1 Introduction

In the current climate of globalisation, New Zealand (NZ) is witnessing a burgeoning migrant population that has escalating health needs. This poses a challenge to the health system as the migrant populations bring unique health needs, including different cultural practices, language barriers, and varying levels of understanding of the healthcare system, which can complicate the delivery of care. Various factors drive the migration to a new country including the possibility of improving employment opportunities, a refuge from political unrest, educational opportunities, health benefits and an overall favourable environment [1]. Migration does not come without its issues and those who take this step face several difficulties in navigating healthcare systems due to the unfamiliarity of the social, structural, and cultural practices unique to their new place of residence [2]. This creates barriers to access, frequently leading to health disparities that are manifested through poor health outcomes [3].

Pakistan, the fifth most populous country in the world, comprises several primary ethnic groups including the main ones such as Punjabis, Pashtuns, Sindhis, and Balochis. The healthcare system in Pakistan is divided into a predominantly underfunded or unfunded public healthcare system and an exorbitantly expensive private healthcare system. Despite the cost associated, up to 79% of the Pakistani population opt for private healthcare services in Pakistan due to higher patient satisfaction [4]. The 2018 NZ census population data indicated there are 6135 Pakistanis residing in the country with the majority (75.9%) having been born overseas and migrated at various points in their lives [5]. A significant proportion falls within the 20 – 69 age range, with 57% of male and 53.2% of female Pakistani migrants belonging to this age demographic [5].

Health literacy is defined as one's ability to access, understand, appraise, and apply health information to make judgements and take decisions in everyday life concerning healthcare, disease prevention, and health promotion [6]. This proficiency allows individuals to be empowered enough to make well-informed and effective medical decisions [6]. Recognised globally by healthcare professionals and researchers, health literacy is an important determinant of the health and health-seeking behaviour of immigrants [7]. Health literacy levels are independent of the educational background of any population [8]. At least 44.1% of Pakistanis in NZ possess advanced qualifications with at least a bachelor's degree and are actively employed within a variety of professional sectors [5]. These statistics underscore the high qualification of Pakistani immigrants in NZ; however, considering the contrasting health systems of the two countries, there may be gaps in their knowledge and awareness of the healthcare system. Consequently, these gaps could potentially contribute to challenges including limited access, delays in treatment, and areas of miscommunication between the healthcare providers and patients [8].

One of the examples of how the healthcare systems in the two countries vary is the role of the pharmacists. In Pakistan, over half of registered pharmacists gravitate towards employment within the pharmaceutical industry, while the remaining percentage engages in diverse professional settings, encompassing community and hospital pharmacies, pharmaceutical marketing, and regulatory affairs. Notably, the clinical involvement of pharmacists in these roles is either restricted or absent altogether [9]. Conversely, in NZ, pharmacists play a multifaceted role within the healthcare landscape. Beyond dispensing medications, they are integral members of healthcare teams, providing medication counselling, management of chronic conditions, and vaccination services. Pharmacists also engage in medication reviews, ensuring the safe and effective use of medications, and contribute to public health initiatives such as smoking cessation programs and health promotion campaigns. Additionally, they play a pivotal role in pharmacovigilance, reporting adverse drug reactions to safeguard patient safety. The lack of recognition in the healthcare system has led to the under-utilisation of pharmacists which has consequently limited the interaction between pharmacists and patients in Pakistan [10]. As a consequence, migrants from Pakistan may face challenges in drawing parallels between the healthcare systems of the two countries. The experience of migrants in NZ may not be that pharmacists are important in addressing community health issues. This is especially true if the migrants are from countries with significantly different healthcare systems. This potential misalignment could pose challenges in obtaining timely healthcare in NZ, where pharmacists play a significantly larger role in addressing and alleviating healthcare concerns of the community.

Our study aimed to explore the healthcare-seeking behaviours, awareness, and experiences of Pakistani immigrants in NZ. The study also aims to identify barriers and opportunities for improving healthcare delivery and support for this community through culturally tailored strategies. We primarily focused on the experiences of first-generation Pakistani immigrants and their families within the NZ healthcare system. These individuals were born in Pakistan and later migrated to NZ. This population has specific cultural practices and beliefs about healthcare, as well as potential language barriers, which can affect how they navigate the healthcare system. By understanding these unique challenges, we aim to inform more culturally sensitive healthcare practices that better address the needs of this growing population in NZ.

2 Methods

3 Results

The mean age of the participants in this study was 40.9 years, with all households having older husbands than wives, and there was a 1:1 ratio of males and females. Most participants were employed and most commonly belonged to the engineering profession while most of the women were housewives. The participants in this study were located in Dunedin, Wellington, Auckland, and New Plymouth. The demographic details of the participants are presented in Table 1.

Four core themes were inductively identified: healthcare-seeking behaviour; cognisance of the NZ healthcare system; Aspects of healthcare quality that are important to Pakistani immigrants; and Difficulties or barriers while accessing healthcare in NZ. Illustrative quotes are provided in the text, with themes summarised in Table 2.

4 Discussion

This study examined the patterns of health services and medicine usage amongst first-generation Pakistani immigrants in NZ. The participants predominantly had a positive perspective on NZ's healthcare system, the influence of their past experiences shaped their expectations and level of satisfaction with their current healthcare providers and system. These experiences were reflective of participants' behaviour and understanding of the NZ health system which also revealed barriers that hampered the extensive utilisation of healthcare services.

A recurrent trend that this study identified was the use of self-medication for minor ailments, preceding any decision to consult a healthcare professional. This included using OTC medications, herbal and traditional medicines, home remedies, and medicines brought over from Pakistan. The types of medicines that were often brought from Pakistan included pain relief medications and antibiotics. This was in line with the study by Akhtar et al. where the list of medications most often brought from Pakistan included antiemetics, antibiotics, antidiarrhoeals, laxatives, cough, flu, and cold medications at antipyretics, anti-allergic medications, and even topical steroid creams [13]. The study also highlighted that choosing the medicine, dosage, and interval was most often decided by the mothers in the household by consulting family and friends, information online and in the leaflets of the medications [13]. This behaviour stems from differences in the healthcare systems of Pakistan and NZ and could lead to misalignment of expectations. The accessibility and over-prescription of antibiotics in Pakistan contribute to the anticipation of frequent antibiotic use among Pakistani migrants in NZ, quite often leading to dissatisfaction with the healthcare services [14]. Compared to Pakistan, NZ healthcare has emphasised antimicrobial stewardship resulting in a significant reduction in antibiotic dispensing from 2015 onwards [15]. Studies such as those by Lescure et al. have highlighted the trend that GPs often experience pressure from immigrant patients to prescribe antibiotics and even face issues in communicating this in a culturally sensitive way [16].

Another contributor to self-medication is the inaccessibility of NZ prescribers due to extended wait times and the associated costs. Subsequently, participants often exhaust all known treatments at home based on their personal knowledge and experiences before resorting to visiting a healthcare professional. In Pakistan, the common practice of self-medication is partly due to the ease of access to obtaining medicines without a prescription [17].

In cases involving children, the study participants did not delay in seeking consultations with their GPs and starting conventional treatment. Parents in this study demonstrated protective behaviour towards their children, prioritising professional treatment to prevent any exacerbations. This trend may be attributed to the free medical services for children in NZ. The minimal cost associated with paediatric health serves as a facilitator, enhancing access and utilisation of such medical services provided in NZ [18].

In contrast, the study by Akhtar et al. indicated that parents often treated their children for colds, fever, or diarrhoea for up to 3 days at home before seeing further professional healthcare treatment. Immediate medical attention was reserved for serious injuries instead. The research found that mothers, in particular, were reluctant to visit the GP unless a serious injury was involved and the hesitancy was because the GP would most likely not provide them with adequate medications to treat the illness and that often their opinions were dismissed [19].

Our study also highlighted the active involvement of the wives and mothers in providing care for the unwell members of their households and this recurrent theme was found amongst the majority of the participants and was consistent with the earlier findings by another researcher [13]. It was evident that wives and mothers had a notably proactive role in caring for sick family members. Most of the participant responses suggested the role taken by the females included assessment or triage and treatment of the unwell family member as well as preparing and administering the home remedies. The role encompassed the identification and management of familiar symptoms and illnesses using a combination of Western medicines, traditional medicines, and/or home remedies that had previously shown effectiveness in alleviating the symptoms [20]. The practice of self-diagnosis in Pakistani households was characterised by the common storage of medicine pre-emptively for future use. Research indicates that amongst Pakistani households the most commonly stored medications include analgesics, antibiotics, cough and cold medicines, anti-diarrhoeal, and antiemetic agents [21]. This practice, coupled with the ability to purchase prescription medicines without a prescription in Pakistan, allows individuals to readily access medicines for prompt symptomatic relief [21]. While this practice persists post-migration, there is a disparity in the expectations when dealing with the NZ healthcare system. In contrast to Pakistan, medications are rigorously regulated in NZ and are not easily obtained without the involvement of a healthcare provider. Although this practice has followed through post-migration, there is a mismatch in expectations from the NZ health system. These regulations are vital to reduce the risk of medicine misuse but can inadvertently limit access. Additionally, there is evidence suggesting that self-diagnosis and self-treatment at home are associated with the risk of administering inappropriate medicines and delaying treatment which can result in overall poor health outcomes [22, 23].

In Pakistan, people are accustomed to visiting hospitals to consult with doctors or specialists for any medical concerns. These expectations are carried onwards by Pakistani migrants in NZ and the longer wait time associated with NZ's referral process is perceived as a barrier reducing access to specialist care. Migrants also had the expectation of a comprehensive diagnosis during the first meeting with their treating doctor, though this is not feasible in every case and many patients require further investigations. These unmet expectations contribute to participants forming a perception that their health was not being adequately prioritised. Additionally, many Pakistani immigrants were not utilising other health services, placing an increased burden on general practitioners (GPs). The ongoing GP crisis in NZ further adds to the challenge of getting prompt appointments [24]. The higher costs and limited services associated with private hospitals in NZ prevent utilisation leaving patients to wait for public health services, often involving longer waiting periods [25]. This is in contrast to the situation in Pakistan where the private healthcare sector is commonly utilised and associated with significantly shorter wait times, as well as being able to cope with the growing healthcare needs of the population [26, 27].

A significant proportion of the study participants had a lack of awareness when questioned about their knowledge of services provided by NZ's community pharmacies. This is in line with the study by Abdul Aziz et al. where pharmacists provide many professional services without remuneration and yet remain underutilized by the public [28]. This seems to be a recurring theme in Pakistani immigrants moving to high-income countries such as NZ [29]. Consequently, GPs remain their primary point of contact for various health concerns irrespective of their severity. Due to the substantial differences in the structure, function, and overall role of NZ community pharmacies when compared to Pakistan, migrant Pakistanis face challenges in the appropriate usage of NZ's well-developed pharmacy services. The role of community pharmacists has evolved beyond that of dispensing, allowing a more active role in providing healthcare. In NZ, pharmacists now provide several services that are similar to GPs, including reviewing medicine use, chronic or long-term condition services, selected oral contraceptives, blood pressure monitoring, anticoagulant monitoring services, and vaccinations [30]. These services have been expanded to allow community pharmacists to help cope with the high influx of complicated medical conditions coupled with GP shortages [31]. However, our study revealed that the Pakistani migrants were predominantly unaware of these services and this could be explained by their sources of information focusing on GPs as the initial point of care. There is a knowledge gap regarding other health services, as their information sources are limited to family and close friends within the same community. Consequently, the expectations of Pakistani migrants concerning healthcare providers are not met and this contributes to their ineffective utilisation of NZ's health services. This pattern can be justified by the unfamiliarity with and dissimilarity between the different health systems in both countries, further accentuating the observed pattern of self-diagnosis and self-medication in this particular population.

5 Conclusions

This study sheds light on the healthcare-seeking behaviour, awareness, and experiences of Pakistani immigrants in NZ. The findings highlight a unique blend of traditional practices, self-reliance, and adaptation to a new healthcare system. Participants primarily relied on home remedies and self-medication for minor ailments, supplementing these approaches with conventional healthcare when necessary. Bringing medications from Pakistan underscores the challenges some immigrants face with accessibility and perceived adequacy of treatment options in NZ. The study revealed a general appreciation for the quality of care and professionalism within NZ's healthcare system, particularly its cautious approach to prescribing antibiotics and emphasis on comprehensive care. However, barriers such as cost, long waiting times, and limited knowledge of available pharmacy services were notable.

These insights underline the importance of culturally tailored healthcare strategies to address the expectations and challenges faced by immigrant populations. Strengthening awareness about accessible services, bridging cultural gaps, and reducing financial barriers could enhance the healthcare experience for this community.

Author Contributions

Noor A Mann: formal analysis, writing–original draft, writing–review and editing. Zain A Khan: writing–original draft, writing–review and editing, formal analysis. Saima Asghar: data curation, investigation, formal analysis, writing–review and editing. Afshan Rani: investigation, methodology, data curation, writing–review and editing. Nadia Hussain: validation, writing–original draft, writing–review and editing. Sumera S Akhtar: data curation, formal analysis, writing–review and editing. Susan Heydon: supervision, conceptualisation, methodology, writing–review and editing. Mudassir Anwar: conceptualisation, methodology, supervision, writing–review and editing.

Ethics Statement

The study received ethical approval from the University of Otago Human Ethics Committee (ref: D20/167). Before the interviews, eligible participants were briefed on the objectives of the study, and their verbal and written consent was acquired as an ethical prerequisite for their involvement.

Conflicts of Interest

The authors declare no conflicts of interest.