Section 3 Providing Quality

[18] Onyeji E. NHIS: Regulators should be Blamed for Poor Coverage of Nigerians—Official. Premium Times, Sunday, March 3 2019. Retrieved from: https://www.premiumtimesng.com/ news/more-news/260920-nhisregulators-blamed-poor-coveragenigerians-official.html [Accessed:

[26] World Health Organization. Progress Report on Decade of Traditional Medicine in the African Region. AFR/RC61/PR2, 5 July 2011. Available from: https://afro.who.int/ sites/default/files/sessions/working\_ documents/AFR-RC61-PR-2-Progressreport-on-decade-of-traditionalmedicine-in-the-African-Region.pdf

[Retrieved: March 20, 2019]

86(11):817-908

16, 2019]

29(3):19-26

[27] Lagarde M, Palmer N. The impact of user fees on health service utilization in low- and middle-income countries: How strong is the evidence? Bulletin of the World Health Organization. 2008;

[28] Koenig HG. Religion, Spirituality and Health: The Research and Clinical Implications. 2012. Available from: http://www.hindawi.com/journals/isrn/ 2012/278730/[IPMC [Retrieved: March

[29] Koenig HG. Religion, spirituality, and health: A review and update. Advances in Mind-Body Medicine. 2015;

[19] Edeh JN, Udoikah JM. National Health Insurance Scheme and

healthcare administration in Nigeria: An assessment. International Journal of Social Science Research. 2015;6(4):

[20] Alubo SO. Underdevelopment and the health care crisis in Nigeria. Medical

Anthropology. 1985;9:319-335

[21] Alubo SO, Hunduh V. Medical dominance and resistance in Nigeria's health care system. International Journal of Health Services. 2017;47(4):778-794

[22] Makanjuola AB. A cost comparison of traditional and orthodox mental health care. The Nigerian. Postgraduate Medical Journal. 2003;10(3):155-161

[23] Abiola T, Udofia O, Abdullahi AT. Patient-doctor relationship: The practice orientation of doctors in Kano. Nigerian Journal of Clinical Practice. 2014;17(2):

perception of patients of doctor-patient relationship in otorhinolaryngology clinics of the University of Port Harcourt Teaching Hospital (UPTH) Nigeria. Port Harcourt Medical Journal.

[25] Onotai LO. Inpatients' perception of

[24] Onotai LO, Ibekwe U. The

doctors' attitude towards the management of their ill health in a Nigerian University Teaching Hospital. IOSR Journal of Dental and Medical Sciences. 2017;16(1):102-109

March 16, 2019]

Universal Health Coverage

2383-2394

241-247

2012;6(1):65-73

58

**61**

**Chapter 5**

**Abstract**

Caring for Older People -

*Sandra Pennbrant and Margareta Karlsson*

Improving Healthcare Quality to

The aim of caring is to promote health. The global trend is that people are living longer, but in many cases, there is no support system for the care of older people, leading to major challenges in ensuring their health and well-being. The proportion of older people is expected to increase globally, and skilled healthcare professionals will be required to care for them. There is a risk that older people as suffering and vulnerable human beings will be forgotten due to the increasingly effective and technical care worldwide. A caring culture and relationship should be prioritised and developed to promote participation, well-being and dignity for older people in order to fulfil their care needs and ensure quality healthcare. It is important that research focusing on universal health coverage identifies the benefits of increased investment in service quality. To contribute to the improvement of this output, we propose the application of Eriksson's caritative theory. The aim of this theoretical chapter is to provide examples of how the dignity and well-being of older people can be promoted, at no additional cost to the person, by means of Eriksson's carita-

Ensure Well-Being and Dignity

tive theory, which can strengthen healthcare for universal health coverage.

Human beings' becoming in health and suffering can be both promoted and inhibited. Human becoming is characterised by life in a movement and to live means being in a constant movement of change and feeling of existence [1].

Nursing is of importance for improving and maintaining older people health [2]. As suffering human beings older people need to meet healthcare professionals who see

Ethical care for older people concerns being aware of their vulnerability and respecting them as human beings. In caring it is important to promote participation and focus on the older people's resources [4]. One study compared nursing home residents with community-dwelling older adults and found that older people in nursing homes were more depressed and that their well-being was impaired [5]. Professional care involves caring for a human being where the relationship differs according to the specific context. There is a risk that empathy and compassion can be lacking if the circumstances under which patients are cared for are continuously deprived of the necessary resources for high quality and safe care.

**Keywords:** caring, dignity, healthcare quality, older person,

universal health coverage, well-being

and take responsibility for their suffering [3].

**1. Introduction**

#### **Chapter 5**

## Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity

*Sandra Pennbrant and Margareta Karlsson*

#### **Abstract**

The aim of caring is to promote health. The global trend is that people are living longer, but in many cases, there is no support system for the care of older people, leading to major challenges in ensuring their health and well-being. The proportion of older people is expected to increase globally, and skilled healthcare professionals will be required to care for them. There is a risk that older people as suffering and vulnerable human beings will be forgotten due to the increasingly effective and technical care worldwide. A caring culture and relationship should be prioritised and developed to promote participation, well-being and dignity for older people in order to fulfil their care needs and ensure quality healthcare. It is important that research focusing on universal health coverage identifies the benefits of increased investment in service quality. To contribute to the improvement of this output, we propose the application of Eriksson's caritative theory. The aim of this theoretical chapter is to provide examples of how the dignity and well-being of older people can be promoted, at no additional cost to the person, by means of Eriksson's caritative theory, which can strengthen healthcare for universal health coverage.

**Keywords:** caring, dignity, healthcare quality, older person, universal health coverage, well-being

#### **1. Introduction**

Human beings' becoming in health and suffering can be both promoted and inhibited. Human becoming is characterised by life in a movement and to live means being in a constant movement of change and feeling of existence [1]. Nursing is of importance for improving and maintaining older people health [2]. As suffering human beings older people need to meet healthcare professionals who see and take responsibility for their suffering [3].

Ethical care for older people concerns being aware of their vulnerability and respecting them as human beings. In caring it is important to promote participation and focus on the older people's resources [4]. One study compared nursing home residents with community-dwelling older adults and found that older people in nursing homes were more depressed and that their well-being was impaired [5].

Professional care involves caring for a human being where the relationship differs according to the specific context. There is a risk that empathy and compassion can be lacking if the circumstances under which patients are cared for are continuously deprived of the necessary resources for high quality and safe care.

Relationships are of importance when caring for human beings. However, an ethics of care with a relational ontology is preferable [6]. When meeting other people, it is important to respect the dignity of the individual, especially in meetings with people who depend on others on a daily basis to cope with everyday life [7]. Nurses have a responsibility to treat all people with dignity and respect [2]. When caring for older people it is important that healthcare professionals confirm the older people's dignity as a human being and promote an experience of well-being in her/his complex healthcare situation. One way of promoting the older people's dignity and well-being is to use Eriksson's theory of caritative caring [8]. The aim of this theoretical chapter is to highlight Eriksson's theory for promoting older people dignity and well-being in the perspective of service quality of universal health coverage.

#### **2. Older people care from a global perspective**

The number of older people aged over 60 years is steadily increasing all over the world, thus their care and care needs will become an increasingly important part of healthcare. Improving the health and functional capacity of older people, as well as their social participation and security, is challenging for society [9]. The need for healthcare is universal and in the nature of care lies respect for human rights, including cultural rights, dignity, well-being and to be treated with respect [10, 11]. Older people want quality care. Despite this, the care they receive is not always perceived as respectful and dignified. In healthcare today, violations of the dignity of older people are common [12, 13]. A British study revealed that older people with a high sense of well-being live longer than their peers who are less satisfied. The study highlights the feeling of having a reason for existence as an independent factor with a strong connection to health. Care should not be focused solely on curing diseases but also on giving people the prerequisites for a meaningful life [14]. Health is a fundamental prerequisite for people's ability to achieve their full potential. For that reason, we need to invest in health by devoting resources to quality-assured healthcare systems, which implies that we are reinvesting in the development of society as a whole [15]. Caring for older people means providing qualified care and many do not receive the care they need [16]. Older people feel safe and secure with the healthcare they receive but believe that they are a low priority group [17]. There are no clear strategies for developing the care of older people in terms of how dignified and continuous care can be ensured [11]. Every person should have access to quality healthcare without risking financial difficulties. The challenge for many countries lies in determining how to expand healthcare to meet existing needs with limited resources. A cost-effective part of the solution is having motivated health workers [18], whose demeanour enhances the patient's sense of self-dignity and well-being.

#### **3. Dignity in caring for older people**

Dignity is related to human beings' body, soul and spirit. Absolute dignity means that each human being has inner freedom and responsibility for both her/ his own life and that of others [3, 19]. The absolute dignity of the human being, i.e. the inner dimension, is free from values. Relative dignity, i.e. the external dimension, is influenced by the culture and context in which the human being is present. The human being has an absolute dignity that contains the spiritual dimension. Absolute dignity cannot be violated or taken away from the human being due to its indestructible holiness. The human being's duty consists of being in communion in reciprocity, love and service [19].

**63**

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity*

Relative dignity contains an inner ethical dignity that belongs to the spiritual dimension and an aesthetic dignity that belongs to the bodily dimension. Relative dignity depends on the human being's cultural values and is unique for each individual as it is based on her/his culture and situation [19]. Individualised care can

Preserving dignity when caring for older people means individualised care, good treatment, listening, showing respect [21] and being well treated [22]. Autonomy, respect and dignity are important for enabling older people to live a dignified life in nursing homes [23, 24]. Dignity and self-esteem are promoted through respectful treatment, listening, giving choices and respecting privacy [25]. Safeguarding dignity also means taking the older people's perspective into account, i.e. personality, identity and self-determination. Being a unique person of value is important for human health and well-being [26]. An investigation conducted in Sweden revealed deficiencies in care because older people have to adapt to the care instead of the other way around. Having to adapt to the healthcare offered can be perceived as unworthy by the older person. The experience of dignity is crucial for the feeling of

Personal commitment on the part of healthcare professionals is required to get to know and confirm older patients [28]. The healthcare professional can confirm the older people's dignity by being present, showing pity and respect. In elder care, the older people's well-being can be strengthened by healthcare professionals enhancing her/his sense of meaningfulness in life. This achieved by creating different forums for connectedness that can strengthen the older people's self-esteem. In this way, the healthcare professional is involved in the older people's life situation [29]. To provide good care it is necessary to ensure that healthcare professionals receive sufficient education and support in understanding the concept of dignity, as well as

the necessary resources to translate dignity into their everyday work [30].

The concept of well-being is central in healthcare science and related to health, quality of life and life satisfaction [31]. Well-being describes how a person feels at a certain time and be a measure of happiness or misfortune [32]. Well-being and health are interlinked, and health is defined as a: "state of complete physical, mental, and social well-being and not merely the absence of disease" [33]. This means that health is not only a goal, but also a resource in daily life, and that well-being may contribute to health or to the maintenance of health [33]. From a healthcare science perspective, the body can be understood as being in a movement between health and disease, a habitation of well-being and suffering in the pursuit of dignity [34]. Health is thus achieved through a combination of physical, mental, emotional and social well-being. In this way, health involves well-being and physical, mental and social dimensions. Well-being is important for the individual's self-assessment, degree of autonomy, control and ability to manage the everyday environment [31]. The feeling of well-being is a condition where human beings experience their own health, regardless of illness or disability, which is an important human experience [7]. Well-being is a feeling, thus cannot be observed by others, while health is defined as a wholeness with soundness, freshness and well-being [35]. The use of a computer and the Internet can contribute to enhancing an older people's well-being, as factors such as learning, social benefits, participation and positive feelings have been identified [36]. The quality of life and well-being of older people are not only affected by health, but also influenced by other factors such as social and family

**4. Well-being in caring for older people**

relationships, social roles and activities [37].

*DOI: http://dx.doi.org/10.5772/intechopen.85598*

confirm the human being's dignity [20].

well-being [27].

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org/10.5772/intechopen.85598*

Relative dignity contains an inner ethical dignity that belongs to the spiritual dimension and an aesthetic dignity that belongs to the bodily dimension. Relative dignity depends on the human being's cultural values and is unique for each individual as it is based on her/his culture and situation [19]. Individualised care can confirm the human being's dignity [20].

Preserving dignity when caring for older people means individualised care, good treatment, listening, showing respect [21] and being well treated [22]. Autonomy, respect and dignity are important for enabling older people to live a dignified life in nursing homes [23, 24]. Dignity and self-esteem are promoted through respectful treatment, listening, giving choices and respecting privacy [25]. Safeguarding dignity also means taking the older people's perspective into account, i.e. personality, identity and self-determination. Being a unique person of value is important for human health and well-being [26]. An investigation conducted in Sweden revealed deficiencies in care because older people have to adapt to the care instead of the other way around. Having to adapt to the healthcare offered can be perceived as unworthy by the older person. The experience of dignity is crucial for the feeling of well-being [27].

Personal commitment on the part of healthcare professionals is required to get to know and confirm older patients [28]. The healthcare professional can confirm the older people's dignity by being present, showing pity and respect. In elder care, the older people's well-being can be strengthened by healthcare professionals enhancing her/his sense of meaningfulness in life. This achieved by creating different forums for connectedness that can strengthen the older people's self-esteem. In this way, the healthcare professional is involved in the older people's life situation [29]. To provide good care it is necessary to ensure that healthcare professionals receive sufficient education and support in understanding the concept of dignity, as well as the necessary resources to translate dignity into their everyday work [30].

#### **4. Well-being in caring for older people**

The concept of well-being is central in healthcare science and related to health, quality of life and life satisfaction [31]. Well-being describes how a person feels at a certain time and be a measure of happiness or misfortune [32]. Well-being and health are interlinked, and health is defined as a: "state of complete physical, mental, and social well-being and not merely the absence of disease" [33]. This means that health is not only a goal, but also a resource in daily life, and that well-being may contribute to health or to the maintenance of health [33]. From a healthcare science perspective, the body can be understood as being in a movement between health and disease, a habitation of well-being and suffering in the pursuit of dignity [34]. Health is thus achieved through a combination of physical, mental, emotional and social well-being. In this way, health involves well-being and physical, mental and social dimensions. Well-being is important for the individual's self-assessment, degree of autonomy, control and ability to manage the everyday environment [31]. The feeling of well-being is a condition where human beings experience their own health, regardless of illness or disability, which is an important human experience [7].

Well-being is a feeling, thus cannot be observed by others, while health is defined as a wholeness with soundness, freshness and well-being [35]. The use of a computer and the Internet can contribute to enhancing an older people's well-being, as factors such as learning, social benefits, participation and positive feelings have been identified [36]. The quality of life and well-being of older people are not only affected by health, but also influenced by other factors such as social and family relationships, social roles and activities [37].

*Universal Health Coverage*

Relationships are of importance when caring for human beings. However, an ethics of care with a relational ontology is preferable [6]. When meeting other people, it is important to respect the dignity of the individual, especially in meetings with people who depend on others on a daily basis to cope with everyday life [7]. Nurses have a responsibility to treat all people with dignity and respect [2]. When caring for older people it is important that healthcare professionals confirm the older people's dignity as a human being and promote an experience of well-being in her/his complex healthcare situation. One way of promoting the older people's dignity and well-being is to use Eriksson's theory of caritative caring [8]. The aim of this theoretical chapter is to highlight Eriksson's theory for promoting older people dignity and well-being in the perspective of service quality of universal health coverage.

The number of older people aged over 60 years is steadily increasing all over the world, thus their care and care needs will become an increasingly important part of healthcare. Improving the health and functional capacity of older people, as well as their social participation and security, is challenging for society [9]. The need for healthcare is universal and in the nature of care lies respect for human rights, including cultural rights, dignity, well-being and to be treated with respect [10, 11]. Older people want quality care. Despite this, the care they receive is not always perceived as respectful and dignified. In healthcare today, violations of the dignity of older people are common [12, 13]. A British study revealed that older people with a high sense of well-being live longer than their peers who are less satisfied. The study highlights the feeling of having a reason for existence as an independent factor with a strong connection to health. Care should not be focused solely on curing diseases but also on giving people the prerequisites for a meaningful life [14]. Health is a fundamental prerequisite for people's ability to achieve their full potential. For that reason, we need to invest in health by devoting resources to quality-assured healthcare systems, which implies that we are reinvesting in the development of society as a whole [15]. Caring for older people means providing qualified care and many do not receive the care they need [16]. Older people feel safe and secure with the healthcare they receive but believe that they are a low priority group [17]. There are no clear strategies for developing the care of older people in terms of how dignified and continuous care can be ensured [11]. Every person should have access to quality healthcare without risking financial difficulties. The challenge for many countries lies in determining how to expand healthcare to meet existing needs with limited resources. A cost-effective part of the solution is having motivated health workers [18], whose demeanour enhances the patient's sense of self-dignity and well-being.

Dignity is related to human beings' body, soul and spirit. Absolute dignity means that each human being has inner freedom and responsibility for both her/ his own life and that of others [3, 19]. The absolute dignity of the human being, i.e. the inner dimension, is free from values. Relative dignity, i.e. the external dimension, is influenced by the culture and context in which the human being is present. The human being has an absolute dignity that contains the spiritual dimension. Absolute dignity cannot be violated or taken away from the human being due to its indestructible holiness. The human being's duty consists of being in communion in

**2. Older people care from a global perspective**

**3. Dignity in caring for older people**

reciprocity, love and service [19].

**62**

In elder care, the older people's well-being can be strengthened by the healthcare professionals facilitating the rebuilding of her/his sense of meaningfulness in life. This can be done by creating different forums for connectedness, which can strengthen the older people's self-esteem.

#### **5. Katie Eriksson's theory of caritative caring**

One of the pioneers of caring science in the Nordic countries is Katie Eriksson. Her theory of caritative caring is also internationally known [8].

Caring consists of meeting the other with respect, warmth, honesty and closeness in time and space [8]. The fundamental motive for caring is love and healthcare professionals deeply want to do well, even if it is not always visible in their actions. A caritative approach means that care is an ethical act that involves taking responsibility for others. Caring ethics is feeling responsible for the other and a willingness to serve. The ethics of caring is constantly present and cannot be divided into parts. Good technological care is related to how well the art of care is performed [38].

Caring is an act performed in love. To convey love to another person means being generous and involves the people's basic attitude to life [39]. The starting point in caring is that there is something natural in every human being. The ability to nurture is developed in a favourable environment. Caring involves tending, playing and learning and includes the whole human being with body, soul and spirit. To care is to share and heal and has a health promoting purpose. The basic substance is always the same, even if the caring takes different forms [40].

Tending in caring refers to a concrete action of love and means confirming the other as a human being. It is characterised by warmth, closeness and touch. Play is important in caring due to the fact that it is an expression of achieving health, wishes and an art form in caring*.* Learning means developing as a human being and can open new possibilities [41]. Caring ethics implies seeing the reality as it appears to the patient and recognising her/his right to be confirmed as a unique person with an absolute dignity [38]. Non-ethical situations can, for example, be a slipshod piece of work, being heavy-handed, not respecting the people's right to be involved or not listening or taking account of the patient's integrity [42]. Love can provide possibilities to feel compassion and be involved in a communion with the suffering human being, while for the suffering person, knowing that there is someone who is present and remains close creates trust and makes the suffering less unbearable [43]. To share in caring means being able to participate, for example, share in feelings, experiences or how to distribute concrete work activities [44]. It is therefore important that Eriksson's theory has a clear structure. The structure must ensure visibility and clarity for healthcare professionals. In this way, healthcare professionals can work together with the older person in a social interaction to create a whole.

#### **6. Eriksson's theory of caritative caring for promoting dignity and well-being in elder care**

Eriksson's theory can be used when caring for older people to promote and strengthen their dignity and well-being, thus facilitating the provision of highquality care.

In a caring relationship, caring ethics requires that healthcare professionals have the will to do well and treat the human being with respect and an absolute dignity, in addition to being willing to sacrifice something of themselves [8]. Caring for older people can mean that healthcare professionals are there for them, see and confirm their

**65**

older person [47].

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity*

respect, responsibility, self-determination and equality [46].

them, which can give the feeling of a home environment [7].

older person with the outside world [48].

**6.1 Example of care actions that can promote well-being and dignity** 

**progressing towards quality service within universal health coverage**

The condition for providing caritative care is that the healthcare professional uses her/his professional knowledge when she/he is part of a communion with the

The care activity *tending* involves the older person being able to experience security in the form of reliability, where proximity and distance are respected by the healthcare professionals in the care relationship [7]. Tending care may involve the healthcare professionals maintaining trust, hope and bodily relief by the love in their hands and the warmth in their voices [34]. To increase the older people's sense of security in an unfamiliar environment, healthcare professionals can invite the older people's relatives to become involved in her/his everyday life. An additional factor in tending is that the older people have their own personal belongings around

Through the care activity *play*, the older people's satisfaction can be enhanced by the fulfilment of needs and desires. The fact that the healthcare professionals employ a playful approach means that they have the ability to reconcile imagination with reality. To find the older people's health resources, healthcare professionals can encourage and support her/him by means of caring play where the activity is adapted to the people's needs and resources [7]. Healthcare professionals can use different symbols and metaphors to access the older people's inner world. Through this approach, they can contribute to the creation of a new reality for the older person in her/his situation, which can contribute to hope and reconciliation of the

The care activity *learning* is based on meaningfulness, preserving the older people's everyday habits and strengthening the feeling of a normal environment. Healthcare professionals teach the older person to preserve her/his life story, habits and interests [45]. The purpose of the care activity is to maintain the older people's life experiences and skills. In this care activity new understanding can be created, where strengths, resources and health barriers can be clarified, thus allowing the older person to gain a deeper insight into the self and the/her/his situation [48]. The care should be person-centred in order to create a meaningful everyday life for older

suffering and listen to their narratives. This can create trust in the caring relationships, leading to bodily and spiritual well-being. Through tending, playing and learning older people health process can be supported and maintained for a sustainable old age.

A caring relationship means that the human being must be allowed to be a person and confirmed in the care [20]. Caring means relieving a people's suffering through mercy, faith, hope and love. It manifests itself by tending, playing and learning in the caring relationship with the patient [3]. Caritative care is based on ethical decisions made to alleviate human suffering and becomes visible through thought, posture and action [27]. The person who suffers is in the midst of her/his own suffering and therefore needs to meet healthcare professionals who can confirm her/his suffering in nursing [3]. To be able to understand a patient who is suffering, healthcare professionals need to be able to see, confirm and invite the patient to a healthcare communion where there is the possibility to alleviate the suffering [45]. Care should be perceived as meaningful by the patient and what is meaningful should be felt in body, mind and spirit [3]. Dignity includes healthcare professionals' will and ability to see and respect the other's needs and desires. In the caring communion there is warmth and care. Security is created through healthcare professionals' ability to be present. When healthcare professionals protect the patient's privacy, they promote

*DOI: http://dx.doi.org/10.5772/intechopen.85598*

#### *Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org/10.5772/intechopen.85598*

suffering and listen to their narratives. This can create trust in the caring relationships, leading to bodily and spiritual well-being. Through tending, playing and learning older people health process can be supported and maintained for a sustainable old age.

A caring relationship means that the human being must be allowed to be a person and confirmed in the care [20]. Caring means relieving a people's suffering through mercy, faith, hope and love. It manifests itself by tending, playing and learning in the caring relationship with the patient [3]. Caritative care is based on ethical decisions made to alleviate human suffering and becomes visible through thought, posture and action [27]. The person who suffers is in the midst of her/his own suffering and therefore needs to meet healthcare professionals who can confirm her/his suffering in nursing [3]. To be able to understand a patient who is suffering, healthcare professionals need to be able to see, confirm and invite the patient to a healthcare communion where there is the possibility to alleviate the suffering [45]. Care should be perceived as meaningful by the patient and what is meaningful should be felt in body, mind and spirit [3]. Dignity includes healthcare professionals' will and ability to see and respect the other's needs and desires. In the caring communion there is warmth and care. Security is created through healthcare professionals' ability to be present. When healthcare professionals protect the patient's privacy, they promote respect, responsibility, self-determination and equality [46].

#### **6.1 Example of care actions that can promote well-being and dignity progressing towards quality service within universal health coverage**

The condition for providing caritative care is that the healthcare professional uses her/his professional knowledge when she/he is part of a communion with the older person [47].

The care activity *tending* involves the older person being able to experience security in the form of reliability, where proximity and distance are respected by the healthcare professionals in the care relationship [7]. Tending care may involve the healthcare professionals maintaining trust, hope and bodily relief by the love in their hands and the warmth in their voices [34]. To increase the older people's sense of security in an unfamiliar environment, healthcare professionals can invite the older people's relatives to become involved in her/his everyday life. An additional factor in tending is that the older people have their own personal belongings around them, which can give the feeling of a home environment [7].

Through the care activity *play*, the older people's satisfaction can be enhanced by the fulfilment of needs and desires. The fact that the healthcare professionals employ a playful approach means that they have the ability to reconcile imagination with reality. To find the older people's health resources, healthcare professionals can encourage and support her/him by means of caring play where the activity is adapted to the people's needs and resources [7]. Healthcare professionals can use different symbols and metaphors to access the older people's inner world. Through this approach, they can contribute to the creation of a new reality for the older person in her/his situation, which can contribute to hope and reconciliation of the older person with the outside world [48].

The care activity *learning* is based on meaningfulness, preserving the older people's everyday habits and strengthening the feeling of a normal environment. Healthcare professionals teach the older person to preserve her/his life story, habits and interests [45]. The purpose of the care activity is to maintain the older people's life experiences and skills. In this care activity new understanding can be created, where strengths, resources and health barriers can be clarified, thus allowing the older person to gain a deeper insight into the self and the/her/his situation [48]. The care should be person-centred in order to create a meaningful everyday life for older

*Universal Health Coverage*

strengthen the older people's self-esteem.

**5. Katie Eriksson's theory of caritative caring**

Her theory of caritative caring is also internationally known [8].

always the same, even if the caring takes different forms [40].

In elder care, the older people's well-being can be strengthened by the healthcare professionals facilitating the rebuilding of her/his sense of meaningfulness in life. This can be done by creating different forums for connectedness, which can

One of the pioneers of caring science in the Nordic countries is Katie Eriksson.

Caring consists of meeting the other with respect, warmth, honesty and closeness in time and space [8]. The fundamental motive for caring is love and healthcare professionals deeply want to do well, even if it is not always visible in their actions. A caritative approach means that care is an ethical act that involves taking responsibility for others. Caring ethics is feeling responsible for the other and a willingness to serve. The ethics of caring is constantly present and cannot be divided into parts. Good technological care is related to how well the art of care is performed [38]. Caring is an act performed in love. To convey love to another person means being generous and involves the people's basic attitude to life [39]. The starting point in caring is that there is something natural in every human being. The ability to nurture is developed in a favourable environment. Caring involves tending, playing and learning and includes the whole human being with body, soul and spirit. To care is to share and heal and has a health promoting purpose. The basic substance is

Tending in caring refers to a concrete action of love and means confirming the other as a human being. It is characterised by warmth, closeness and touch. Play is important in caring due to the fact that it is an expression of achieving health, wishes and an art form in caring*.* Learning means developing as a human being and can open new possibilities [41]. Caring ethics implies seeing the reality as it appears to the patient and recognising her/his right to be confirmed as a unique person with an absolute dignity [38]. Non-ethical situations can, for example, be a slipshod piece of work, being heavy-handed, not respecting the people's right to be involved or not listening or taking account of the patient's integrity [42]. Love can provide possibilities to feel compassion and be involved in a communion with the suffering human being, while for the suffering person, knowing that there is someone who is present and remains close creates trust and makes the suffering less unbearable [43]. To share in caring means being able to participate, for example, share in feelings, experiences or how to distribute concrete work activities [44]. It is therefore important that Eriksson's theory has a clear structure. The structure must ensure visibility and clarity for healthcare professionals. In this way, healthcare professionals can work together with the older person in a social interaction to create a whole.

**6. Eriksson's theory of caritative caring for promoting dignity and** 

Eriksson's theory can be used when caring for older people to promote and strengthen their dignity and well-being, thus facilitating the provision of high-

In a caring relationship, caring ethics requires that healthcare professionals have the will to do well and treat the human being with respect and an absolute dignity, in addition to being willing to sacrifice something of themselves [8]. Caring for older people can mean that healthcare professionals are there for them, see and confirm their

**64**

quality care.

**well-being in elder care**

people. The care activities of playing and learning can create a bridge between the body's reality and the possibilities of health [34].

The care activities *tending*, *playing* and *learning* can provide a meaningful everyday life for older people and be strengthened when healthcare professionals are educated, supervised and encouraged to reflect on these care activities. Through tending, playing and learning in caring, older people dignity and well-being can be promoted. To share in caring means being able to participate in feelings, experiences or the distribution of concrete work activities [44].

#### **7. Closing reflections**

It is in everyday care that the dignity and well-being of older people can be promoted for a sustainable life. To create a good relationship in the care of the older person, it is important to become aware of her/his suffering. Older people deserve care that is focused on their unique needs for dignity and well-being, and not what is most suitable for the healthcare professionals involved in their care. Understanding the vulnerability of the older person can provide nourishment in the care relationship. Seeing and meeting the older people's face and gaze can confirm her/his dignity and promote health. The nurse's responsibility to develop the care means that knowledge is harnessed to benefit the older person. Critical reflection on the activities together with others can lead to the elimination of inefficient care methods and ways of working. Healthcare professionals have the opportunity to create a high-quality care environment for older people with the help of Eriksson's caritative theory, which is viable in the global healthcare system. Healthcare systems should be concerned not only with disease and illness, but with supporting methods that are sustainable and effective in the long term for improving the health, quality of life, well-being and dignity of older people. In order to strengthen older people' well-being and dignity, at no additional cost, healthcare professionals can use the caring relationship model (see **Figure 1**). This model is a collaborative

#### **Figure 1.**

*An illustration of a model and process to improve the caring relationship activities of tending, playing and learning in order to enhance the quality of healthcare for older people, thus promoting their well-being and dignity.*

**67**

**Author details**

provided the original work is properly cited.

Sandra Pennbrant\* and Margareta Karlsson University West, Trollhättan, Sweden

\*Address all correspondence to: sandra.pennbrant@hv.se

care environment for older people at no additional cost.

The authors declare that they have no competing interests.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity*

process comprising five steps. The steps involve different approaches that healthcare professionals can employ to improve the care relationship activities of tending, playing and learning in the meeting with the older person by: (1) inviting the older person to participate in care activities, (2) communicating with true presence, (3) taking responsibility in the caring relationship, (4) seeing and listening to the older person's life story and (5) confirming the older person as unique with resources,

In order to improve the caring relationship with older people and to promote their well-being and dignity, it is important that healthcare professionals have the opportunity to use Eriksson's caritative theory combined with a collaborative process model. This theory and model are viable in the global healthcare system and can create national and international research networks to improve the coverage of health services within and between countries, and thereby promote a high-quality

*DOI: http://dx.doi.org/10.5772/intechopen.85598*

needs and absolute dignity.

**8. Conclusion**

**Conflict of interest**

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org/10.5772/intechopen.85598*

process comprising five steps. The steps involve different approaches that healthcare professionals can employ to improve the care relationship activities of tending, playing and learning in the meeting with the older person by: (1) inviting the older person to participate in care activities, (2) communicating with true presence, (3) taking responsibility in the caring relationship, (4) seeing and listening to the older person's life story and (5) confirming the older person as unique with resources, needs and absolute dignity.

### **8. Conclusion**

*Universal Health Coverage*

**7. Closing reflections**

body's reality and the possibilities of health [34].

ences or the distribution of concrete work activities [44].

people. The care activities of playing and learning can create a bridge between the

The care activities *tending*, *playing* and *learning* can provide a meaningful everyday life for older people and be strengthened when healthcare professionals are educated, supervised and encouraged to reflect on these care activities. Through tending, playing and learning in caring, older people dignity and well-being can be promoted. To share in caring means being able to participate in feelings, experi-

It is in everyday care that the dignity and well-being of older people can be promoted for a sustainable life. To create a good relationship in the care of the older person, it is important to become aware of her/his suffering. Older people deserve care that is focused on their unique needs for dignity and well-being, and not what is most suitable for the healthcare professionals involved in their care. Understanding the vulnerability of the older person can provide nourishment in the care relationship. Seeing and meeting the older people's face and gaze can confirm her/his dignity and promote health. The nurse's responsibility to develop the care means that knowledge is harnessed to benefit the older person. Critical reflection on the activities together with others can lead to the elimination of inefficient care methods and ways of working. Healthcare professionals have the opportunity to create a high-quality care environment for older people with the help of Eriksson's caritative theory, which is viable in the global healthcare system. Healthcare systems should be concerned not only with disease and illness, but with supporting methods that are sustainable and effective in the long term for improving the health, quality of life, well-being and dignity of older people. In order to strengthen older people' well-being and dignity, at no additional cost, healthcare professionals can use the caring relationship model (see **Figure 1**). This model is a collaborative

*An illustration of a model and process to improve the caring relationship activities of tending, playing and learning in order to enhance the quality of healthcare for older people, thus promoting their well-being and* 

**66**

**Figure 1.**

*dignity.*

In order to improve the caring relationship with older people and to promote their well-being and dignity, it is important that healthcare professionals have the opportunity to use Eriksson's caritative theory combined with a collaborative process model. This theory and model are viable in the global healthcare system and can create national and international research networks to improve the coverage of health services within and between countries, and thereby promote a high-quality care environment for older people at no additional cost.

#### **Conflict of interest**

The authors declare that they have no competing interests.

#### **Author details**

Sandra Pennbrant\* and Margareta Karlsson University West, Trollhättan, Sweden

\*Address all correspondence to: sandra.pennbrant@hv.se

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Nyström L. Hälsa, lidande och liv [Health, suffering and life]. In: Wärnå-Furu C, editor. Hälsans Praxis—I Liv Och Arbete [Health Practice—In Life and Work]. Stockholm: Liber; 2014. pp. 13-47

[2] International Council of Nurses (ICN). Ageing [Internet]. 2019. Available from: https://www.icn.ch/ nursing-policy/icn-strategic-priorities/ ageing [Accessed: Feb 12, 2019]

[3] Eriksson K. Vårdvetenskap Som Akademisk Disciplin [Caring Science as an Academic Discipline]. 3rd ed. Vaasa: Department of Caring Sciences, Åbo Academy; 2001. p. 80

[4] Høy B, Kloppenberg K. A dignity supporting elder care. Klinisk Sygepleie. 2012;**26**:4-14

[5] Cesetti G, Vescovelli F, Ruini C. The promotion of well-being in aging individuals living in nursing homes: A controlled pilot intervention with narratives. Clinical Gerontologist. 2017;**40**:380-391. DOI: 10.1080/07317115.2017.1292979

[6] Nortvedt P, Hem MH, Skirbekk H. The ethics of care: Role of obligations and moderate partiality in health care. Nursing Ethics. 2011;**18**:192-200

[7] Eriksson K. Hälsans Idé [The Idea of Health]. 2nd ed. Stockholm: Liber; 1993. p. 146

[8] Lindström UÅ, Lindholm L, Zetterlund JE. Katie Eriksson: Theory of caritative caring. In: Marriner-Tomey A, Alligood MR, editors. Nursing Theorists and Their Work. 7th ed. USA: Missouri, Mosby Elsevier; 2010. pp. 191-221

[9] World Health Organization. World Report on Ageing and Health [Internet]. 2015. Available from: https://www.who.int/ageing/events/

world-report-2015-launch/en/ [Accessed: Feb 12, 2019]

[10] United Nations. World Population Ageing 2013 [Internet]. 2013. Available from: www.un.org/en/development/ desa/population/publications/pdf/ ageing/WorldPopulationAgeing2013. pdf [Accessed: Feb 12, 2019]

[11] Svensk Sjuksköterskeförening. Äldre Personers Rätt Till Omvårdnad—Behov, Kompetenser, Myter och Evidens [Older People's Right to Nursing Care—Needs, Competences, Myths and Evidence]. Stockholm: Sweden; 2014. p. 22

[12] SOU. Värdigt Liv i Äldreomsorgen [Dignified Life in Elder Care]. Vol. 51. Stockholm: Fritzes; 2008. 367 p

[13] Jakobson R, Sørlie V. Dignity of older people in a nursing home: Narratives of care providers. Nursing Ethics. 2010;**17**:289-300. DOI: 10.1177/0969733009355375

[14] Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2014;**14**:640-648. DOI: 10.1016/S0140-6736(13)61489-0

[15] United Nations. Transforming our world: The 2030 agenda for sustainable development. A/RES/70/1 [Internet]. 2015. Available from: https:// sustainabledevelopment.un.org/index. php?page=view&type=400&nr=2125& menu=1515 [Accessed: Feb 3, 2019]

[16] Nordam A, Torjuul K, Sörlie V. Ethical challenges in the care of older people and risk of being burned out among male nurses. Journal of Clinical Nursing. 2005;**14**:1248-1256. DOI: 10.1111/j.1365-2702.2005.01230.x|

[17] Werntoft E, Hallberg RI, Edberg A. Older people's reasoning about agerelated prioritization in health care. Nursing Ethics. 2007;**14**:399-412

**69**

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity*

Anthology]. 1st ed. Åbo: Åbo Akademins Förlag; 2000. p. 175

University; 2004

[27] Söderlund M. Som drabbad av en orkan. Anhörigas tillvaro när en närstående drabbas av demens [As if Struck by a Hurricane: The Situation of the Relatives of Someone Suffering from Dementia] [thesis]. Department of Caring Science, Åbo Academy

[28] Franklin LL, Ternestedt BM, Nordenfelt L. Views on dignity of elderly nursing home residents. Nursing

[29] Näsman Y. Hjärtats vanor, tankens välvilja och handens gärning—dygd som vårdetiskt grundbegrepp [habits of the heart, benevolence of the mind, and deeds of the hand—virtue as a basic concept in caring ethics] [thesis]. Department of Caring Science, Åbo

Ethics. 2006;**13**:130-146

Academy University; 2010

10.1186/1472-6955-7-11

p. 320

2004. p. 160

[30] Gallagher A, Lee D, Li S, Rees Jones I, Wainwright P. Dignity in the care of older people—A review of the theoretical and empirical literature. BMC Nursing. 2008;**7**:11. DOI:

[31] Dehlin O, Hagberg B. Gerontologi: Åldrandet i ett Biologiskt, Psykologiskt och Socialt Perspektiv [Gerontology: Aging in a Biological, Psychological and Social Perspective]. 1st ed. Sweden: Falköping: Natur och Kultur; 2000.

[32] Nordenfelt L. Livskvalitet och Hälsa—Teori och Praktik [Quality of Life and Health—Theory and Practice]. 2nd ed. Linköping: The Tema Institute, Health and Society. Linköping University, Faculty of Arts and Sciences;

[33] World Health Organisation. Constitution of the World Health Organization. New York: WHO, International Health Conference

*DOI: http://dx.doi.org/10.5772/intechopen.85598*

[18] World Health Report 2013: Research for universal health coverage [Internet]. 2013. Available from: https://www.who. int/whr/en/ [Accessed: Feb 18, 2019]

[19] Edlund M. Människans värdighet ett grundbegrepp i vårdvetenskapen [Human dignity: A basic caring science concept] [thesis]. Department of Caring Science, Åbo Academy University; 2002

[20] Eriksson K. Lidandet i vården [The Suffering in the Care]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm:

[21] Anderberg P, Berglund A, Lepp M, Segesten K. Preserving dignity in caring for older adults: A concept analysis. Journal of Advanced Nursing. 2007;**59**:635-643. DOI: 10.1111/j.1365-

[22] Anderberg P. Bevarad värdighet i vård av äldre personer på äldreboende [preserved dignity in the care of older people in a nursing home] [thesis]. Karlstad: Karlstad University Studies;

[23] Slettebö Å, Haugen Baunch E. Solving ethically difficult care situations in nursing homes. Nursing Ethics.

[24] Teeri S, Leino-Kilpi H, Välimäki M. Long-term nursing care of elderly people: Identifying ethically problematic experiences among

patients, relatives and nurses in Finland.

[25] Woolhead G, Calnan M, Dieppe P, Tadd W. Dignity in older age: What do older people in the United Kingdom think? Age and Ageing. 2004;**33**:165-170

Nursing Ethics. 2006;**13**:116-129

[26] Eriksson K, Lindström U. Gryning—En Vårdvetenskaplig Antologi [Dawn—A Care Scientific

Liber; 2018a. pp. 384-399

2648.2007.04375.x|

2004;**11**:543-552

2009

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org/10.5772/intechopen.85598*

[18] World Health Report 2013: Research for universal health coverage [Internet]. 2013. Available from: https://www.who. int/whr/en/ [Accessed: Feb 18, 2019]

[19] Edlund M. Människans värdighet ett grundbegrepp i vårdvetenskapen [Human dignity: A basic caring science concept] [thesis]. Department of Caring Science, Åbo Academy University; 2002

[20] Eriksson K. Lidandet i vården [The Suffering in the Care]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018a. pp. 384-399

[21] Anderberg P, Berglund A, Lepp M, Segesten K. Preserving dignity in caring for older adults: A concept analysis. Journal of Advanced Nursing. 2007;**59**:635-643. DOI: 10.1111/j.1365- 2648.2007.04375.x|

[22] Anderberg P. Bevarad värdighet i vård av äldre personer på äldreboende [preserved dignity in the care of older people in a nursing home] [thesis]. Karlstad: Karlstad University Studies; 2009

[23] Slettebö Å, Haugen Baunch E. Solving ethically difficult care situations in nursing homes. Nursing Ethics. 2004;**11**:543-552

[24] Teeri S, Leino-Kilpi H, Välimäki M. Long-term nursing care of elderly people: Identifying ethically problematic experiences among patients, relatives and nurses in Finland. Nursing Ethics. 2006;**13**:116-129

[25] Woolhead G, Calnan M, Dieppe P, Tadd W. Dignity in older age: What do older people in the United Kingdom think? Age and Ageing. 2004;**33**:165-170

[26] Eriksson K, Lindström U. Gryning—En Vårdvetenskaplig Antologi [Dawn—A Care Scientific Anthology]. 1st ed. Åbo: Åbo Akademins Förlag; 2000. p. 175

[27] Söderlund M. Som drabbad av en orkan. Anhörigas tillvaro när en närstående drabbas av demens [As if Struck by a Hurricane: The Situation of the Relatives of Someone Suffering from Dementia] [thesis]. Department of Caring Science, Åbo Academy University; 2004

[28] Franklin LL, Ternestedt BM, Nordenfelt L. Views on dignity of elderly nursing home residents. Nursing Ethics. 2006;**13**:130-146

[29] Näsman Y. Hjärtats vanor, tankens välvilja och handens gärning—dygd som vårdetiskt grundbegrepp [habits of the heart, benevolence of the mind, and deeds of the hand—virtue as a basic concept in caring ethics] [thesis]. Department of Caring Science, Åbo Academy University; 2010

[30] Gallagher A, Lee D, Li S, Rees Jones I, Wainwright P. Dignity in the care of older people—A review of the theoretical and empirical literature. BMC Nursing. 2008;**7**:11. DOI: 10.1186/1472-6955-7-11

[31] Dehlin O, Hagberg B. Gerontologi: Åldrandet i ett Biologiskt, Psykologiskt och Socialt Perspektiv [Gerontology: Aging in a Biological, Psychological and Social Perspective]. 1st ed. Sweden: Falköping: Natur och Kultur; 2000. p. 320

[32] Nordenfelt L. Livskvalitet och Hälsa—Teori och Praktik [Quality of Life and Health—Theory and Practice]. 2nd ed. Linköping: The Tema Institute, Health and Society. Linköping University, Faculty of Arts and Sciences; 2004. p. 160

[33] World Health Organisation. Constitution of the World Health Organization. New York: WHO, International Health Conference

**68**

p. 146

*Universal Health Coverage*

[1] Nyström L. Hälsa, lidande och liv [Health, suffering and life]. In: Wärnå-Furu C, editor. Hälsans Praxis—I Liv Och Arbete [Health Practice—In Life and Work]. Stockholm: Liber; 2014.

world-report-2015-launch/en/ [Accessed: Feb 12, 2019]

pdf [Accessed: Feb 12, 2019]

[10] United Nations. World Population Ageing 2013 [Internet]. 2013. Available from: www.un.org/en/development/ desa/population/publications/pdf/ ageing/WorldPopulationAgeing2013.

[11] Svensk Sjuksköterskeförening. Äldre Personers Rätt Till Omvårdnad—Behov, Kompetenser, Myter och Evidens [Older People's Right to Nursing Care—Needs, Competences, Myths and Evidence]. Stockholm: Sweden; 2014. p. 22

[12] SOU. Värdigt Liv i Äldreomsorgen [Dignified Life in Elder Care]. Vol. 51. Stockholm: Fritzes; 2008. 367 p

[13] Jakobson R, Sørlie V. Dignity of older people in a nursing home: Narratives of care providers. Nursing Ethics. 2010;**17**:289-300. DOI: 10.1177/0969733009355375

[14] Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2014;**14**:640-648. DOI: 10.1016/S0140-6736(13)61489-0

[15] United Nations. Transforming our world: The 2030 agenda for sustainable development. A/RES/70/1 [Internet]. 2015. Available from: https:// sustainabledevelopment.un.org/index. php?page=view&type=400&nr=2125& menu=1515 [Accessed: Feb 3, 2019]

[16] Nordam A, Torjuul K, Sörlie V. Ethical challenges in the care of older people and risk of being burned out among male nurses. Journal of Clinical Nursing. 2005;**14**:1248-1256. DOI: 10.1111/j.1365-2702.2005.01230.x|

[17] Werntoft E, Hallberg RI, Edberg A. Older people's reasoning about agerelated prioritization in health care. Nursing Ethics. 2007;**14**:399-412

[2] International Council of Nurses (ICN). Ageing [Internet]. 2019. Available from: https://www.icn.ch/ nursing-policy/icn-strategic-priorities/

ageing [Accessed: Feb 12, 2019]

Academy; 2001. p. 80

2012;**26**:4-14

[3] Eriksson K. Vårdvetenskap Som Akademisk Disciplin [Caring Science as an Academic Discipline]. 3rd ed. Vaasa: Department of Caring Sciences, Åbo

[4] Høy B, Kloppenberg K. A dignity supporting elder care. Klinisk Sygepleie.

[5] Cesetti G, Vescovelli F, Ruini C. The promotion of well-being in aging individuals living in nursing homes: A controlled pilot intervention with narratives. Clinical Gerontologist. 2017;**40**:380-391. DOI: 10.1080/07317115.2017.1292979

[6] Nortvedt P, Hem MH, Skirbekk H. The ethics of care: Role of obligations and moderate partiality in health care. Nursing Ethics. 2011;**18**:192-200

[7] Eriksson K. Hälsans Idé [The Idea of Health]. 2nd ed. Stockholm: Liber; 1993.

Zetterlund JE. Katie Eriksson: Theory of caritative caring. In: Marriner-Tomey A, Alligood MR, editors. Nursing Theorists and Their Work. 7th ed. USA: Missouri, Mosby Elsevier; 2010. pp. 191-221

[8] Lindström UÅ, Lindholm L,

[9] World Health Organization. World Report on Ageing and Health [Internet]. 2015. Available from: https://www.who.int/ageing/events/

**References**

pp. 13-47

[Internet]. 1946. Available from: https://www.who.int/governance/eb/ who\_constitution\_en.pdf [Accessed: Feb 12, 2019]

[34] Lindwall L. Kroppen som bärare av hälsa och lidande [The Body as a Carrier of Health and Suffering] [thesis]. Department of Caring Science, Åbo Academy University; 2004

[35] Eriksson K. Hälsa är sundhet, friskhet och välbefinnande [Health is healthiness, freshness and well-being]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018b. pp. 152-165

[36] Shapira N, Barak A, Gal I. Promoting older adults' wellbeing through Internet training and use. Aging & Mental Health. 2007;**11**:477-484

[37] Dolan P, White MP. How can measures of subjective well-being be used to inform public policy? Perspective Psychology Sciences. 2007;**2**:71-84

[38] Eriksson K. Mot en caritativ vårdetik [Towards a caritative ethics]. In: Eriksson K, editor. Mot en Caritativ Vårdetik. Department of Caring Sciences, Åbo: Åbo Academy; 1995. pp. 9-39

[39] Eriksson K. Caritas tanken—människokärleken som vårdvetenskapens kunskapsobjekt [The idea of caritas—human love as the knowledge object of care sciences]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018. pp. 445-456

[40] Eriksson K. Vårdandets idé och ursprung [The idea and origin of caring]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018. pp. 237-239

[41] Eriksson K. Vårdsubstansen—att ansa, leka och lära [Care substance-to tend, play and learn]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018. pp. 245-257

[42] Herberts S, Eriksson K. Vårdarnas etiska profil [Caring ethical profile]. In: Eriksson K, editor. Mot en Caritativ Vårdetik [Nurses Ethical Profile. Towards a Caritative Caring Ethics]. Department of Caring Sciences, Åbo Academy; 1995. pp. 41-62

[43] Eriksson K. Den Lidande Människan [The Suffering Human Being]. 2nd ed. Stockholm: Liber; 1994. p. 112

[44] Eriksson K. Att vårda är att dela [To nurture is to share]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018f. pp. 263-266

[45] Söderlund M. Mänsklig värdighet i vården [Human dignity in health care]. In: Eriksson K, Lindström UÅ, editors. Gryning en Vårdvetenskaplig Antologi [Dawn a Care Scientific Anthology]. Department of Caring Sciences, Åbo: Åbo Academy; 2000. pp. 141-159

[46] Frilund M. En vårdvetenskaplig syntes mellan vårdandets ethos och vårdintensitet [A synthesizer of Caring science and nursing intensity] [thesis]. Vasa: Oy Arkmedia; 2013

[47] Eriksson K. Pro Caritate. En Lägesbestämning av Caritativ Vård

**71**

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity*

*DOI: http://dx.doi.org/10.5772/intechopen.85598*

[A Situational Determination of Caritative Care]. 3rd ed. Vasa:

Åbo Academy; 1990. p. 122

Department of Caring Sciences, Åbo:

[48] Malm M. Själen [The soul]. In: Wiklund Gustin L, Bergbom I, editors. Vårdvetenskapliga Begrepp i Teori Och Praktik [Concepts of Caring Science in Theory and Practice]. 2nd ed. Stockholm: Liber; 2012. pp. 144-154

*Caring for Older People - Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org/10.5772/intechopen.85598*

[A Situational Determination of Caritative Care]. 3rd ed. Vasa: Department of Caring Sciences, Åbo: Åbo Academy; 1990. p. 122

*Universal Health Coverage*

12, 2019]

pp. 152-165

2007;**2**:71-84

[Internet]. 1946. Available from: https://www.who.int/governance/eb/ who\_constitution\_en.pdf [Accessed: Feb

Academy University; 2004

[35] Eriksson K. Hälsa är sundhet, friskhet och välbefinnande [Health is healthiness, freshness and well-being]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018b.

[36] Shapira N, Barak A, Gal I. Promoting older adults' wellbeing through Internet training and use. Aging & Mental Health. 2007;**11**:477-484

[37] Dolan P, White MP. How can measures of subjective well-being be used to inform public policy? Perspective Psychology Sciences.

Åbo Academy; 1995. pp. 9-39

tanken—människokärleken som vårdvetenskapens kunskapsobjekt [The idea of caritas—human love as the knowledge object of care sciences]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm: Liber; 2018.

[40] Eriksson K. Vårdandets idé och ursprung [The idea and origin

[39] Eriksson K. Caritas

[38] Eriksson K. Mot en caritativ vårdetik [Towards a caritative ethics]. In: Eriksson K, editor. Mot en Caritativ Vårdetik. Department of Caring Sciences, Åbo:

[34] Lindwall L. Kroppen som bärare av hälsa och lidande [The Body as a Carrier of Health and Suffering] [thesis]. Department of Caring Science, Åbo

of caring]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm:

[41] Eriksson K. Vårdsubstansen—att ansa, leka och lära [Care substance-to tend, play and learn]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm:

[42] Herberts S, Eriksson K. Vårdarnas etiska profil [Caring ethical profile]. In: Eriksson K, editor. Mot en Caritativ Vårdetik [Nurses Ethical Profile. Towards a Caritative Caring Ethics]. Department of Caring Sciences, Åbo

[43] Eriksson K. Den Lidande Människan [The Suffering Human Being]. 2nd ed.

Liber; 2018. pp. 237-239

Liber; 2018. pp. 245-257

Academy; 1995. pp. 41-62

Stockholm: Liber; 1994. p. 112

Liber; 2018f. pp. 263-266

[44] Eriksson K. Att vårda är att dela [To nurture is to share]. In: Eriksson K, editor. Vårdvetenskap. Vetenskapen om Vårdandet och det Tidlösa i Tiden [Caring Science. The Science of Caring and the Timeless in Time]. Stockholm:

[45] Söderlund M. Mänsklig värdighet i vården [Human dignity in health care]. In: Eriksson K, Lindström UÅ, editors. Gryning en Vårdvetenskaplig Antologi [Dawn a Care Scientific Anthology]. Department of Caring Sciences, Åbo: Åbo Academy; 2000. pp. 141-159

[46] Frilund M. En vårdvetenskaplig syntes mellan vårdandets ethos och vårdintensitet [A synthesizer of Caring science and nursing intensity] [thesis].

Vasa: Oy Arkmedia; 2013

[47] Eriksson K. Pro Caritate. En Lägesbestämning av Caritativ Vård

**70**

pp. 445-456

[48] Malm M. Själen [The soul]. In: Wiklund Gustin L, Bergbom I, editors. Vårdvetenskapliga Begrepp i Teori Och Praktik [Concepts of Caring Science in Theory and Practice]. 2nd ed. Stockholm: Liber; 2012. pp. 144-154

**73**

**Chapter 6**

**Abstract**

system response.

**1. Introduction**

of such inequities.

An Intersectional Innovative

Discourses Interact with Universal

Intersectionality is an analytical tool for understanding the ways gender intersects with and is constituted by other social factors such as social class, age, and ethnicity, among others. The chapter discusses the theoretical and analytical intersectionality perspective, focusing on its application to an analysis of empirical data obtained from qualitative research. Semi-structured interviews took place with healthcare providers in Cordoba, Argentina. Thematic analysis was conducted. The findings show the existence of multiple domination systems incorporated in providers' discourses. All of them interact and contribute to gender inequalities in health, specifically on women's access to universal healthcare for violence against women and/or health of migrant women increasing their vulnerability. Training and sensitization among providers regarding gender and health from an intersectional approach are highly recommended as the first step toward a better healthcare

**Keywords:** intersectionality, gender, access to health, qualitative methodology, healthcare providers, migration, migrant's healthcare, violence against women

Intersectionality has increasingly been applied to health system research, especially works that aim to understand and respond to how multifaceted power structures and process produce and sustain health inequalities [1, 2]. Emerged from black feminist thought and first formulated by American sociologist Kimberlé Crenshaw in 1989 [3], intersectionality moves researchers beyond understanding individuals' unique circumstances and identities toward considering the drivers of inequality and to examining power relations at both individual and macro levels. Intersectionality challenges practices that privilege any specific form of inequality, such as race, ethnicity, class, or gender, and emphasizes the potential of different configurations of social locations and interacting social processes in the production

Intersectionality approach has been applied to healthcare studies and health inequalities to achieve two crucial aims. First, it brings attention to relevant differences within population groups that are often portrayed as relatively homogenous

Analysis of How Providers'

Healthcare Access

*Lorena Saletti-Cuesta and Lila Aizenberg*

#### **Chapter 6**

## An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal Healthcare Access

*Lorena Saletti-Cuesta and Lila Aizenberg*

### **Abstract**

Intersectionality is an analytical tool for understanding the ways gender intersects with and is constituted by other social factors such as social class, age, and ethnicity, among others. The chapter discusses the theoretical and analytical intersectionality perspective, focusing on its application to an analysis of empirical data obtained from qualitative research. Semi-structured interviews took place with healthcare providers in Cordoba, Argentina. Thematic analysis was conducted. The findings show the existence of multiple domination systems incorporated in providers' discourses. All of them interact and contribute to gender inequalities in health, specifically on women's access to universal healthcare for violence against women and/or health of migrant women increasing their vulnerability. Training and sensitization among providers regarding gender and health from an intersectional approach are highly recommended as the first step toward a better healthcare system response.

**Keywords:** intersectionality, gender, access to health, qualitative methodology, healthcare providers, migration, migrant's healthcare, violence against women

#### **1. Introduction**

Intersectionality has increasingly been applied to health system research, especially works that aim to understand and respond to how multifaceted power structures and process produce and sustain health inequalities [1, 2]. Emerged from black feminist thought and first formulated by American sociologist Kimberlé Crenshaw in 1989 [3], intersectionality moves researchers beyond understanding individuals' unique circumstances and identities toward considering the drivers of inequality and to examining power relations at both individual and macro levels. Intersectionality challenges practices that privilege any specific form of inequality, such as race, ethnicity, class, or gender, and emphasizes the potential of different configurations of social locations and interacting social processes in the production of such inequities.

Intersectionality approach has been applied to healthcare studies and health inequalities to achieve two crucial aims. First, it brings attention to relevant differences within population groups that are often portrayed as relatively homogenous

#### *Universal Health Coverage*

such as migrants, indigenous people, or healthcare professionals. For example, it sheds light to an understanding that a white poor woman might be discriminated for her gender and class status when accessing healthcare but has the relative advantage of ethnicity or race over an indigenous or migrant woman. Second, it highlights the fact that health outcomes resulted from power structures of social domination and historical discriminations [4].

Thus, intersectionality moves beyond examining individual factors of health inequities such as biology, socioeconomic status, sex, age, gender, and race or the sum of them. On the contrary, it focuses on the relationships and interactions between such factors and across multiple levels of society to determine how gendered inequalities intersect with other aspects of oppressions that include not just gender but multiple social dominations [5]. Gendered inequalities thus intersect with other aspects of oppression, resulting in unique constellations that include not just gender but race, sexuality, ability, age, social class, caste, or position as a citizen, indigenous person, and refugee, among others. For example, an undocumented migrant will have qualitatively different experiences from a migrant who holds citizenship status.

Therefore, intersectionality has the potential to enrich public health research through improved validity and greater attention to both heterogeneity of effects and causal processes producing health inequalities [5]. As an overarching concept, intersectionality has much to offer to population health in providing a more precise identification of inequalities, in developing intervention strategies, and in ensuring that results are relevant within specific communities. Moreover, it was recently identified as an important theoretical framework for public health [6], as well as for gender and health studies [7].

To illustrate the relevance of intersectionality on understanding providers' discourses, we consider two important health issues on women's access to universal healthcare: violence against women and health of migrant women.

It is well-known that violence against women is an extreme manifestation of gender inequity, targeting women and girls because of their subordinate social status in society [8, 9]. In its multiple forms, it is recognized as a global healthcare problem and a serious violation of women's rights [10–13]. Moreover, violence affects women in different ways, particularly their health [14–16]. Therefore, healthcare systems have a crucial role in detecting, referring, and caring for women affected by violence [17]. A recent systematic review has explored primary care providers' opinions and experiences of tackling violence against women. The findings show that providers hold a range of opinions on the causes of violence against women. For example, some primary care providers perceived violence as a private matter mainly caused by relationship problems, drug abuse, or unemployment. Therefore, there is a need to better understand the social gendered roots of violence against women [18]. This is important considering that healthcare providers frequently, and often unknowingly, encounter violence among their users.

On the other hand, the increasing participation of women in migration processes, the growing tendency to incorporate gender approaches in the social sciences, and the conceptual opening to the figure of the migrant woman [19] have shown that migration processes are complex phenomenon shaped considerably by gender relations [20]. Social sciences have highlighted the need to approach the dynamic intersection between the different components present in the historical structures of domination [21, 22]. Social science analyses have demonstrated the value of the intersectionality of gender dimensions, ethnicity, social class, and national origin in migration studies [23] and the outcomes of the interactions of the categories which, in the case of female migrants, are placed in the social periphery. This has led to a growing attention to the relationships between migration;

**75**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal…*

intra-family dynamic, social contexts of women; impacts of displacement on gender roles; and migration outcomes on the quality of life of women, including

Migration is, therefore, recognized as a key determinant of health [4]. For example, compared to their native counterparts, migrant women experience a higher number of unwanted pregnancies and report lower use of contraceptives and a lower propensity to attend reproductive health services in Latin America [25]. In this sense, migration has been identified as a risk factor, showing that the confluence of gender, ethnicity, and nationality and the lack of official citizenship documents can lead to the most extreme human rights violations, including sexual abuse, deterioration of reproductive health, and threats to physical integrity [26]. In the specific case of women, migrants are even more exposed to encountering obstacles to healthcare services. In addition to the difficulties they have as migrants, women face obstacles due to factors associated with their social class, gender, and ethnic-cultural background [27]. Despite these factors, studies have overemphasized cultural differences between migrant populations and the health system as relationships based on distrust among professionals and users due to cultural gaps [28]. This is why intersectional lens are crucial to understand multilevel factors shaping healthcare provision, practices, and use among migrant groups [4]. This article aims to include intersectionality theory to better understand the multiple axes of inequalities that cross healthcare providers' discourses on violence against women and health problems of migrant women. Intersectional lens becomes a promising approach to highlight the limits to health research and healthcare responses to migration and violence against women that overemphasize a single causal element of health outcomes—such as cultural differences or class—while highlighting multiple factors that shape healthcare views and healthcare practices in

This qualitative study was conducted in two phases in Cordoba, Argentina. In phase one, healthcare providers from primary care centers or a regional hospital from urban and semi-urban regions of Cordoba were recruited using purposive sampling. Data were collected in different periods from June 2013 to November 2016. In phase two, we used purposive sampling to recruit healthcare providers who worked in primary care centers or in a regional hospital from a semi-urban northern region of Cordoba. Professionals with least than a year of experience working in the setting were excluded. Data were collected over a period of 15 months from

In both phases semi-structured interviews were conducted. All interviews were conducted by the authors. The interview guides used in each phase were pilot tested. It included basic sociodemographic information. In phase one the guide included questions that gathered their perceptions regarding migrant populations in general and the Bolivian flow in particular, as well as the existing barriers and facilitators in the access and use of health services by migrant women. In phase two the questions focused on four main topic areas: violence against women's opinions, experiences, barriers to provide care, and ways to overcome these obstacles. The interviews were conducted during regular working hours in a private place located in the health center or in the hospital. Each interview lasted ~60 minutes. They were audio recorded and transcribed verbatim for analysis. Full signed and informed consent was gained from all participants. Ethical approval was obtained through

*DOI: http://dx.doi.org/10.5772/intechopen.86208*

their sexual and reproductive health [24].

Argentinian healthcare system.

November 2016 to February 2018.

the College of Psychologists of Cordoba.

**2. Method**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal… DOI: http://dx.doi.org/10.5772/intechopen.86208*

intra-family dynamic, social contexts of women; impacts of displacement on gender roles; and migration outcomes on the quality of life of women, including their sexual and reproductive health [24].

Migration is, therefore, recognized as a key determinant of health [4]. For example, compared to their native counterparts, migrant women experience a higher number of unwanted pregnancies and report lower use of contraceptives and a lower propensity to attend reproductive health services in Latin America [25]. In this sense, migration has been identified as a risk factor, showing that the confluence of gender, ethnicity, and nationality and the lack of official citizenship documents can lead to the most extreme human rights violations, including sexual abuse, deterioration of reproductive health, and threats to physical integrity [26].

In the specific case of women, migrants are even more exposed to encountering obstacles to healthcare services. In addition to the difficulties they have as migrants, women face obstacles due to factors associated with their social class, gender, and ethnic-cultural background [27]. Despite these factors, studies have overemphasized cultural differences between migrant populations and the health system as relationships based on distrust among professionals and users due to cultural gaps [28]. This is why intersectional lens are crucial to understand multilevel factors shaping healthcare provision, practices, and use among migrant groups [4].

This article aims to include intersectionality theory to better understand the multiple axes of inequalities that cross healthcare providers' discourses on violence against women and health problems of migrant women. Intersectional lens becomes a promising approach to highlight the limits to health research and healthcare responses to migration and violence against women that overemphasize a single causal element of health outcomes—such as cultural differences or class—while highlighting multiple factors that shape healthcare views and healthcare practices in Argentinian healthcare system.

#### **2. Method**

*Universal Health Coverage*

historical discriminations [4].

holds citizenship status.

gender and health studies [7].

such as migrants, indigenous people, or healthcare professionals. For example, it sheds light to an understanding that a white poor woman might be discriminated for her gender and class status when accessing healthcare but has the relative advantage of ethnicity or race over an indigenous or migrant woman. Second, it highlights the fact that health outcomes resulted from power structures of social domination and

Thus, intersectionality moves beyond examining individual factors of health inequities such as biology, socioeconomic status, sex, age, gender, and race or the sum of them. On the contrary, it focuses on the relationships and interactions between such factors and across multiple levels of society to determine how gendered inequalities intersect with other aspects of oppressions that include not just gender but multiple social dominations [5]. Gendered inequalities thus intersect with other aspects of oppression, resulting in unique constellations that include not just gender but race, sexuality, ability, age, social class, caste, or position as a citizen, indigenous person, and refugee, among others. For example, an undocumented migrant will have qualitatively different experiences from a migrant who

Therefore, intersectionality has the potential to enrich public health research through improved validity and greater attention to both heterogeneity of effects and causal processes producing health inequalities [5]. As an overarching concept, intersectionality has much to offer to population health in providing a more precise identification of inequalities, in developing intervention strategies, and in ensuring that results are relevant within specific communities. Moreover, it was recently identified as an important theoretical framework for public health [6], as well as for

To illustrate the relevance of intersectionality on understanding providers' discourses, we consider two important health issues on women's access to universal

It is well-known that violence against women is an extreme manifestation of gender inequity, targeting women and girls because of their subordinate social status in society [8, 9]. In its multiple forms, it is recognized as a global healthcare problem and a serious violation of women's rights [10–13]. Moreover, violence affects women in different ways, particularly their health [14–16]. Therefore, healthcare systems have a crucial role in detecting, referring, and caring for women affected by violence [17]. A recent systematic review has explored primary care providers' opinions and experiences of tackling violence against women. The findings show that providers hold a range of opinions on the causes of violence against women. For example, some primary care providers perceived violence as a private matter mainly caused by relationship problems, drug abuse, or unemployment. Therefore, there is a need to better understand the social gendered roots of violence against women [18]. This is important considering that healthcare providers

healthcare: violence against women and health of migrant women.

frequently, and often unknowingly, encounter violence among their users.

On the other hand, the increasing participation of women in migration processes, the growing tendency to incorporate gender approaches in the social sciences, and the conceptual opening to the figure of the migrant woman [19] have shown that migration processes are complex phenomenon shaped considerably by gender relations [20]. Social sciences have highlighted the need to approach the dynamic intersection between the different components present in the historical structures of domination [21, 22]. Social science analyses have demonstrated the value of the intersectionality of gender dimensions, ethnicity, social class, and national origin in migration studies [23] and the outcomes of the interactions of the categories which, in the case of female migrants, are placed in the social periphery. This has led to a growing attention to the relationships between migration;

**74**

This qualitative study was conducted in two phases in Cordoba, Argentina. In phase one, healthcare providers from primary care centers or a regional hospital from urban and semi-urban regions of Cordoba were recruited using purposive sampling. Data were collected in different periods from June 2013 to November 2016.

In phase two, we used purposive sampling to recruit healthcare providers who worked in primary care centers or in a regional hospital from a semi-urban northern region of Cordoba. Professionals with least than a year of experience working in the setting were excluded. Data were collected over a period of 15 months from November 2016 to February 2018.

In both phases semi-structured interviews were conducted. All interviews were conducted by the authors. The interview guides used in each phase were pilot tested. It included basic sociodemographic information. In phase one the guide included questions that gathered their perceptions regarding migrant populations in general and the Bolivian flow in particular, as well as the existing barriers and facilitators in the access and use of health services by migrant women. In phase two the questions focused on four main topic areas: violence against women's opinions, experiences, barriers to provide care, and ways to overcome these obstacles. The interviews were conducted during regular working hours in a private place located in the health center or in the hospital. Each interview lasted ~60 minutes. They were audio recorded and transcribed verbatim for analysis. Full signed and informed consent was gained from all participants. Ethical approval was obtained through the College of Psychologists of Cordoba.

Inductive thematic analysis was conducted following Braun and Clarke's method [29] for identifying, analyzing, and reporting patterns (themes) within data. Transcripts of each phase have been reviewed independently by the researchers in an iterative process with the following stages: familiarization with the data, production of initial codes from the data, identifying themes, reviewing themes, and defining and naming themes. Saturation was achieved within the themes and categories. When all of the transcripts from each phase were coded and analyzed, the investigators met to reorganize them all into meaningful themes focusing on intersectionality and taking into account sociodemographic information. As Anuj Kapilashrami and Olena Hankivsky [4] mentioned, there is no single way to approach intersectionality and no preferred method. However, the authors recognized the importance of interpreting the commonalities and differences within and across population groups without being reductionists and linking individual levels of experience to social structures of power. This last stage resulted in an organized and comprehensive summary of multiple domination systems incorporated in providers' discourses. ATLAS.ti version 7.5.4 was used to help with management of the data.

A total of 50 providers (39 female and 11 male) participated in the research aged 30–59 years. They were from five communities (three from northern Cordoba, one from the center of Cordoba, and one from the periphery of Cordoba City). Regarding their professions, 20 of them were physicians, 13 nurses, 8 psychologists, 6 social workers, 2 dentists, and 1 radiologist.

#### **3. Violence against women**

The opinions of the healthcare providers regarding violence against women were varied and show how multiple factors shape healthcare opinions and practices contributing, some of them, to gender inequalities.

A mutual couple conflict, being in an unhealthy couple relationship, no respect, or lack of values were the root causes of violence against women according to the majority of healthcare providers. From this point of view, violence was as a private/ domestic matter, making either men or women responsible for violence. For some providers interviewed, both members of the couple were considered "sick." From their point of view, these "unhealthy links" would cause a vicious circle between both members. Moreover, due to the naturalization of the violence, it was difficult to identify certain acts as violence and, therefore, to break circle of violence, according to providers' points of view.

*"From my medical point of view, I believe that it is a disease of both. I think probably he has previously gone through other situations and came to this one…." (Woman physician, hospital)*

*"The violence starts with the values, the limits, the culture that they receive, first from the family, the school, the social environment… We always see the last part of the film, when we have to act … with someone already physically or psychologically injured. But we see the end, almost the end, because that story started many years ago. Why a person becomes an aggressor, becomes violent with another, and why that other one did not respond to stop that violence and accepts and justifies it…We works with two sick people…." (Men physician, primary care)*

This psychologization of the problem is a way of reducing a complex social problem to an individual or couple's disorder or conflict, which would reveal that the health sector does not correctly address the problem of violence against

**77**

health sector [36].

their violence.

*(Woman radiologist, hospital)*

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal…*

patients, giving them a leading role in the decision-making process [32].

[35], which contributes to perpetuate this serious problem.

traditional gender roles, or their fear of social stigmatization.

women by not understanding it as a multifaceted phenomenon that is produced by the complex interaction of individual, relational, community, and social factors [30, 31]. Also, they defined violence against women as a pathology or a defect. Understanding violence as a sign of disease reveals biomedical conception of health and places the health sector in an active and expert role. From this place, healthcare providers would have the knowledge/power on how the relationships between men and women "should be." Healthcare providers have been trained to investigate and diagnose a disease, to solve a problem, and to help their patients. However, in the case of violence against women, this role must be left aside to focus on the needs of

On the other hand, several people interviewed consider that women, mainly from vulnerable sectors, were partly responsible for their situation of violence since, from their perspective, they are also "sick" and justified the mistreatment they receive. These ideas not only release men from their responsibility but also contribute to normalizing violence against women by blaming vulnerable women for remaining in situations of violence [33]. It has been pointed out that not knowing about violence against women not only could hinder professionals to not inquire about this problem [18, 34] but also could influence women's trust in professionals

This is important because it is related to how providers understand women as victims of violence and the barriers that prevent women from reporting their situation. For instance, some providers highlighted women's tendencies to hide abuse, low self-esteem, lack of family support, economic dependency, and social isolation, as well as their feelings of shame, guilt, or insecurity, their own acceptance of

Moreover, violence against women was understood as a patron of behavior transmitted from generation to generation. From providers' opinions, lacking values and limits, especially in childhood, childhood abuse, and/or violence experienced in childhood within the family context would explain why men perform violence in their adult life and also why women choose violent couples and justify

*"…it is always repeating, things that have happened as a child they will do it again and so…afterwards it will happen later with the creatures raised in that family. It will continue, it seems to me. There is a lack of education, of emotional contention."* 

*"Mainly that women become aware and take conscience of the situation… I think it will take a long-term work, I would tell you from the time they are girls, from elementary school, to do a raising awareness work focusing on women to show them that this situation is not normal, even though they see it at their homes: my dad hit my mom or spit on her, or insulted her, and those situations goes unnoticed. It is important that girls become aware that violence is not good… so they are clear* 

These opinions stated families not only as a power structure but also as the main agent of socialization that produce and sustain violence and gender disparities. This belief could be an important barrier to understand violence against women as a multifactorial phenomenon that is part of the patriarchal social structure where all social agents are responsible for its maintenance and reproduction, including the

Moreover, social class bias underlined providers' ideas about family models, violence, and education illustrating how various factors are affecting providers' opinions

*about what is right and what is wrong." (Men physician, hospital)*

*DOI: http://dx.doi.org/10.5772/intechopen.86208*

#### *An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal… DOI: http://dx.doi.org/10.5772/intechopen.86208*

women by not understanding it as a multifaceted phenomenon that is produced by the complex interaction of individual, relational, community, and social factors [30, 31]. Also, they defined violence against women as a pathology or a defect. Understanding violence as a sign of disease reveals biomedical conception of health and places the health sector in an active and expert role. From this place, healthcare providers would have the knowledge/power on how the relationships between men and women "should be." Healthcare providers have been trained to investigate and diagnose a disease, to solve a problem, and to help their patients. However, in the case of violence against women, this role must be left aside to focus on the needs of patients, giving them a leading role in the decision-making process [32].

On the other hand, several people interviewed consider that women, mainly from vulnerable sectors, were partly responsible for their situation of violence since, from their perspective, they are also "sick" and justified the mistreatment they receive. These ideas not only release men from their responsibility but also contribute to normalizing violence against women by blaming vulnerable women for remaining in situations of violence [33]. It has been pointed out that not knowing about violence against women not only could hinder professionals to not inquire about this problem [18, 34] but also could influence women's trust in professionals [35], which contributes to perpetuate this serious problem.

This is important because it is related to how providers understand women as victims of violence and the barriers that prevent women from reporting their situation. For instance, some providers highlighted women's tendencies to hide abuse, low self-esteem, lack of family support, economic dependency, and social isolation, as well as their feelings of shame, guilt, or insecurity, their own acceptance of traditional gender roles, or their fear of social stigmatization.

Moreover, violence against women was understood as a patron of behavior transmitted from generation to generation. From providers' opinions, lacking values and limits, especially in childhood, childhood abuse, and/or violence experienced in childhood within the family context would explain why men perform violence in their adult life and also why women choose violent couples and justify their violence.

*"…it is always repeating, things that have happened as a child they will do it again and so…afterwards it will happen later with the creatures raised in that family. It will continue, it seems to me. There is a lack of education, of emotional contention." (Woman radiologist, hospital)*

*"Mainly that women become aware and take conscience of the situation… I think it will take a long-term work, I would tell you from the time they are girls, from elementary school, to do a raising awareness work focusing on women to show them that this situation is not normal, even though they see it at their homes: my dad hit my mom or spit on her, or insulted her, and those situations goes unnoticed. It is important that girls become aware that violence is not good… so they are clear about what is right and what is wrong." (Men physician, hospital)*

These opinions stated families not only as a power structure but also as the main agent of socialization that produce and sustain violence and gender disparities. This belief could be an important barrier to understand violence against women as a multifactorial phenomenon that is part of the patriarchal social structure where all social agents are responsible for its maintenance and reproduction, including the health sector [36].

Moreover, social class bias underlined providers' ideas about family models, violence, and education illustrating how various factors are affecting providers' opinions

*Universal Health Coverage*

Inductive thematic analysis was conducted following Braun and Clarke's method [29] for identifying, analyzing, and reporting patterns (themes) within data. Transcripts of each phase have been reviewed independently by the researchers in an iterative process with the following stages: familiarization with the data, production of initial codes from the data, identifying themes, reviewing themes, and defining and naming themes. Saturation was achieved within the themes and categories. When all of the transcripts from each phase were coded and analyzed, the investigators met to reorganize them all into meaningful themes focusing on intersectionality and taking into account sociodemographic information. As Anuj Kapilashrami and Olena Hankivsky [4] mentioned, there is no single way to approach intersectionality and no preferred method. However, the authors recognized the importance of interpreting the commonalities and differences within and across population groups without being reductionists and linking individual levels of experience to social structures of power. This last stage resulted in an organized and comprehensive summary of multiple domination systems incorporated in providers' discourses. ATLAS.ti version 7.5.4 was used to help with management of the data.

A total of 50 providers (39 female and 11 male) participated in the research aged

30–59 years. They were from five communities (three from northern Cordoba, one from the center of Cordoba, and one from the periphery of Cordoba City). Regarding their professions, 20 of them were physicians, 13 nurses, 8 psychologists,

The opinions of the healthcare providers regarding violence against women were varied and show how multiple factors shape healthcare opinions and practices

*"From my medical point of view, I believe that it is a disease of both. I think probably he has previously gone through other situations and came to this one…."* 

*"The violence starts with the values, the limits, the culture that they receive, first from the family, the school, the social environment… We always see the last part of the film, when we have to act … with someone already physically or psychologically injured. But we see the end, almost the end, because that story started many years ago. Why a person becomes an aggressor, becomes violent with another, and why that other one did not respond to stop that violence and accepts and justifies it…We* 

This psychologization of the problem is a way of reducing a complex social problem to an individual or couple's disorder or conflict, which would reveal that the health sector does not correctly address the problem of violence against

*works with two sick people…." (Men physician, primary care)*

A mutual couple conflict, being in an unhealthy couple relationship, no respect, or lack of values were the root causes of violence against women according to the majority of healthcare providers. From this point of view, violence was as a private/ domestic matter, making either men or women responsible for violence. For some providers interviewed, both members of the couple were considered "sick." From their point of view, these "unhealthy links" would cause a vicious circle between both members. Moreover, due to the naturalization of the violence, it was difficult to identify certain acts as violence and, therefore, to break circle of violence,

6 social workers, 2 dentists, and 1 radiologist.

contributing, some of them, to gender inequalities.

**3. Violence against women**

according to providers' points of view.

*(Woman physician, hospital)*

**76**

and practices simultaneously. Belonging to the working class was a risk factor for violence against women, according to some providers.

*"It is very difficult for the victim of violence to get out of that situation and when she does sometimes, she not has a supportive family network… she not has the resources…it is very complicated… I have people who have decided, have been gone two, three years and after she returned to the violent relationship…." (Woman social worker, primary care)*

Finally, it is important to note that no differences were noted within healthcare level of care, professions, gender, or years of experience regarding opinions of understanding violence against women.

#### **4. Healthcare of Bolivian migrant women**

The intersectional approach also highlighted the limits of providers' responses to migration that mainly stress cultural differences between them and migrants or that focus primarily on developing intercultural programs to address cultural barriers.

Among migrants that arrive to health services in Argentina, the Bolivian one appears as "the other" more differentiated, with its own characteristics (language, dress, customs) and phenotypic features, according to providers. Women have a particular weight in the stories of professionals about the Bolivian flow that is largely explained by the type of services analyzed, mainly linked to health. Relationships between migrants and the health system are conflicting as a result of the cultural differences perceived by providers. Cultural differences are mainly related with Bolivian women's traditional figure, associated with submission and docility [37].

*"In general, the perception of the health team [about Bolivians] is hygiene. It is a main rejection. The other thing is the language. The rhythms are different. They are calmer, more leisurely; they do not ask many questions, or they stay waiting; They do not dare to ask if they need anything. One is very helpless talking but not knowing what happens on the other side." (Woman gynecologist-obstetrician, third level of care)*

*"The feeling that I have is that they do not have an expression. You do not know if the message was really understood. With an Argentinian woman, it does not happen that much; Argentinian are more questioning, but according to them [Bolivians] everything is always very good." (Women gynecologist-obstetrician, third level of care)*

*"Those who arrive from there (from Bolivia) have a language that is sometimes difficult to communicate, and they have a deeply rooted culture, the culture they have is very strong. For example, the culture they have is that the husband is the one who transmits everything to his wife." (Women nurse, third level of care)*

*"The difference (between the Bolivians) with the Argentine ones is the level of education; the Bolivian is submissive, mainly elementary; that is their cultural characteristic; she talks very little and we cannot understand her." (Women psychologist, third level of care)*

Intersectionality analysis contributes to the knowledge offered by existing studies that have sought to understand the relationship of migrant women to health services and have tended to look at the relationship between migrant patients and providers

**79**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal…*

shape opinions and experiences of providers toward Bolivian migrants.

on issues related to communications or cultural interpersonal relations, rather than the simultaneous disadvantages behind the exclusion of certain population groups such as migrant women. In this case, the power of intersectionality approach allows opening the cultural "umbrella" behind opinions and experiences of providers toward Bolivian migrants by enhancing a deeper understanding on how and why this group is looked. It not only shows gender stereotypes (women subject of male domination) but also other social inequalities based on structural roots (such as poverty, xenophobic and discrimination attitudes, ethnic-/race-based discrimination) that

Moreover, the lens highlights the importance of taking the migration process as an opportunity to redefine the health-disease-care process in places of migration, placing migrants within the broader contexts where they experience their health. This implies not only focusing on the cultural interpersonal relationships between migrants and providers but recovering the explanations of the multiple causes (cultural, economic, political, social) behind healthcare in migration processes.

The findings show the existence of multiple domination systems incorporated in providers' discourses. All of them interact and contribute to gender inequalities in health, specifically on women's access to universal healthcare for violence against women and/or health problems in migrant women increasing their vulnerability. For instance, understanding women as responsible for violence, thinking that violence is a prevalent problem among vulnerable sectors, and conceiving migrants from a solely cultural lens were identified barriers to provide universal healthcare. Working toward universal health coverage is a powerful mechanism for achieving better health and well-being and for promoting human development by ensuring that everyone has access to the health services they need without suffering financial

Intersectionality approach contributed to understand providers' opinions and how in their practices they tended to focus on some factors reproducing inequalities, such as the naturalization of violence against women. In that sense, training and sensitization among providers regarding gender, health, and migration are highly recommended as the first step toward a better healthcare system response and goals defined as improving health and health equity, in ways that are responsive, are financially fair, and make the best, or most efficient, use of available resources [39]. However, it has been pointed that those steps are necessary but not enough to address the multilevel factors shaping healthcare provision [4]. As Thurston and Eisener [40] noted, gender, organizational healthcare culture and structure, and other contextual related variables may play an important role in maintaining barriers and should be studied in depth, avoiding a focus on individual (healthcare

Therefore, and tacking into account our findings, we propose to question the culture, policies, and practices of the broader structures in which healthcare systems are situated. Opening opportunities to discuss gendered assumptions is essential to promoting gender equity access to health in our context. For instance, this should highlight the importance of taking migrant women's voices to understand how they redefine their understanding of healthcare in their migration process as well as their assets as a way of coping with the multiple obstacles encountered in the health-disease-healthcare at their places of destination. This is why the intersectional approach enhances understanding of inequalities in health and should be

*DOI: http://dx.doi.org/10.5772/intechopen.86208*

**5. Conclusions**

hardship as a result [38].

provider) level variables.

strengthened in healthcare policies.

#### *An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal… DOI: http://dx.doi.org/10.5772/intechopen.86208*

on issues related to communications or cultural interpersonal relations, rather than the simultaneous disadvantages behind the exclusion of certain population groups such as migrant women. In this case, the power of intersectionality approach allows opening the cultural "umbrella" behind opinions and experiences of providers toward Bolivian migrants by enhancing a deeper understanding on how and why this group is looked. It not only shows gender stereotypes (women subject of male domination) but also other social inequalities based on structural roots (such as poverty, xenophobic and discrimination attitudes, ethnic-/race-based discrimination) that shape opinions and experiences of providers toward Bolivian migrants.

Moreover, the lens highlights the importance of taking the migration process as an opportunity to redefine the health-disease-care process in places of migration, placing migrants within the broader contexts where they experience their health. This implies not only focusing on the cultural interpersonal relationships between migrants and providers but recovering the explanations of the multiple causes (cultural, economic, political, social) behind healthcare in migration processes.

#### **5. Conclusions**

*Universal Health Coverage*

and practices simultaneously. Belonging to the working class was a risk factor for

*"It is very difficult for the victim of violence to get out of that situation and when she does sometimes, she not has a supportive family network… she not has the resources…it is very complicated… I have people who have decided, have been gone two, three years and after she returned to the violent relationship…." (Woman* 

Finally, it is important to note that no differences were noted within healthcare level of care, professions, gender, or years of experience regarding opinions of

The intersectional approach also highlighted the limits of providers' responses to migration that mainly stress cultural differences between them and migrants or that focus primarily on developing intercultural programs to address cultural barriers. Among migrants that arrive to health services in Argentina, the Bolivian one appears as "the other" more differentiated, with its own characteristics (language, dress, customs) and phenotypic features, according to providers. Women have a particular weight in the stories of professionals about the Bolivian flow that is largely explained by the type of services analyzed, mainly linked to health. Relationships between migrants and the health system are conflicting as a result of the cultural differences perceived by providers. Cultural differences are mainly related with Bolivian women's traditional figure, associated with submission and docility [37].

*"In general, the perception of the health team [about Bolivians] is hygiene. It is a main rejection. The other thing is the language. The rhythms are different. They are calmer, more leisurely; they do not ask many questions, or they stay waiting; They do not dare to ask if they need anything. One is very helpless talking but not knowing what happens on the other side." (Woman gynecologist-obstetrician, third level of care)*

*"The feeling that I have is that they do not have an expression. You do not know if the message was really understood. With an Argentinian woman, it does not happen that much; Argentinian are more questioning, but according to them [Bolivians] everything is always very good." (Women gynecologist-obstetrician,* 

*"Those who arrive from there (from Bolivia) have a language that is sometimes difficult to communicate, and they have a deeply rooted culture, the culture they have is very strong. For example, the culture they have is that the husband is the one* 

*"The difference (between the Bolivians) with the Argentine ones is the level of education; the Bolivian is submissive, mainly elementary; that is their cultural characteristic; she talks very little and we cannot understand her." (Women* 

Intersectionality analysis contributes to the knowledge offered by existing studies that have sought to understand the relationship of migrant women to health services and have tended to look at the relationship between migrant patients and providers

*who transmits everything to his wife." (Women nurse, third level of care)*

violence against women, according to some providers.

*social worker, primary care)*

understanding violence against women.

*third level of care)*

*psychologist, third level of care)*

**4. Healthcare of Bolivian migrant women**

**78**

The findings show the existence of multiple domination systems incorporated in providers' discourses. All of them interact and contribute to gender inequalities in health, specifically on women's access to universal healthcare for violence against women and/or health problems in migrant women increasing their vulnerability. For instance, understanding women as responsible for violence, thinking that violence is a prevalent problem among vulnerable sectors, and conceiving migrants from a solely cultural lens were identified barriers to provide universal healthcare. Working toward universal health coverage is a powerful mechanism for achieving better health and well-being and for promoting human development by ensuring that everyone has access to the health services they need without suffering financial hardship as a result [38].

Intersectionality approach contributed to understand providers' opinions and how in their practices they tended to focus on some factors reproducing inequalities, such as the naturalization of violence against women. In that sense, training and sensitization among providers regarding gender, health, and migration are highly recommended as the first step toward a better healthcare system response and goals defined as improving health and health equity, in ways that are responsive, are financially fair, and make the best, or most efficient, use of available resources [39].

However, it has been pointed that those steps are necessary but not enough to address the multilevel factors shaping healthcare provision [4]. As Thurston and Eisener [40] noted, gender, organizational healthcare culture and structure, and other contextual related variables may play an important role in maintaining barriers and should be studied in depth, avoiding a focus on individual (healthcare provider) level variables.

Therefore, and tacking into account our findings, we propose to question the culture, policies, and practices of the broader structures in which healthcare systems are situated. Opening opportunities to discuss gendered assumptions is essential to promoting gender equity access to health in our context. For instance, this should highlight the importance of taking migrant women's voices to understand how they redefine their understanding of healthcare in their migration process as well as their assets as a way of coping with the multiple obstacles encountered in the health-disease-healthcare at their places of destination. This is why the intersectional approach enhances understanding of inequalities in health and should be strengthened in healthcare policies.

### **Acknowledgements**

The authors are grateful to the participating healthcare professionals and their local health coordinators for their collaboration. Phase two of the project was supported by funds from the Scientific and Technological Research Fund (FONCYT PICT2016-0475). Many thanks to Agostina Ferioli, Fany del Valle Martínez, Elizabeth Viel, Victoria Baudin, Paola Romero, Natalia Funk, Ana Claudia González, and Anahi Rodríguez for their collaboration in phase two of the study. This study was also supported by the Science and Technology Secretary of the National University of Cordoba, Argentina.

### **Conflict of interest**

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

### **Author details**

Lorena Saletti-Cuesta\* and Lila Aizenberg Culture and Society Research and Study Centre, National Scientific and Technical Research Council, National University of Cordoba (CIECS-CONICET-UNC), Córdoba, Argentina

\*Address all correspondence to: lorenasaletti@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**81**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal…*

[9] Hunnicutt G. Varieties of patriarchy and violence against women. Resurrecting "patriarchy" as a theoretical tool. Violence Against Women. 2009;**15**:553-573. DOI: 10.1177/1077801208331246

[10] World Health Organization.

[11] Kelmendi K. Violence against women: Methodological and ethical issues. Psychology. 2013;**4**:559-565. DOI:

[12] García-Moreno C, Hegarty K, Lucas dÓliveira a F, Koziol-McLain J, Colombini M, Feder G. The healthsystems response to violence against women. Lancet. 2015;**385**:1567-1579. DOI: 10.1016/S0140-6736(14)61837-7

[13] Montesanti SR, Thurston W. Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women's Health. 2015;**15**:100. DOI: 10.1186/

[14] García-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C. WHO Multi-Country Study on Women's Health and Domestic Violence Against Women: Initial Results on Prevalence, Health Outcomes and Women's Responses. Geneva: World Health

Organization; 2005. p. 206

[15] Plichta SB. Interactions between victims of intimate partner violence against women and the health care system. Trauma, Violence & Abuse. 2007;**8**:226-239. DOI: 10.1177/1524838007301220

[16] Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB. Intimate partner violence against

s12905-015-0256-4

10.4236/psych.2013.47080

Prevention of Violence: A Public Health Priority. WHA 49.5. Geneva: World Health Assembly; 1996. pp. 20-25

*DOI: http://dx.doi.org/10.5772/intechopen.86208*

[1] Bowleg L. When black + lesbian + woman ≠ black lesbian woman: The methodological challenges of qualitative and quantitative intersectionality research. Sex Roles. 2008;**59**:312-325. DOI: 10.1007/s11199-008-9400-z

[2] Iyer A, Sen G, Ostlin P. The intersections of gender and class in health status and health care. Global Public Health. 2008;**3**(Suppl 1):13-24. DOI: 10.1080/17441690801892174

[3] Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal

Forum. 1989;**140**:139-167

S0140-6736(18)31431-4

[5] Bauer GR. Incorporating

health research methodology:

2014;**110**:10-17. DOI: 10.1016/j.

[6] Bowleg L. The problem with the phrase "women and minorities": Intersectionality, an important theoretical framework for public health. American Journal of Public Health. 2012;**2**:1267-1273. DOI: 10.2105/

socscimed.2014.03.022

AJPH.2012.300750

s11199-005-4204-x

[7] Shields SA. Gender: An

intersectionality perspective. Sex Roles: A Journal of Research. 2008;**59**:301-311.

[8] Anderson K. Theorizing gender in intimate partner violence research. Sex Roles. 2005;**52**:853-865. DOI: 10.1007/

DOI: 10.1007/s11199-008-9501-8

intersectionality theory into population

Challenges and the potential to advance health equity. Social Science Medicine.

[4] Kapilashrami A, Hankivsky O. Intersectionality and why it matters to global health. The Lancet. 2018;**391**:2589-2591. DOI: 10.1016/

**References**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal… DOI: http://dx.doi.org/10.5772/intechopen.86208*

#### **References**

*Universal Health Coverage*

**Acknowledgements**

**Conflict of interest**

National University of Cordoba, Argentina.

research, authorship, and/or publication of this article.

The authors are grateful to the participating healthcare professionals and their local health coordinators for their collaboration. Phase two of the project was supported by funds from the Scientific and Technological Research Fund (FONCYT PICT2016-0475). Many thanks to Agostina Ferioli, Fany del Valle

The authors declared no potential conflicts of interest with respect to the

Culture and Society Research and Study Centre, National Scientific and Technical Research Council, National University of Cordoba (CIECS-CONICET-UNC),

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Martínez, Elizabeth Viel, Victoria Baudin, Paola Romero, Natalia Funk, Ana Claudia González, and Anahi Rodríguez for their collaboration in phase two of the study. This study was also supported by the Science and Technology Secretary of the

**80**

**Author details**

Córdoba, Argentina

Lorena Saletti-Cuesta\* and Lila Aizenberg

provided the original work is properly cited.

\*Address all correspondence to: lorenasaletti@gmail.com

[1] Bowleg L. When black + lesbian + woman ≠ black lesbian woman: The methodological challenges of qualitative and quantitative intersectionality research. Sex Roles. 2008;**59**:312-325. DOI: 10.1007/s11199-008-9400-z

[2] Iyer A, Sen G, Ostlin P. The intersections of gender and class in health status and health care. Global Public Health. 2008;**3**(Suppl 1):13-24. DOI: 10.1080/17441690801892174

[3] Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum. 1989;**140**:139-167

[4] Kapilashrami A, Hankivsky O. Intersectionality and why it matters to global health. The Lancet. 2018;**391**:2589-2591. DOI: 10.1016/ S0140-6736(18)31431-4

[5] Bauer GR. Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Social Science Medicine. 2014;**110**:10-17. DOI: 10.1016/j. socscimed.2014.03.022

[6] Bowleg L. The problem with the phrase "women and minorities": Intersectionality, an important theoretical framework for public health. American Journal of Public Health. 2012;**2**:1267-1273. DOI: 10.2105/ AJPH.2012.300750

[7] Shields SA. Gender: An intersectionality perspective. Sex Roles: A Journal of Research. 2008;**59**:301-311. DOI: 10.1007/s11199-008-9501-8

[8] Anderson K. Theorizing gender in intimate partner violence research. Sex Roles. 2005;**52**:853-865. DOI: 10.1007/ s11199-005-4204-x

[9] Hunnicutt G. Varieties of patriarchy and violence against women. Resurrecting "patriarchy" as a theoretical tool. Violence Against Women. 2009;**15**:553-573. DOI: 10.1177/1077801208331246

[10] World Health Organization. Prevention of Violence: A Public Health Priority. WHA 49.5. Geneva: World Health Assembly; 1996. pp. 20-25

[11] Kelmendi K. Violence against women: Methodological and ethical issues. Psychology. 2013;**4**:559-565. DOI: 10.4236/psych.2013.47080

[12] García-Moreno C, Hegarty K, Lucas dÓliveira a F, Koziol-McLain J, Colombini M, Feder G. The healthsystems response to violence against women. Lancet. 2015;**385**:1567-1579. DOI: 10.1016/S0140-6736(14)61837-7

[13] Montesanti SR, Thurston W. Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women's Health. 2015;**15**:100. DOI: 10.1186/ s12905-015-0256-4

[14] García-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C. WHO Multi-Country Study on Women's Health and Domestic Violence Against Women: Initial Results on Prevalence, Health Outcomes and Women's Responses. Geneva: World Health Organization; 2005. p. 206

[15] Plichta SB. Interactions between victims of intimate partner violence against women and the health care system. Trauma, Violence & Abuse. 2007;**8**:226-239. DOI: 10.1177/1524838007301220

[16] Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB. Intimate partner violence against

adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: A systematic review and metaanalysis. Social Science & Medicine. 2012;**75**:959-975

[17] World Health Organization. Strengthening Health Systems to Respond to Women Subjected to Intimate Partner Violence or Sexual Violence: A Manual for Health Managers. Geneva: World Health Organization; 2017. p. 155

[18] Saletti-Cuesta L, Aizenberg L, Ricci-Cabello I. Opinions and experiences of primary healthcare providers regarding violence against women: A systematic review of qualitative studies. Journal of Family Violence. 2018;**33**:405-420. DOI: 10.1007/s10896-018-9971-6

[19] Oso L. La migración Hacia España de Mujeres Jefas de Hogar. Madrid: Instituto de la Mujer; 1998. p. 438

[20] Pessar P, Mahler S. Transnational migration: Bringing gender. International Migration Review. 2003;**37**:812-846

[21] Lugones M. Colonialidad y género. Tabula Rasa. 2008;**9**:73-102

[22] Stolke V. La mujer es puro cuento: La cultura del género. Estudos Feministas. 2004;**12**:77-105. DOI: 10.1590/ S0104-026X2004000200005

[23] Donato K, Gabaccia D, Holdaway J, Manalasan M, Pessar P. A glass half full? Gender in migration studies. International Migration Review. 2006;**40**:3-26

[24] Mora L. Las Fronteras de la Vulnerabilidad. Género, Migración y Derechos Sexuales y Reproductivos. Santiago de Chile: UNFPA; 2002

[25] United Nation Fund for Population Activities. Estado de la Población

Mundial 2006. Hacia la esperanza, Las Mujeres y la migración Internacional. New York: UNFPA; 2006. p. 116

[26] Martínez-Pizarro J, Reboira-Finardi L. Migración, derechos humanos y salud sexual y reproductiva: Delicada ecuación en las fronteras. Papeles de Población. 2010;**16**:9-29

[27] Cerrutti M. Salud y Migración Internacional: Mujeres Bolivianas en la Argentina. Buenos Aires: PNUD-CENEP/UNFPA; 2011

[28] Aizenberg L, Baeza B. Reproductive health and Bolivian migration in restrictive contexts of access to the health system in Córdoba, Argentina. Health Sociology Review. 2017;**26**:254-265. DOI: 10.1080/14461242.2017.1370971

[29] Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research Psychology. 2006;**3**:77-101. DOI: 10.1191/1478088706qp063oa

[30] Porto M. Violência contra a mulher e atendimento psicológico: O que pensam os/as gestores/as municipais do SUS. Psicologia: Ciência e Profissão. 2006;**26**:426-439. DOI: 10.1590/ S1414-98932006000300007

[31] Heisse L. Violence against women: An integrated, ecological framework. Violence Against Women. 1998;**4**:262-290. DOI: 10.1177/1077801298004003002

[32] Williston CJ, Lafreniere KD. "Holy cow does that ever open up a can of worms": Health care providers 'experiences of inquiring about intimate partner violence. Health Care Women International. 2013;**34**:814-831. DOI: 10.1080/07399332.2013.794460

[33] Thapar-Björkert S, Morgan K. "But sometimes I think . . . They put themselves in the situation": Exploring blame and responsibility

**83**

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal…*

*DOI: http://dx.doi.org/10.5772/intechopen.86208*

in interpersonal violence. Violence Against Women. 2010;**16**:32-59. DOI:

[34] Sprague S, Madden K, Simunovic N, Godin K, Pham N, Bhandari M, et al. Barriers to screening for intimate partner violence. Women Health. 2012;**52**:587-605. DOI: 10.1080/03630242.2012.690840

[35] Schraiber LB, D'Oliveira AFPL. Romper com a violência contra a mulher: Como lidar desde a perspectiva

[36] Saletti-Cuesta L. Violencia contra las mujeres: Definiciones del personal sanitario en los centros de atención primaria de Córdoba, Argentina [violence against women: Definitions by health professionals at primary care centers in Cordoba, Argentina]. Revista de Salud Pública. 2018;**22**(1):66-76. DOI: 10.31052/1853.1180.v22.n1.17802

[37] Magliano M. Migración, género y desigualdad social. La migración de mujeres bolivianas hacia Argentina. Revista Estudios Feministas. 2009;**17**:349-367. DOI: 10.1590/ S0104-026X2009000200004

[38] Dye C, Boerma T, Evans D, Harries A, Lienhardt C, McManus J, et al. Research for Universal Health Coverage. The World Health Report 2013. Geneva: World Health Organization; 2013. p. 168

[39] World Health Organization. Everybody Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva: World Health

[40] Thurston W, Eisener A. Successful integration and maintenance of screening for domestic violence in the health sector: Moving beyond individual responsibility. Trauma, Violence & Abuse. 2006;**7**:83-92. DOI:

Organization; 2007. p. 45

10.1177/1524838005285915

do campo da saúde. Athenea.

2008;**14**:229-236

10.1177/1077801209354374

*An Intersectional Innovative Analysis of How Providers' Discourses Interact with Universal… DOI: http://dx.doi.org/10.5772/intechopen.86208*

in interpersonal violence. Violence Against Women. 2010;**16**:32-59. DOI: 10.1177/1077801209354374

*Universal Health Coverage*

2012;**75**:959-975

adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: Mundial 2006. Hacia la esperanza, Las Mujeres y la migración Internacional. New York: UNFPA; 2006. p. 116

Reboira-Finardi L. Migración, derechos humanos y salud sexual y reproductiva: Delicada ecuación en las fronteras. Papeles de Población. 2010;**16**:9-29

[27] Cerrutti M. Salud y Migración Internacional: Mujeres Bolivianas en la Argentina. Buenos Aires: PNUD-

health and Bolivian migration in restrictive contexts of access to the health system in Córdoba, Argentina. Health Sociology Review. 2017;**26**:254-265. DOI: 10.1080/14461242.2017.1370971

[28] Aizenberg L, Baeza B. Reproductive

[29] Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research Psychology. 2006;**3**:77-101. DOI: 10.1191/1478088706qp063oa

[30] Porto M. Violência contra a mulher e atendimento psicológico: O que pensam os/as gestores/as municipais do SUS. Psicologia: Ciência e Profissão. 2006;**26**:426-439. DOI: 10.1590/ S1414-98932006000300007

[31] Heisse L. Violence against women: An integrated, ecological framework. Violence Against Women. 1998;**4**:262-290. DOI: 10.1177/1077801298004003002

[32] Williston CJ, Lafreniere KD. "Holy cow does that ever open up a can of worms": Health care providers 'experiences of inquiring about intimate partner violence. Health Care Women International. 2013;**34**:814-831. DOI: 10.1080/07399332.2013.794460

[33] Thapar-Björkert S, Morgan K. "But sometimes I think . . . They put themselves in the situation": Exploring blame and responsibility

[26] Martínez-Pizarro J,

CENEP/UNFPA; 2011

A systematic review and metaanalysis. Social Science & Medicine.

[17] World Health Organization. Strengthening Health Systems to Respond to Women Subjected to Intimate Partner Violence or Sexual Violence: A Manual for Health Managers. Geneva: World Health

[18] Saletti-Cuesta L, Aizenberg L, Ricci-Cabello I. Opinions and experiences of primary healthcare providers regarding violence against women: A systematic review of qualitative studies. Journal of Family Violence. 2018;**33**:405-420. DOI:

[19] Oso L. La migración Hacia España de Mujeres Jefas de Hogar. Madrid: Instituto de la Mujer; 1998. p. 438

[20] Pessar P, Mahler S. Transnational

[21] Lugones M. Colonialidad y género.

[22] Stolke V. La mujer es puro cuento: La cultura del género. Estudos Feministas.

[23] Donato K, Gabaccia D, Holdaway J, Manalasan M, Pessar P. A glass half full? Gender in migration studies. International Migration Review.

[25] United Nation Fund for Population Activities. Estado de la Población

Organization; 2017. p. 155

10.1007/s10896-018-9971-6

migration: Bringing gender. International Migration Review.

Tabula Rasa. 2008;**9**:73-102

2004;**12**:77-105. DOI: 10.1590/ S0104-026X2004000200005

[24] Mora L. Las Fronteras de la Vulnerabilidad. Género, Migración y Derechos Sexuales y Reproductivos. Santiago de Chile: UNFPA; 2002

2003;**37**:812-846

2006;**40**:3-26

**82**

[34] Sprague S, Madden K, Simunovic N, Godin K, Pham N, Bhandari M, et al. Barriers to screening for intimate partner violence. Women Health. 2012;**52**:587-605. DOI: 10.1080/03630242.2012.690840

[35] Schraiber LB, D'Oliveira AFPL. Romper com a violência contra a mulher: Como lidar desde a perspectiva do campo da saúde. Athenea. 2008;**14**:229-236

[36] Saletti-Cuesta L. Violencia contra las mujeres: Definiciones del personal sanitario en los centros de atención primaria de Córdoba, Argentina [violence against women: Definitions by health professionals at primary care centers in Cordoba, Argentina]. Revista de Salud Pública. 2018;**22**(1):66-76. DOI: 10.31052/1853.1180.v22.n1.17802

[37] Magliano M. Migración, género y desigualdad social. La migración de mujeres bolivianas hacia Argentina. Revista Estudios Feministas. 2009;**17**:349-367. DOI: 10.1590/ S0104-026X2009000200004

[38] Dye C, Boerma T, Evans D, Harries A, Lienhardt C, McManus J, et al. Research for Universal Health Coverage. The World Health Report 2013. Geneva: World Health Organization; 2013. p. 168

[39] World Health Organization. Everybody Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva: World Health Organization; 2007. p. 45

[40] Thurston W, Eisener A. Successful integration and maintenance of screening for domestic violence in the health sector: Moving beyond individual responsibility. Trauma, Violence & Abuse. 2006;**7**:83-92. DOI: 10.1177/1524838005285915

**85**

Section 4

Universal Healthcare

Cases

Section 4
