Arabic‐speaking male immigrants' perceptions of preventive initiatives: An interview study

Abstract Background Arabic‐speaking men are a sparsely investigated population in health promotion and disease prevention. This may hamper their ability to achieve the highest obtainable health due to less accessibility and acceptability of preventive measures. Aim We explored Arabic‐speaking (Palestinian, Iraqi and Somali) male immigrants' perceptions of preventive initiatives in general and such initiatives for cardiovascular diseases (CVD) in particular to understand how to address inequalities in engagement in prevention. Methods This qualitative study employed content analysis of semistructured interviews with 60–66‐year‐old Arabic‐speaking men living in Denmark. Supplementary, structured data, for example, health data, were collected. From June to August 2020, 10 men were interviewed. Findings Preventive initiatives were found ethically and culturally acceptable alongside personally and socially relevant; they were perceived as humanitarian and caring for the participants' health, respecting of their self‐determination and enabling their empowerment. Thus, the participants entreated that their fellow countrymen be assisted in achieving the prerequisite coping capabilities to address inequality in access, perceived acceptance and relevance. This led us to define one main category ‘Preventive initiatives ‐ Caring and humanitarian aid empower us’ with the underlying subcategories: ‘We are both hampered and strengthened by our basic assumptions’ and ‘We need help to achieve coping capabilities enabling us to engage in preventive initiatives’. Conclusion Prevention was perceived as acceptable and relevant. Even so, Arabic‐speaking men may be a hard‐to‐reach group due to their basic assumptions and impaired capabilities for engaging in prevention. Addressing inequality in accessibility, acceptability and relevance in regard to prevention may be promoted through a person‐centred approach embracing invitees' preferences, needs and values; and by strengthening invitees' health literacy through efforts at the structural, health professional and individual levels. Public Contribution This study was based on interviews. The interviewees were recruited as public representatives to assist us in building an understanding of Arabic‐speaking male immigrants' perceptions of preventive initiatives in general and preventive initiatives for CVD in particular.


| INTRODUCTION
According to the World Health Organization (WHO), cardiovascular diseases (CVD) account for the majority of deaths from noncommunicable diseases, 1 and efforts are therefore warranted to prevent CVD. Preventive initiatives include 'measures to reduce the occurrence of risk factors, prevent the occurrence of disease, to arrest its progress and reduce its consequences once established'. 2 Preventive initiatives should also embrace health promotion strategies empowering people, especially those most marginalized. 3 In prevention, empowerment is a process whereby people achieve greater control over decisions and actions influencing their health. 2 Preventive initiatives must ensure equal opportunities for the target population and allow them to enjoy their highest attainable level of health. 4 Thus, preventive initiatives must be acceptable and accessible. Acceptability refers to being ethically and culturally appropriate and being person-centred while catering to target group needs, preferences and values. 3,4 In screening programmes, acceptability refers to, for example, the acceptance rate and whether the target population finds the proposed prevention efforts relevant. 5 Accessibility implies that preventive initiatives are accessible to all without discrimination. 4 However, nonparticipation in preventive initiatives is more prevalent amongst people with low income, low levels of education and amongst immigrants. [6][7][8] In Denmark, disease prevention is publicly financed and equal access to health services is a healthcare cornerstone. Disease prevention rests mainly on opportunistic risk assessment generally performed by general practitioners (GPs) although systematic screening for cancer is offered. Recently, further efforts to prevent CVD have been in focus in research evaluating the effect of systematic cardiovascular screening. [9][10][11] The Danish trial 'Fighting Social Inequality in Cardiovascular Health' (FISICH) randomised men in their 60s to screening for various CVDs to reduce social inequality in cardiovascular health. 12 After the trial, FISICH was supplemented with the present qualitative immigrant study.
Qualitative research exploring acceptability showed that Danish women declined cardiovascular screening as they found it personally irrelevant 13 ; a perception embedded in personal beliefs like feeling healthy, low perceived risk and relying on being capable of feeling whether something is brewing or not. 13 Amongst Danish women, previous unfavourable experiences with the healthcare system may also influence screening acceptance. 13 Similarly, Abdelmessih and colleagues found that Arabic-speaking immigrants with poor trust in healthcare systems expressed reluctance towards seeking medical care despite having a CVD diagnosis. 14 Moreover, they found that taking into account language proficiency and health literacy was essential for accessibility. 14 However, these issues are sparsely investigated from ethnic minorities' perspectives, in particular within the context of early CVD detection. This is concerning as such knowledge is central for inclusive policies addressing ethnicity-based inequality in access and health. Thus, to bridge this knowledge gap, we explored Arabic-speaking (Palestinian, Iraqi and Somali) male immigrants' perception of preventive initiatives in general while focusing on cardiovascular screening, in particular, to understand how to address inequalities in engagement in prevention.
We conducted a qualitative study with semi-structured individual telephone interviews supplemented by structured data; telephone interviews are an acknowledged approach to exploring perceptions of a sensitive nature without personal confrontation. 15 We followed the consolidated criteria for reporting qualitative research (Supporting Information Material: S1). 16

| Participants and recruitment
Eligible interview participants were purposively selected after the trial amongst men with Arabic names in a control arm of the cardiovascular screening programme, FISICH. In brief, FISICH randomised men in their 60s to screening for various CVDs. 12 In the present study, potential participants were invited by surface mail. Accepting and cancelling were possible by text message, phone or e-mail. All received information about FISICH as a proposed prevention strategy and were informed about the present study's aim. Initially, 12 responded, but after the interviews, 2 withdrew their consent as they were concerned that their signature might be abused by the authorities.

| Data collection
A study-specific semistructured interview guide was developed; informed by ethical aspects related to preventive services 5

| Data analysis
We conducted an interpretive, inductive content analysis; a recognized approach for achieving replicable and valid inferences from contextual data and producing new understandings followed by practical guides to action. 19 The first author and the interviewer read the transcribed and translated interviews while collecting the data. As the last 2 interviews provided no new perspectives to the analysis, we deemed data saturation had been reached. 19 Next, the transcribed interviews were reread to build an overall impression of the data. We (M. D. and R. S. A.-A.) then identified units of analysis and conducted dialogue meetings to verify the meaning. Subsequently, the first author synthesized coded contents into subcategories. This abstraction process was iterative, shifting between raw data, coded contents and subcategories: it also included dialogue meetings with an expert in qualitative research (S. F. S.) until a consensus was reached on data interpretations and sufficient data abstraction.
Finally, the main category and underlying subcategories were discussed with the research team. The interviewees provided no feedback on transcripts or findings. The analysis was facilitated by using NVivo 12 (International Pty). Figure 1 illustrates the analysis process with an example of the coding tree.
As 2 participants withdrew their written consent due to confidentiality preferences, the interviews were reanalyzed; even with the withdrawn interviews, we verified data saturation.

| Research group
The research group comprised experts within the field of nursing and medicine with and without involvement in cardiovascular screening.
This ensured the representation of various perspectives and the study's trustworthiness. The interviewer was a female bilingual and bicultural health science student of Arabic origin. No one knew the interview participants beforehand.

| FINDINGS
Ten Arabic-speaking 60-66-year-old male immigrants participated; all had lived in Denmark for 20-36 years and held residence permits. Table 1 provides selected information from the structured data; information that contributed to the in-depth analysis.
In our analysis, we identified one main category 'Preventive initiatives -Caring and humanitarian aid empower us' with the underlying subcategories: 'We are both hampered and strengthened by our basic assumptions' and 'We need help to achieve coping capabilities enabling us to engage in preventive initiatives'. Figure 2 shows that inviting Arabic-speaking men to preventive initiatives demands awareness of how to improve their feeling of empowerment by strengthening their coping capabilities and acknowledging their basic assumptions. Empowerment, basic assumptions and coping capabilities were interrelated factors for engagement in prevention. This quote expresses trust in the GP. In summary, a personcentred invitation approach is needed to promote engagement in prevention and informed decision-making. Given their basic assumptions and coping capabilities, we found it questionable whether Arabic-speaking immigrants possessed sufficient competencies and resources to engage in prevention. These concerns suggest that their health literacy should be strengthened to ensure inclusive preventive initiatives.

| DISCUSSION
This study aimed to explore Arabic-speaking male immigrants' perceptions of preventive initiatives to understand how to address inequality in engagement. We found that living in Denmark, these men found preventive initiatives ethically and culturally acceptable. We found that distrust may also be curbed by involving people with whom a trustful relationship already exists, for example, GPs.
Furthermore, Patel et al. found that using health professionals who speak the refugees' language gave the refugees a feeling of speaking to a trusted person with the same cultural and linguistic background. 23 We argue that trust is central to building culturally appropriate prevention services in which acceptability and thereby accessibility may also be facilitated through intercultural agents. Such agents' key roles are to facilitate trust and underpin empowerment by informing about and interacting with health services. 24 We found that coping capabilities were likely to influence health literacy for engagement in prevention from an accessibility and acceptability viewpoint. Limited language proficiency hampered information access and thereby also prevented participation. Sending a written invitation was an inadequate approach regardless of the language used because we cannot expect all older immigrants to be literate. Similarly, Abdelmessih et al. found that Arabic-speaking participants requested verbal information because they were illiterate. Preferring verbal information is also related to the fact that the Arab and Somali communities in Denmark are verbal cultures. 25 Similarly, we found that Arabs 'handle things personally, not in writing'. Therefore, an invitation approach involving children and GPs was suggested. Conveying prevention may also be possible through immigrant communities. Accordingly, Tatari et al. found that within Arab and Somali communities in Denmark, people are a central source of information for each other. 25 Social relationships and networks are a potential resource for health literacy; still, we draw attention to the fact that immigrant laypeople may be unable to convey the relevance of prevention because of their cultural and religious assumptions. Therefore, such an approach may not remedy ethnicity-based inequality in acceptability and accessibility.
Arabic-speaking men's response to preventive invitations may be understood within the theory of self-efficacy. In this theory, an individual's ability to cope is affected by similar previous challenges and emotions related to the specific challenges encountered. 26 Thus, we argue that prevention is well-perceived culturally and is ethically acceptable to those with re-established trust towards authorities.
Inversely, those distrusting and fearing authorities respond emotionally on the basis of their basic assumptions. This is inexpedient because when engaging in prevention, the capacity to make an informed rather than an emotional decision is essential. We, therefore, find it urgent to address  30 As such our study illuminates the complexity of promoting equal engagement in prevention.
Although we did not aim to elicit differences and similarities between ethnicities and cultures, we found one distinctive difference. Apart from Somali origin, religion was prominent in how health-related basic assumptions were expressed. Furthermore, traumatic life experiences were a commonality. These findings are supported by Lechner-Meichsner and Comtesse amongst refugees from Arabic countries and Sub-Saharan Africa. 31 Another commonality was a concern for their fellow countrymen's capabilities to engage in prevention.
In summary, we found that acknowledging basic assumptions and coping capabilities was central to a person-centred approach catering to diverse populations' needs, preferences and values in accordance with the WHO's definition of acceptability. 3 We argue that basic assumptions and coping capabilities may influence inclusivity in prevention; a concern that may be addressed by strengthening health literacy.

| Implications for addressing ethnicity-based inequality in the prevention
We found it urgent to address health literacy to promote equal access to prevention and thereby to health. According to the WHO, health literacy is key to informed decision-making on whether to participate or not, and it empowers individuals and communities alike. Thus, health literacy may be addressed at structural, health professional and individual levels.
To uncover invitees' needs, we recommend investigating their health literacy to design interventions addressing their needs before evaluating any intervention effects. At the structural level, we suggest that prevention initiatives be designed by involving representatives from vulnerable groups. Public involvement is an acknowledged approach to improving the quality and relevance of healthcare alongside improving information readability and facilitating participation. 32 Ethnicity-based inequality in engagement is a general concern.
Our proposed recommendations may be applicable to healthcare services in general. From a practice, research and policy perspective, this study sheds light on Arab-speaking immigrants' challenges and needs. Our findings support inclusive prevention; responding to ethnicity-based inequality with the potential to improve health outcomes amongst immigrants at both individual and societal levels.

| Methodological considerations
Data were collected during the Covid-19 pandemic; telephone interviews were used to encourage participation by using technology requiring few technological skills, enabling anonymity and prompting comfortability in disclosing sensitive information 15,35 However, limitations of telephone interviews are acknowledged. The interviewer was unable to observe nonverbal expressions that support detailed elaboration on perceptions. In telephone interviews, silence and pausing may be experienced as awkward. 36 Nevertheless, we succeeded in achieving an in-depth understanding of the research question by using an interpretive analytical approach.
Amongst those approaches, 26% participated, leaving 10 participants in our study. We acknowledge that this is a potential limitation, entailing certain reservations towards our findings. Nevertheless, our study contributed to a valuable understanding of ethnicity-based disparity in access, acceptance and relevance in prevention. In future research, it would be interesting to explore the perspectives of those who do not participate in preventive measures and of women. In Arabic societies, women may differ from men in terms of health-related decisions. We found that men may consult their GP. In contrast, women may consult their husband 37 reflecting a patriarchal structure of society. 38 The participants in our study expressed an erased patriarchy; one of their motives for participating DAHL ET AL.
| 1625 was safeguarding the female interviewer's career. Similarly, men may position themselves as fathers or enlighteners towards female interviewers. 39 Both fatherly and enlightener positions influence interactions in interviews; such interview dynamics are yet unexplored.
Although our study population represented distinct countries, life narratives were alike and motives for participating were equivalent to reduce inequality in prevention engagement and help the interviewer. Despite the Arabic dialects varying, no one was excluded from participation. Moreover, the study population represented males in their 60s. These factors enabled us to reach data saturation although the study population was small.
Approaching Arabic-speaking men, we used a culture-sensitive and person-centred approach enabling us to collect empirical data.
The interviewer's name appeared from the interview invitation; hence, the candidates were aware that it came from a country fellow.
Moreover, the bilingual and bicultural interviewer gave voice to those who were monolingual and ensured cultural appropriateness and sensitivity throughout the research process.

| CONCLUSION
Prevention was perceived as ethically and culturally acceptable alongside personally and socially relevant; and representative of Arab-speaking men living in Denmark. Acceptability originated from a feeling of strengthened empowerment. Relevance was rooted in viewing prevention as personally and socially beneficial. But Arabic-speaking men may be a hard-to-reach group due to their basic assumptions and capabilities for engaging in prevention; raising concerns related to acceptability and accessibility which are essential to the human right to good health.
Addressing inequality in accessibility, acceptability and relevance in regard to prevention may be promoted through a person-centred approach embracing invitees' preferences, needs and values. A person-centred approach will then strengthen Arabic-speaking men's empowerment; a key element in health-promoting and diseasepreventive efforts. Inclusivity may further be addressed by strengthening invitees' health literacy through efforts at the structural, health professional and individual levels.

AUTHOR CONTRIBUTIONS
Study initiators were Marie Dahl, Axel Diederichsen and Jes S.