsmetod. 2. Uppdaterade och uto
€k. uppl. ed. Lund:
underso
Studentlitteratur; 2010.
Festinger L. A theory of cognitive dissonance. Stanford (CA):
Stanford U.P.; 1957.