1. Design and Participants

This study employed a descriptive design and qualitative methods. We used purposive and snowball sampling to recruit a total of 15 MIW (four Korean-Chinese women, four Japanese women, four Vietnamese women, and three Filipino women) from churches and multicultural family support centers, which were attended predominantly by MIW. The inclusion criteria were adult first-generation Korean-Chinese, Japanese, Vietnamese, or Filipino MIW who had experience using PHCs, were able to communicate in Korean, and used a cell phone with photo-taking functions.

This study was reviewed and approved by the research ethics committee of the first author's institution (IRB No. 1040198-160603-HR-039-05). Informed consent was obtained from all participants.

2. Data Collection and Procedures

Four focus group interviews (one per country of origin) were conducted from December 2016 to March 2017 across several locations according to the participants' preferences: in cafes (two groups), a church (one group), and a multicultural family support center (one group). Before each focus group interview, the participants were asked to use their cell phones to take photographs that represented their perceptions related to PHC services. Where possible, the photograph files were obtained from participants and printed in letter size, and the interviews were conducted while looking at the printed photographs. However, only eight participants (53.3%) brought photographs; the rest participated without photographs. Of the total of 34 photographs provided, 12 were taken by the participants themselves, and 22 were from unidentified Internet sources. In this study, we selected three photographs as examples that vividly revealed the perspectives of the participants.

Each focus group interview was conducted in Korean and lasted about 90 minutes. The interviews started with questions such as "How was your experience using PHC services?" and "What do you expect from PHC services?" and "Please tell us more about this photograph." The participants who submitted photographs provided an interpretation of how their photographs were related to their PHC service experiences and needs. The participants were then asked specific questions such as "What difficulties were caused by cultural differences when using PHC services?" and "What cultural characteristics of yours should public health workers consider when providing services?" All interviews were conducted by the first author, who has extensive experience in nurses' cultural competence and in immigrant healthcare, using a semi-structured interview guide. All interviews were audiotaped. Two research assistants participated in the interviews and wrote field notes. Data were collected until data saturation was achieved and no new information was obtained.

3. Analytic Strategy

We used an inductive content analysis approach to analyze the qualitative data [20]. Three researchers independently read the focus group interview transcripts in-depth to gain an overall understanding of the experiences and needs expressed by the participants. Each researcher divided the text into meaning units (sentences) that were then condensed and coded. Through subsequent discussion and reflection, the three researchers interpreted the codes and compared them for similarities and differences. Finally, the researchers reached a consensus on 10 categories of experiences and needs. The trustworthiness of the data was maintained by adhering to recommended measures throughout the steps of the research process [20, 21]. Credibility was assured through peer debriefings during the research team meetings. Confirmability was strengthened by having two of the focus group participants review the codes and categories to ensure that our findings were consistent with their lived experience. We used Microsoft Excel to code and thematically analyze the qualitative data.

1. Participant Characteristics

A total of 15 MIW were recruited for this study. Their ages ranged from 28 to 59 years (mean=43.20±9.10 years), and their time living in Korea ranged from 4.8 to 28 years (mean=13.62±6.51 years) (Table 1).

Table 1 General Characteristics of Study Participants (N=15) Click for larger image

2. Participant Experiences Using PHC Services

Five categories of PHC service experiences were identified: language barriers, hectic environment, affordable and practical primary healthcare, feeling ignored and discriminated against, and feeling frustrated (Figure 1).

Figure 1 Public health center service experiences and needs of immigrant women. Click for larger image

5) Feeling frustrated

One barrier to accessing PHC services was revealed through Photovoice. Participants said that although they visited PHCs with certain expectations, they often returned with unmet expectations and felt disappointed and dissatisfied. One participant expressed her experience with a photograph of an empty house and cart (Figure 2-A).

Figure 2 Photovoice of participants’ public health center service experiences and needs. Click for larger image

I went to the PHC because of my child, but every time I went, I didn't get anything like this, and I felt frustrated… like an empty house.. It's the same feeling when I shop and buy nothing. (Group 2, Participant A)

Because there are a lot of people and it is complicated, work is busy. They rush the treatment and call the next person right away. I want to ask more, but I can't. After returning home, I feel somewhat frustrated and dissatisfied. (Group 3, Participant A)

3. Participants' Needs for PHC Services

Five categories of PHC service needs were identified: language assistance services, ease of access, healthcare across the lifespan, expansion of affordable healthcare, and being accepted as they are (Figure 1).

1. PHC Service Experiences and Needs

In most cases, the MIW's experiences reflected needed improvements in PHC services. First, language barriers remain a persistent challenge for MIW when attempting to access PHC services in Korea. Insufficient proficiency in Korean limited the ability of MIW to comprehend public health workers' instructions, leading to distrust of or dissatisfaction with the care received. Like marriage-based Thai immigrants in Norway [22], when MIW in Korea used PHC services, their Korean husbands or family members often served as interpreters; however, the family members were frequently not able to interpret effectively. Furthermore, even MIW who had lived in Korea for more than a decade had difficulty understanding what Korean public health workers were saying. Although the importance of language assistance services for immigrants has often been emphasized [22, 23, 24, 25, 26], and Korea's PHC services have taken steps in this regard, additional improvements are needed. It is essential not only to provide interpretation services and informative materials in multiple languages, but also to train public health workers in how to communicate effectively with immigrants.

Cross et al. [27] defined cultural competence as "a series of appropriate actions, attitudes and policies for systems, organisations or professionals to work effectively in transcultural situations." In other words, for public health workers to provide appropriate services tailored to the cultural and linguistic needs of immigrant clients from various countries, their organizations and systems—such as principles and commitments, leadership, human resources, and physical environment and resources—should support diversity [28]. The U.S. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care provide a sample blueprint for healthcare organizations seeking to offer services that are respectful and responsive to individuals' cultural health beliefs and practices and preferred languages [29].

Second, MIW perceived PHCs as having a hectic environment. When they visited the centers, they were uncomfortable with the busy and congested environment. The participants wanted ease of access to PHC services, but the environment could negatively affect the feelings and behaviors of public health workers and MIW alike. Therefore, not only should the procedures for using PHC services be made easier and more convenient, but a more user-friendly environment should be established within PHCs. Due to lack of information on Korean PHC services, MIW felt confused when attempting to access healthcare and could not fully utilize the PHC services available to them. They wanted clearer communication so that they could obtain needed information about PHC services. To better meet MIW's communication needs, one strategy would be to provide PHC service information within the language and culture courses commonly taken by immigrants [26]. Another strategy would be public health workers conducting outreach through immigrant networks, such as local nongovernmental organization community groups and multicultural family support centers, to improve MIW's knowledge of the PHC services.

Third, MIW reported various types of affordable and practical primary healthcare as being facilitators for using PHC services. However, as their children grew up and they themselves grew older, the participants felt they needed access to healthcare services across the lifespan. They showed strong interest in health promotion and expressed concerns about chronic diseases. In addition, the participating MIW expressed strong needs for psychological counseling and dental care.

First-generation immigrants are known to be at increased risk of mental illness, especially depression [30]. A recent study reported that MIW in Korea were more than twice as likely to experience depression as Korean-born women [31]. Korea has universal health coverage, and immigrants who reside in Korea for more than 6 months are entitled to Korean National Health Insurance [32]. However, like immigrants in Canada [33], MIW experienced barriers to accessing mainstream mental healthcare. In Korea, opportunities to obtain psychotherapy from a psychiatrist are limited, and counseling by a psychologist is not yet covered by Korean National Health Insurance [34]. Furthermore, the free mental healthcare provided by community- based mental health centers in both Korea and Canada have presented language and cultural obstacles for MIW [33, 35].

With respect to dental care, MIW in Korea are known to have a significantly higher number of untreated dental caries than Korean-born women [36]. Because Korean National Health Insurance covers a limited number of basic dental services, MIW have difficulty accessing affordable dental care. Studies in the United States and Canada have also reported unmet needs for dental care among immigrants related to low income and lack of dental insurance [37, 38]. Korean public health personnel should strive to link MIW with existing resources and to develop public policies for providing MIW with affordable and sustainable mental health and dental services.

A fourth need for improvement in Korea's PHC services that was uncovered by this study comes from MIW's reports of feeling ignored or discriminated against and frustrated in their encounters with public health workers. Previous studies have reported that healthcare providers frequently view immigrants as "others" and as being different from "them" [19]. Interestingly, just as immigrant women in Switzerland perceived discrimination by administrative staff at a registration desk [26], MIW in this study perceived an indifferent and cold attitude among Korean administrative staff. Consequently, this study's findings support previous arguments that cultural competence training should be provided to all healthcare personnel who serve immigrants [26, 39].

In addition, MIW in this study expressed that they wanted to be accepted as they are. In Figure 2-B (hot coffee with a heart) and Figure 2-C (flowers of various colors) reflected MIW's intense desire to be truly accepted and welcomed in their new homeland. In a study of women who had been subjected to genital mutilation before immigrating and were now living in and using maternity services in Australia, the researchers emphasized that when healthcare professionals reflected the women's cultural values, and when the women actively participated in the service process, the quality of care improved [40]. In the current study, one MIW said that she wore a figurative mask to hide her unique cultural attributes in order to pretend that she had adapted to Korean society. The statements of several of the participating MIW indicated that it was difficult for them to establish therapeutic relationships with public health workers, as they did not dare to reveal their true feelings if they felt that the workers did not respect their culture.

This study's results make it clear that public health workers' provision of culturally competent care to immigrants at the individual level is important but insufficient. As noted earlier, organizational and system-level cultural competence is essential to facilitate delivery of optimal PHC services to immigrants. Consequently, implementation of institutional policy and procedural changes is called for, including new equity and antidiscrimination policies, language assistance services, cultural competence training for individual public health workers, and culturally tailored services aimed at improving care for diverse community residents [28, 41]. Furthermore, according to a study on the experiences of public health workers in Korea who provide care to immigrants [39], they also reported difficulties in communicating and building trusting relationships with immigrants and were aware of their lack of preparation for culturally competent care and of the vulnerability of immigrant clients. The results of our study will contribute to providing information for healthcare providers and users and reducing their mutual gaps.

2. Advantages of the Photovoice Interview Method

A known advantage of the Photovoice interview method is that it can vividly reveal the perspectives of vulnerable populations [42]. In this study, Photovoice helped participants express their thoughts more openly through symbolic photographic images and provided us with greater insight into their experiences and needs. For example, one participant revealed her PHC service experience through a photograph of an empty house and cart. Using this photograph as a medium, we were able to more fully grasp her experiences of disappointment. This study shows that a qualitative nursing inquiry involving participants who have limited ability to express their perspectives in the researchers' language can use the Photovoice approach to facilitate the interview process.

3. Limitations

We acknowledge several limitations to this study. First, although the study was conducted with MIW from four countries, the number of participants from each country was small, and thus data saturation may not have been achieved. Second, because all interviews were conducted in Korean only and participants' Korean language proficiency was limited, we could not always explore participants' meanings in depth. Instead we used Photovoice to more vividly grasp immigrants' experiences and needs from their own perspectives. However, even though we asked participants both orally and through text messages to take photographs with their cell phones, only some participants did so.

In addition, when conducting focus groups, it is desirable to have enough people to generate diverse ideas. Although the optimum number of participants for a focus group may vary, 4 to 12 people are suggested [43]. One group in this study had only three participants, which may have limited data generation based on the synergy of group interaction. Lastly, there were large variations in participants' length of stay in Korea and the number of times they had used PHC services. Some participants, such as MIW with relatively short lengths of stay or fewer visits to PHCs, may have hesitated to participate fully and their perceptions may not be sufficiently captured.

Despite these limitations, we believe this study is meaningful because it explored MIW's experiences with and needs for PHC services, which is a service domain far less studied than clinical healthcare services. Furthermore, this study provides a deeper understanding of MIW's perceptions, such as feelings of discrimination and frustration and the desire to be accepted as they are, which are difficult to capture through quantitative research. Because this study was limited to PHC service experiences and needs, future studies will be needed to explore immigrants' perspectives on treatment at medical institutions and on receipt of preventive and promotive services that have large disparities in use between immigrants and non-immigrants.