“Digital is nice, but only to smart people”: a qualitative analysis of barriers to digital healthcare for migrants in high-income countries

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While these tools have improved service delivery by increasing efficiency and convenience, they have also introduced barriers for certain groups, including migrants. As a result, digitalisation may deepen existing social inequalities, particularly for vulnerable populations. Despite these concerns, there is limited understanding of how migrants engage with digital healthcare in their everyday lives. This study addresses this gap by examining the challenges and consequences of digital healthcare use among Nepali, a minority migrant community in Finland. Results The data comprise semi-structured interviews with 27 Nepali migrants. The study identified four key challenges: limited digital skills, language barriers, reliance on proxy users, and a strong preference for in-person care. Although most participants had access to smartphones and digital platforms, many lacked the confidence or ability to use them independently for healthcare-related tasks. This, combined with language barriers, often led to a reliance on proxy users, with healthcare tasks frequently assisted by family members, including underage children. While these practices sometimes reflected cultural norms of collective care, they also raised significant concerns about privacy, autonomy, and the overall accessibility of digital healthcare systems for migrants. Conclusions Access to digital tools alone does not guarantee meaningful engagement with healthcare. Reliance on proxy users and complex digital interfaces can reinforce inequality, particularly under the ‘digital by default’ model of high-income countries. To support inclusive access, the study recommends multilingual interfaces, user-friendly design, tailored digital literacy training, and the continued availability of in-person services. Further research is needed to inform policies that reflect the needs of diverse populations. Digital healthcare digital literacy proxy users in-person care Nepali migrants migrants’ health Finland social exclusion Background The digitalisation of healthcare has seen rapid growth globally, with the COVID-19 pandemic serving as a significant accelerator [1, 2]. To achieve Universal Health Coverage under the Sustainable Development Goals (SDGs) 2030, the World Health Organization (WHO) has prioritised the transition to digital healthcare services and the development of a people-centred health system [3]. Digitalisation is generally claimed with promoting equitable access to healthcare services, enhancing transparency, and empowering patients to manage their health [4, 5]. In high-income countries, healthcare services are increasingly delivered through digital platforms. The Nordic region, including Finland, is notable for its high levels of digital competence among healthcare providers and the availability of advanced digital healthcare infrastructure [6]​. The use of digital technologies in healthcare is also driven by economic benefits, such as reducing the reliance on human resources and streamlining processes like document storage [7]. Through digitalisation, it is also assumed to address the labour shortage resulting from the aging population [8]. For example, in the recent health and social care reform (Sote-uudistus), the Finnish government identified digitalisation and electronic services as a key functional mechanism for curbing the growth of healthcare and social welfare costs [9, 10]. While the structural settings of high-income countries have promoted “digital by default”[11] in public services, the literature suggests that this approach can also deepen societal inequalities [12, 13]. This situation extends new forms of exclusion, as residents, particularly those in vulnerable positions, are often unable to use standardised digital technologies [13–15], including online health record access [16, 17]. For instance, a lack of digital skills, limited education, health issues, language barriers, and trust issues are widely discussed as key challenges of digital healthcare use [6, 18–21]. A recent study in Nordic countries found Despite high levels of digitalisation in the region, many migrant women especially those newly arrived, with limited local language skills, or from lower socioeconomic backgrounds, face significant barriers to accessing and benefiting from digital services [22]. Beyond these foundational barriers, it is crucial to recognise that mere access to and technical proficiency with mobile, internet, and digital platforms do not necessarily ensure effective healthcare utilisation [13, 23]. This is particularly evident among migrant populations; while most migrants are familiar with smartphones and digital tools, this familiarity does not always translate to the ability to navigate complex digital healthcare systems in their destination countries [20, 24]. A persistent lack of tailored support and training for using web-based platforms and other digital healthcare services further hinders migrants' proper access to and effective use of digital healthcare [25]. Moreover, differing medical cultures, such as a preference for in-person healthcare-seeking behaviour prevalent in country of origin, also significantly impact clients' willingness to engage with digital healthcare services [19, 26]. While a substantial body of research exists on the digital healthcare experiences of older migrants, there is comparatively less attention given to younger and working-age migrant populations. This study seeks to address this gap by exploring the in-depth experiences of Nepali migrants regarding their digital healthcare use experiences. Study context Finland is recognised as a global leader in digital healthcare, underpinned by its advanced infrastructure and proactive policy initiatives [9]. In 2023, 82% of its population aged 16 to 74 possesses basic digital skills, the highest in the European Union (EU) [27]. This strong foundation has enabled the Finnish government to prioritise digitalisation in healthcare, through initiatives such as the Health 360 Finland. This initiative aims developing innovative digital solutions to improve efficiency and drive economic growth in the health sector [28]. A cornerstone of Finland's digital health ecosystem is nationwide MyKanta (more commonly known as omakanta or kanta), a digital health service platform launched in 2010 that has undergone continuous feature development. MyKanta effectively manages the public information system, allowing individuals to monitor their health records, check prescriptions, book laboratory appointments, communicate with providers, submit prescription renewal requests, and upload social welfare information [9]. However, a limitation is that MyKanta primarily serves in Finnish and Swedish, with only limited services available in English, posing considerable challenges for many migrants [15, 29]. While other platforms like Maisa, available as both a web portal and App, offer more features and provide information in English, their utility is restricted as Maisa is limited to residents of the greater Helsinki region. Electronic identification (e-ID) is crucial to access MyKanta and other digital public services in Finland. This e-ID relies on bank account credentials (or mobile phone credentials), following a check of residency records by the phone company. Securing these credentials can be very challenging for many newcomers or groups that have difficulty accessing full residential status or banking services [30]. Beyond the e-ID access, research has consistently show that vulnerable groups such as older adults, migrants, and people with disabilities face greater obstacles in the use of digital technologies [8, 20, 31]. For instance, a nationwide survey of residents’ experiences in Finland found that Russian speakers are less likely to use digital services than native Finnish speakers [32]. The experiences of diverse user groups, such as migrants from different geographical region, regarding digital healthcare behaviour are critically understudied in Finland. The previous research argues that the digitalisation of public services, including healthcare, in welfare states such as Finland is creating a vicious cycle that broaden existing social exclusion [15, 33]. Studies also consistently underscore the critical need to incorporate the perspectives of marginalised groups, including migrants, in the design and implementation of digital healthcare technologies to ensure fair and inclusive access [2, 13, 34, 35]. This includes the integration of cultural competence principles into strategies and policies at both organisational and system levels to achieve safer and more equitable care [13, 36]. Migration to Finland has steadily increased, rising from less than 1% of the population in 1990 to 11.07% of the total population (5.6 million) in 2024. During the same period, the Nepali migrants grew from just six individuals to ten thousand, with a substantial proportion (76%) aged between 20 and 45 years [37]. More recently, the share of Asian communities such as Chinese, Vietnamese, and Nepali has been rising rapidly, while the growth of Baltic and Middle Eastern language-speaking groups has slowed. This trend has contributed to increasing demographic diversity in Finland, particularly in the capital region [38]. This diversity makes understanding the distinct cultural and healthcare practices of the migrant population particularly pertinent, especially given the sharp contrast with Finland's digitalised, patient-centred healthcare model [39]. For example, Nepalis culture is deeply rooted in values where healthcare decisions are often made collectively by families or household heads, with women and children typically having limited autonomy [40–42]. Similarly, doctors in Nepal are revered as figures of authority and care, with their presence alone often perceived as a form of healing [43]. Further underscoring these differences, healthcare services in Nepal are predominantly provided face-to-face, as the digital infrastructure remains underdeveloped despite a recent increase in internet access and social media use. In Finland, the law allows to handover attorney in handling personal matters including accessing healthcare information in various situations [44]. Research has shown that the expansion of digital services can reduce direct support from public sector workers and increase reliance on third-sector organisations [33]. This shift may also raise the risk of individuals relying on others (referred as proxy users ) to access digital services, potentially compromising privacy and autonomy. These drastically different healthcare systems and medical practices between the countries of origin and destination create an interesting study setting. Study objectives This study aims to examine the digital healthcare challenges from the perspectives of Nepali migrants in Finland. The following research questions guide this investigation: What challenges do Nepali migrants encounter while using digital healthcare services in Finland? What are the consequences of digitalisation in healthcare in Finland for Nepali migrants? Through investigating these questions, the study provides recommendations for policies and future research. Methods Research design This study adopted a qualitative research design, utilising semi-structured interviews to examine the experiences of Nepali migrants residing in the Helsinki (capital) region of Finland. Qualitative method was selected to enable a detailed exploration of participants’ perspectives and to gain in-depth understanding of their interactions with the healthcare system [45]. To adequately reflect the diversity within the migrant community and enrich this exploration, the study aimed to include individuals from varied socio-demographic backgrounds. Recruitment of participants Participants were selected using a combination of convenience, purposive, and snowball sampling techniques [46]. This approach ensured variation in socio-demographic characteristics and the inclusion of individuals with relevant experiences. The inclusion criteria required participants to have used healthcare services in Finland, to have resided in the country for a minimum of one year, and to belong to the working-age population. Following the establishment of these selection criteria, recruitment was conducted through multiple channels. An invitation to participate was posted in a Facebook group widely used by the Nepali community in Finland. While some participants responded directly to this post, others were recruited through snowball sampling or via the researcher’s personal network. In total, 31 individuals were contacted. Of these, four were excluded due to not meeting the inclusion criteria, resulting in a final sample of 27 participants. Data collection The author was involved throughout the data collection and analysis process. Prior to scheduling interviews, participants were fully informed about the study’s objectives and their expected role. Once participants agreed to take part, interview times and venues were arranged based on mutual convenience. In adherence to ethical guidelines, each participant received a printed information sheet in Nepali before data collection commenced. This sheet outlined the study's aims, the voluntary nature of participation, the right to withdraw without providing a reason, and the confidentiality of the data. Written informed consent was obtained from each participant for both participation and audio recording. The Research Ethics Committee in the Humanities and Social and Behavioural Sciences at the University of Helsinki reviewed and approved the study protocol. Data were collected between February and August 2023. To foster an environment where participants felt comfortable expressing themselves more freely, all interviews were conducted in Nepali, their native language. The researcher’s shared background with the participant community further contributed to this setting, facilitating open discussions on sensitive issues and supporting the accurate interpretation of responses. An interview guide [47] was developed based on prior research and revised iteratively in response to emerging insights from initial interviews. Additionally, the researcher maintained a field notes throughout the data collection process to document observations and reflections. Interviews were conducted in various settings such as public libraries and residents to accommodate participants' preferences. Characteristics of the participants The study included 27 participants (13 men, 14 women). Their mean age was 44 years (range: 31–67), and their duration of residence in Finland averaged 12 years (range: 4–29 years). Participants' educational attainment, reported as attended in Nepal, showed varied levels: nine (33%) had completed a basic level (up to 10 years), five (19%) had attained higher secondary education (11–12 years), and the remaining thirteen (48%) had received university-level education. Participants digital skills were also collected as the background information and categorised into three levels: 12 participants (45%) reported poor skills, 9 (33%) indicated average level, and 6 (22%) identified as having advanced skills. Data analysis The interview data were transcribed verbatim and analysed using reflexive thematic techniques [48]. This approach was selected for its structured process and its capacity to integrate reflexivity in qualitative research based on textual data [49, 50]. Consistent with the emphasis on reflexivity inherent in this approach, the potential for insider bias was recognised due to the researcher’s shared background with the participant group, which simultaneously supported the collection of in-depth data. To address this, additional strategies such as peer debriefing and a field journal were employed throughout the analysis [51]. The analysis began with a familiarisation phase, during which the transcripts were read multiple times to gain a thorough understanding of the content. A summary of each interview was prepared to capture key observations. Initial codes were then assigned to these summaries, focusing on salient features and recurring patterns. These codes were grouped into broader categories, which were iteratively reviewed and refined into preliminary themes. This process involved examining the coherence of each theme, identifying overarching patterns, and exploring conceptual links between categories to ensure alignment with the study’s objectives. Through this iterative approach, a set of overarching themes and subthemes was developed, providing the foundation for detailed thematic analysis. Participants were assigned pseudonyms to ensure anonymity during data analysis. While the analysis was predominantly inductive, emerging directly from the data, insights from prior research also served as a guiding lens during the thematic development and refinement. Particular attention was given to themes related to digital skills and knowledge, barriers encountered utilising digital healthcare, and previous experiences with medical practices, especially in relation to digital healthcare services. Results The digitalisation of healthcare services in Finland presents a complex and layered experience for migrants, shaped by multiple, interrelated challenges. Analysis of the data revealed four key themes that reflect the digital healthcare experiences of Nepali migrants: limited digital skills, language barriers, reliance on proxy users and the resulting loss of autonomy, and a strong preference for in-person care. These themes are closely connected, and participants’ accounts often touched on more than one area simultaneously, making it difficult to present them as entirely separate. For instance, discussions of digital skills were frequently intertwined with collective practices, such as involving family members in managing healthcare tasks, while language barriers often reinforced the need for proxy support. This overlap highlights the interdependent nature of these experiences and the challenge of placing them within fixed thematic boundaries. Digital skills and healthcare use A common challenge identified in the study was limited digital literacy, which influenced how participants engaged with Finland’s digital healthcare systems. Although nearly all participants owned smartphones, their use was often limited to basic tasks such as messaging or video calls. Only a few were confident using digital tools for health-related purposes. For instance, some participants described Maisa as a “pocket calculator,” appreciating its convenience for those who could navigate it. However, most participants struggled with functions beyond everyday communication. “I can’t open the computer. I have not used these things for using services in Finland. I can manage normal things like duty list, use messenger and video call on mobile but nothing more.” (P7, male) Despite recognising the potential benefits of digital systems, many participants lacked prior experience with such tools and found them difficult to use independently. “It is very hard through the digital system to use healthcare services. For example, saying hello and using messenger does not mean that I know the method of using available healthcare services.” (P6, female) Several participants expressed a willingness to learn, recognising that digital skills could save time and reduce dependence. “I have seen the booking option in Maisa but haven’t learned how to use it… if I learn, I can book lab time and appointments from home.” (P8, female) Age and previous exposure to technology influenced their use behaviour, with older participants especially feeling left behind. For instance, a participant of sixties reported: “Not everyone knows how to use these digital things. I’m too old for new things. I prefer the paper system we used before.” (P10, male) Many participants were reluctant to use digital tools, instead relying heavily on family members to manage healthcare tasks. This behaviour may not be solely due to a lack of knowledge, but also reflects a practical trust in family members, who were perceived to be more familiar with Finnish systems and more proficient with digital technologies as part of a younger, digitally fluent generation. For example, a participant reported how the devices are shared in a family as: “I don’t know much about it. My Wife reads the report sent by them. Now they have apps, something called maas…., it is downloaded into our mobile , but I don’t know anything. My wife takes care of it.” (P11, male) Some participants felt discomfort with repeated dependence and bothering them. As a participant added: “It’s not easy for me to book an appointment online. I always ask my son to help, but I don’t want to bother him all the time.” (P3, male) Many participants viewed the lack of digital training as a systemic failure. One participant remarked highlighting a sense of exclusion despite fulfilling civic responsibilities. “..but at least they should provide training and teach about new systems to make fair use of digital health technologies. Otherwise, waste of our tax money.” (P16, Female) This frustration was not unique to migrants and echoes concerns expressed by the general population. However, participants felt disproportionately limited in their ability to fully exercise their healthcare rights, leading some to feel like second-class citizens despite contributing equally through taxes. Such experiences indicate that digital solutions are not just about owning a phone or computer. They involve a lack of skills, experience, and support. Even when participants wanted to use the systems, many felt left out because there was no proper help to guide them. In addition, participants had trust to their younger children more than themselves in using smart phones, web portals and digital Apps. Language barriers and digital healthcare use Language skills emerged as another key factor limiting access to digital healthcare. Although some participants had sufficient digital skills, the dominance of Finnish on platforms such as Omakanta made navigation difficult. “There is no English in these platforms which is a big problem. I copy content and convert it to Google Translate... Sometimes, Google provides odd words.” (P17, male) Another participant described uncertainty when using translation tools: “Sometimes I find it very hard to understand what they are asking in Omakanta. I have to translate everything in Google, and I am not sure if I get it right.” (P9, male) Some participants received training in their workplace about digital healthcare, but that was often ineffective due to the language of instruction. “They provided us the training, but it was given together with other Finnish colleagues. How can the same method be catchable to us foreigners?” (P15, female) This mismatch between language of instruction and participant needs reduced the potential impact of such efforts. Similarly, private healthcare providers were seen as more accessible due to the use of English and user-friendly interface in their digital systems. “In private hospitals, everything is in English, so I use both Maisa and their own Apps. Omakanta is not available in English, except for the front page.” (P9, male) However, not everyone could afford private services, contributing to unequal access. Participants also shared views on usability. Browser-based platforms such as MyKanta were seen as harder to access, especially for those without regular use of computers. In contrast, app-based platforms like Maisa were more widely used due to their availability on mobile phones. “The issue with MyKanta is that I need to open the computer and web but for Maisa there is an App, and it’s on mobile. Also, no need to worry about the language since they are also in English.” (P20, male) These narratives point to the need for linguistically inclusive design and user-friendly interfaces that accommodate users’ everyday practices. Participants who were fluent in Finnish and possessed strong digital skills were able to make extensive use of healthcare platforms, while others struggled with even basic functionalities. The following notes illustrate this further. “I don’t use Google anymore. Apart from Maisa and Omakanta, I use the official websites (like THL-Finnish Institute for Health and Welfare) and other portals (for example Terveysportti) for research-based information. ” (P22, female) Whereas some participants accepted digitalisation as an unavoidable reality. As participants noted: “ Digital is nice, but only to smart people . However, development should not be stopped because of us. Let us go ahead with technology, we will manage anyway.” (P11, male) “It has gone to the digital age. I am not the only one to suffer. It is my fault that I can’t use the system. I ask daktor saheb (respected doctors) to communicate me through papers so that my children can help.” (P17, male) These narrations illustrate that language barriers often make digital healthcare even harder to access. Without proper translation and support, many participants had to rely on others. The digital healthcare system appeared to lack certain features necessary to meet the needs of migrants, making it difficult for them to use services independently. Reliance on proxy users and loss of autonomy For many Nepali migrants, healthcare tasks were managed collectively within the wider family rather than individually. Children, spouses, or other close relatives often handled digital healthcare responsibilities, such as reading medical messages or booking appointments. This reflected both cultural norms around shared responsibility and practical needs related to language barriers or limited digital skills. One participant explained: “umm..I don’t use digital things. I watch TV, I know YouTube, and I use my phone and Facebook. But I don’t use a computer. Whatever is needed, my daughter does. I don’t know or care about these things.” (P24, female) Another participant noted: “I gave consent and my login details to my kids… we don’t have privacy in our family.” (P16, female) This kind of support offered emotional comfort and familiarity, especially in a new healthcare environment. Sharing information was seen not as a violation of privacy but as part of caring for one another. Highlighting how open communication within families helped manage uncertainty, a participant noted: “The more we share, the more relaxed we feel. If we share, they suggest, and we can avoid the bad. Why should we worry about sharing with our son or husband? It may burst, if we don’t share.” (P26, female) In contrast to Finland’s healthcare system, which emphasises privacy and self-management, many participants viewed shared access as normal and even necessary. Yet this shift from individual to family-based decision-making was not always a matter of personal choice. In many cases, it resulted from barriers to independent use, such as language, lack of training, or unfamiliarity with digital systems. This created a situation where individuals had little control over their own healthcare. One participant shared that their daughter received digital notifications before they did and regularly accessed their health information: “She knows my login ID and even gets the notifications before I do” (P8, female). These practices raise questions about autonomy and privacy in contexts where the system assumes individual control, but users rely on others to navigate it. These experiences also highlight how Nepali migrants manage digital healthcare through family support, reflecting cultural norms but also pointing to structural barriers. While this approach offers emotional and practical benefits, it reduces individual autonomy and raises concerns around privacy, especially in a system designed for self-managed care. Preference for in-person care Across interviews, participants consistently expressed a strong preference for face-to-face healthcare interactions. In-person visits were seen as more trustworthy, easier to understand, and more emotionally supportive than digital consultations. Describing the emotional comfort of being physically present, a participant shared: “There is a sky-earth difference (aakash jaminko farak) between online and face-to-face services. We understand everything when we see each other. When we have eye contact, half of the illness feels cured.” (P1, male) Participants often felt that online or phone-based consultations failed to convey the seriousness of their symptoms. “Online, I feel like they don’t understand me properly… it’s just not the same.” (P12, male) Others found it difficult to explain their condition without visual cues or gestures, which they believed helped doctors take them more seriously. They even applied the technique of falsifying or exaggerating the stories to get the appointment which is not possible to do over online mediums. “It is difficult to get an appointment online, but if we go there, we can exaggerate the situation through different gestures.” (P5, female) Physical presence was also linked to a sense of reassurance and care. Participants believed that seeing the doctor, being touched, or reading facial expressions contributed to healing. As one participant said: “When we go in person, there is a better chance of getting an appointment. Doctors understand us better when they see us. On the phone or online, how can we explain? There, they understand through gestures. It’s easier when they see and touch us.” (P14, female) In this view, the body itself played a role in communication, something digital platforms were seen to limit or exclude. Some also felt discomfort with video consultations, especially when asked to show parts of their body on camera. A participant reflected cultural discomfort with visual exposure in remote care settings as: “The doctor wanted to assess my knee and asked me to point to the pain area over the video. I was so embarrassed… I wouldn’t have felt this in a physical meeting.” (P23, female) Despite the participants reported part as “knee”, her expression was clearly referring over the lower body part that was needed to access. This statement also indicates the trust issue of sensitive information over online platforms. Participants expressed a clear preference for face-to-face care, citing emotional, cultural, and practical reasons. Digital consultations were often perceived as impersonal, difficult to navigate, or less trustworthy, particularly when symptoms were hard to communicate or when cultural norms influenced expectations of care. Discussion This study investigated how Nepali migrants in Finland engage with digital healthcare services and the challenges they encounter in doing so. It also explored the broader implications of the rapid digitalisation of healthcare in the Finnish context. The empirical findings indicate that digital technologies have made healthcare more accessible and convenient [2, 13] for those migrants who possess higher levels of education, proficiency in digital tools, and command of the local language. For most participants, however, the benefits of digital healthcare were limited due to several barriers potentially extending pre-existing social inequalities. Some participants in this study reported reduced travel time, 24/7 access to healthcare information, and the convenience of digital applications and wearable devices, which enhanced their autonomy in managing health [9, 10]. The study also revealed a preference for mobile applications, particularly Maisa, over web-based portals like Omakanta, underscoring the critical role of usability and interface design [2]. Furthermore, few participants actively utilised translation tools to overcome language barriers and searched for more reliable and research-based information, through portals other than MyKanta and Maisa indicating a gap within minority migrants. These intragroup disparities reflect findings from other contexts, such as among Pakistani migrants in Norway [52] and African migrants in Portugal [23], where acceptance of digital healthcare was influenced by factors such as education, gender, and digital competence. In many cases, acceptance was not based on preference or perceived benefit but rather on the absence of alternative options [11, 20]. The study finds that possessing smartphones and using digital tools in everyday life, was not enough to translate this competence to use healthcare-specific services [15, 17, 20]. Participants extensively discussed the additional challenges including language barriers, weak knowledge of digital technologies and their traditional practices in seeking healthcare. This reinforces the need of incorporating language and cultural familiarity to use digital healthcare service equitably [2, 10, 23]. The study also confirms previous findings that digital healthcare tools are often developed with the general population in mind, leaving minority groups with limited support [2, 12, 53]. The unavailability of digital platforms in English or other minority languages increases health inequalities [15, 54] and further distances already marginalised users. In contrast, private healthcare providers were perceived as more accessible due to their multilingual options, highlighting inequities between public and private healthcare systems in Finland. While digitalisation in public services including healthcare also pose challenges among general population, migrants face significance additional obstacles [8, 20]. Participants’ experiences suggest that the digital training delivered alongside their Finnish colleagues was neither sufficient nor effective for migrants, leading to calls for separate training tailored to their specific needs and circumstances. Another key finding of this study is that many participants relied on family members to manage digital healthcare tasks, such as booking appointments or reading medical messages. While previous research has highlighted the risks of using proxy users to access digital services [33, 55], the participants in this study did not view such reliance as problematic. Instead, they considered it a helpful and routine part of daily life. Unlike Russian speaking migrants, the largest migrant community in Finland, who have been reported to use external agencies to navigate digital healthcare [33], such practices were not observed among Nepali participants. It was common for Nepali migrants to share login credentials and delegate health-related tasks to trusted family members. While this reflects a strong culture of shared decision-making [41], it raises concerns about privacy, autonomy, and accountability. Entrusting healthcare tasks to untrained family members carries risks, particularly if relationships change or if sensitive information is not managed appropriately. Participants did not express concern about maturity of minors accessing parents’ healthcare information. Instead, they were more curious about the age limit at which parents could access their children's health records. This reflects family norms in Nepal, where household responsibilities, including healthcare matters, are often managed collectively. In contrast, Finland’s healthcare system grants minors increasing autonomy from the age of 10, based on maturity and care context [56]. However, these criteria are often unclear and difficult for many parents, to interpret particularly for communities like Nepali. Many participants appeared unaware of a legal framework, including procedures for authorising another person [20, 44], for accessing health records. Importantly, some routinely relied on underaged children to assist with digital healthcare tasks, indicating both a lack of awareness and a gap in support. Beyond legal and privacy concerns, this dependency had emotional implications. While some viewed sharing digital access as a form of emotional support, others described feeling anxious, embarrassed, or disempowered due to their inability to manage healthcare independently. This loss of autonomy may impact confidence in navigating healthcare and runs counter to the principles of patient-centred care that digital systems aim to promote [5, 57]. While video consultations in primary healthcare have been found effective and are expected to increase rapidly in high-income countries [58], they were perceived as inappropriate by Nepali migrants, largely due to cultural considerations. Participants expressed discomfort with video-based interactions involving physical examinations. The preference for face-to-face care is not unique to migrants, but also among the general population [59]. However, among Nepali migrants, the reasons for preferring in-person care appear as a solution to overcome language barriers and cultural norms. Some valued the opportunity to use gestures to convey urgency, while others connected care directly to physical presence and communication. The frequent use of the term “ Daktor Saheb ” illustrates the deep respect afforded to doctors in Nepali culture, reflecting their perception as trusted and authoritative figures [43]. These cultural values help explain the strong preference for in-person consultations over digital alternatives, despite broader trends toward digitalisation. In the context of a welfare state like Finland, recognising and incorporating these cultural differences into healthcare design is therefore essential to address the diverse linguistic, social, and behavioural needs of migrant communities [2, 60]. Strengths and limitations of the study To the best of my knowledge, this study is the first in Finland that explores the digital healthcare experiences of a relatively younger, economically active migrant community from South Asia. It contributes a new perspective to the academic literature and offers practical insights for policymakers. While previous research has examined migrants’ general engagement with digital public services, this study focuses specifically on their experiences with digital healthcare. This focus is particularly timely, given that Finland, like other EU countries, is expanding its digital healthcare systems to advance Universal Health Coverage (UHC) under the Sustainable Development Goals. By drawing on participants’ lived experiences, the study provides more detailed insights than population-based surveys, allowing for a deeper understanding of individual-level challenges. This depth was further enhanced by the researcher’s affiliation with the Nepali community, which facilitated a more contextualised interpretation of the data and a deeper interpreting of participants' narratives. However, the study has several limitations, many of which are common to qualitative research with a small sample size. The possibility of researcher bias, for instance, may have influenced the interpretation of findings. In addition, participants self-reported digital competence and educational background from their country of origin, may not fully reflect the skill levels expected in Finland’s highly digitalised welfare state. This competence was further compounded by the overlap between digital and language barriers, making it difficult at times to determine whether certain challenges stemmed primarily from digital literacy or language proficiency. Additionally, participants frequently reported sharing devices and healthcare information, but the implications of this sharing were not always clear, and therefore require cautious interpretation. A further limitation of this study is its narrow scope, as it focused digital healthcare experiences solely on the use of certain online platforms and service calls. A more comprehensive representation of healthcare digitalisation would encompass various new tools and technologies, including wearable devices. Therefore, while the study provides valuable insights, these limitations should be carefully considered when interpreting and generalising the findings. Conclusions The main aim of this research was to identify the challenges migrants face in using digital healthcare in Finland and to understand the effects of these challenges. This study illustrates the complex relationship between technology, migrants’ behaviour, and healthcare access, reflecting broader concerns about the digital divide in welfare states. Supporting existing research, the findings show that for migrants, digital tools have introduced new forms of dependence and increased vulnerability. Furthermore, the study mirrors that access to digital tools alone does not ensure meaningful engagement with digital healthcare for migrants. Although digital tools are designed to promote self-management, many participants, due to limited knowledge, frequently transferred this responsibility to proxy users. While this strategy may be practical in the short term, it carries increasing risks over time, including long-term privacy concerns and reduced individual control over personal healthcare. This study also highlighted how the ‘digital by default’ approach in high-income countries may deepen existing social inequalities by creating new barriers within already disadvantaged groups. To overcome these challenges, this study recommends efforts such as providing multilingual support, developing user-friendly interfaces, and tailored digital literacy training. Crucially, while digital healthcare continues to develop, in-person services must remain available to support those who cannot or do not wish to use digital tools. Further research is needed to explore the experiences of other migrant groups in different contexts, to support the development of inclusive digital healthcare policies that recognise diverse needs and capabilities. Abbreviations WHO : World Health Organization e-ID : Electronic identification SDGs : Sustainable Development Goals EU : European Union THL : Finnish Institute for Health and Welfare Declarations Ethics approval and consent to participate The Research Ethics Committee in the Humanities and Social and Behavioural Sciences at the University of Helsinki (12/2023) reviewed the study protocols to ensure ethical standards and granted approval for the study. All participants provided written informed consent. Consent for publication Not applicable Availability of data and materials The data generated and analysed during this study are not publicly available but may be obtained from the corresponding author upon reasonable request and subject to appropriate ethical approval. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the Kone Foundation and the Strategic Research Council at the Research Council of Finland [grant numbers 327145, 327148, 352501, 352504]. The Article Processing Charge was covered by the Helsinki University Library. Authors' contributions All aspects of the research were undertaken by SKK. Acknowledgements I would like to express my sincere gratitude to all the research participants who generously shared their valuable experiences through interviews. I am especially thankful to my PhD supervisors and colleagues, for their insightful comments and support during the development of this article. I also gratefully acknowledge the financial support provided by the Kone Foundation, the Research Council of Finland, and the University of Helsinki. I also acknowledge the use of ChatGPT-4.0 to support language refinement and editing of the manuscript. Author’s information Doctoral Researcher, University of Helsinki, Faculty of Social Sciences, Social and Public Policy, Helsinki, Finland Shrwan Kumar Khanal References Stachwitz P, Debatin JF. Digitalization in healthcare: today and in the future. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2023;66. Matlin SA, Hanefeld J, Corte-Real A, da Cunha PR, de Gruchy T, Manji KN, et al. Digital solutions for migrant and refugee health: a framework for analysis and action. The Lancet Regional Health - Europe. 2025;50:101190. EU. European health report 2024: keeping health high on the agenda. Copenhagen: WHO Regional Office for Europe; 2025. Al-Shorbaji N. Improving Healthcare Access through Digital Health: The Use of Information and Communication Technologies. In: Healthcare Access. 2022. Ekman I, Hedman H, Swedberg K, Wallengren C. Commentary: Swedish initiative on person centred care. BMJ (Online). 2015;350. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6949319","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":490350540,"identity":"65e4464e-4381-4f45-9a0b-bd62adaf9eb6","order_by":0,"name":"Shrwan Kumar Khanal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIie3QMUsDMRTA8XcI6WRvfUH0vsI7DqLCfZgLwk2HODqI3hSXdr+h+Bk6ieOVgF0qXSM61OWmCh0tKpirDl1ydHTIf0gg8CN5AfD5/mFR9bsTtevisoY+BGVQEoTMQchsk2xWA/sjXLkIbhOpWgIWAfDSRQ6GDa4fIDnuPU1W8u71iIVavVUXgH3XLKOp4MMZiNPB+RnK+yZhKG/jMQG6ZgGTM7OvIKW6IEu0VBgoviC47iLP3y2ZL5MPOdI3KpxsSOctL/YWQaYQKEudMfsJvOthZPLe56HChMxSnGSPOlZoSUXoJFGV78XvKo3H8yIxqysdheG04YOvFKPS9bJNuMOJz+fz+XbvBxNNWIoykaMnAAAAAElFTkSuQmCC","orcid":"","institution":"University of Helsinki","correspondingAuthor":true,"prefix":"","firstName":"Shrwan","middleName":"Kumar","lastName":"Khanal","suffix":""}],"badges":[],"createdAt":"2025-06-22 11:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6949319/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6949319/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s44247-025-00220-1","type":"published","date":"2025-10-28T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99250177,"identity":"04d80146-f291-436f-a154-81f5a8b785c0","added_by":"auto","created_at":"2025-12-30 18:11:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":705070,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6949319/v1/3167904a-2d61-48ba-91f5-1b7389bdb3ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e“Digital is nice, but only to smart people”: a qualitative analysis of barriers to digital healthcare for migrants in high-income countries\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe digitalisation of healthcare has seen rapid growth globally, with the COVID-19 pandemic serving as a significant accelerator [1, 2]. To achieve Universal Health Coverage under the Sustainable Development Goals (SDGs) 2030, the World Health Organization (WHO) has prioritised the transition to digital healthcare services and the development of a people-centred health system [3]. Digitalisation is generally claimed with promoting equitable access to healthcare services, enhancing transparency, and empowering patients to manage their health [4, 5].\u003c/p\u003e\u003cp\u003eIn high-income countries, healthcare services are increasingly delivered through digital platforms. The Nordic region, including Finland, is notable for its high levels of digital competence among healthcare providers and the availability of advanced digital healthcare infrastructure [6]​. The use of digital technologies in healthcare is also driven by economic benefits, such as reducing the reliance on human resources and streamlining processes like document storage [7]. Through digitalisation, it is also assumed to address the labour shortage resulting from the aging population [8]. For example, in the recent health and social care reform (Sote-uudistus), the Finnish government identified digitalisation and electronic services as a key functional mechanism for curbing the growth of healthcare and social welfare costs [9, 10].\u003c/p\u003e\u003cp\u003eWhile the structural settings of high-income countries have promoted \u0026ldquo;digital by default\u0026rdquo;[11] in public services, the literature suggests that this approach can also deepen societal inequalities [12, 13]. This situation extends new forms of exclusion, as residents, particularly those in vulnerable positions, are often unable to use standardised digital technologies [13\u0026ndash;15], including online health record access [16, 17]. For instance, a lack of digital skills, limited education, health issues, language barriers, and trust issues are widely discussed as key challenges of digital healthcare use [6, 18\u0026ndash;21]. A recent study in Nordic countries found Despite high levels of digitalisation in the region, many migrant women especially those newly arrived, with limited local language skills, or from lower socioeconomic backgrounds, face significant barriers to accessing and benefiting from digital services [22].\u003c/p\u003e\u003cp\u003eBeyond these foundational barriers, it is crucial to recognise that mere access to and technical proficiency with mobile, internet, and digital platforms do not necessarily ensure effective healthcare utilisation [13, 23]. This is particularly evident among migrant populations; while most migrants are familiar with smartphones and digital tools, this familiarity does not always translate to the ability to navigate complex digital healthcare systems in their destination countries [20, 24]. A persistent lack of tailored support and training for using web-based platforms and other digital healthcare services further hinders migrants' proper access to and effective use of digital healthcare [25]. Moreover, differing medical cultures, such as a preference for in-person healthcare-seeking behaviour prevalent in country of origin, also significantly impact clients' willingness to engage with digital healthcare services [19, 26].\u003c/p\u003e\u003cp\u003eWhile a substantial body of research exists on the digital healthcare experiences of older migrants, there is comparatively less attention given to younger and working-age migrant populations. This study seeks to address this gap by exploring the in-depth experiences of Nepali migrants regarding their digital healthcare use experiences.\u003c/p\u003e\n\u003ch3\u003eStudy context\u003c/h3\u003e\n\u003cp\u003eFinland is recognised as a global leader in digital healthcare, underpinned by its advanced infrastructure and proactive policy initiatives [9]. In 2023, 82% of its population aged 16 to 74 possesses basic digital skills, the highest in the European Union (EU) [27]. This strong foundation has enabled the Finnish government to prioritise digitalisation in healthcare, through initiatives such as the Health 360 Finland. This initiative aims developing innovative digital solutions to improve efficiency and drive economic growth in the health sector [28].\u003c/p\u003e\u003cp\u003eA cornerstone of Finland's digital health ecosystem is nationwide MyKanta (more commonly known as omakanta or kanta), a digital health service platform launched in 2010 that has undergone continuous feature development. MyKanta effectively manages the public information system, allowing individuals to monitor their health records, check prescriptions, book laboratory appointments, communicate with providers, submit prescription renewal requests, and upload social welfare information [9]. However, a limitation is that MyKanta primarily serves in Finnish and Swedish, with only limited services available in English, posing considerable challenges for many migrants [15, 29]. While other platforms like Maisa, available as both a web portal and App, offer more features and provide information in English, their utility is restricted as Maisa is limited to residents of the greater Helsinki region.\u003c/p\u003e\u003cp\u003eElectronic identification (e-ID) is crucial to access MyKanta and other digital public services in Finland. This e-ID relies on bank account credentials (or mobile phone credentials), following a check of residency records by the phone company. Securing these credentials can be very challenging for many newcomers or groups that have difficulty accessing full residential status or banking services [30]. Beyond the e-ID access, research has consistently show that vulnerable groups such as older adults, migrants, and people with disabilities face greater obstacles in the use of digital technologies [8, 20, 31]. For instance, a nationwide survey of residents\u0026rsquo; experiences in Finland found that Russian speakers are less likely to use digital services than native Finnish speakers [32].\u003c/p\u003e\u003cp\u003eThe experiences of diverse user groups, such as migrants from different geographical region, regarding digital healthcare behaviour are critically understudied in Finland. The previous research argues that the digitalisation of public services, including healthcare, in welfare states such as Finland is creating a vicious cycle that broaden existing social exclusion [15, 33]. Studies also consistently underscore the critical need to incorporate the perspectives of marginalised groups, including migrants, in the design and implementation of digital healthcare technologies to ensure fair and inclusive access [2, 13, 34, 35]. This includes the integration of cultural competence principles into strategies and policies at both organisational and system levels to achieve safer and more equitable care [13, 36].\u003c/p\u003e\u003cp\u003eMigration to Finland has steadily increased, rising from less than 1% of the population in 1990 to 11.07% of the total population (5.6\u0026nbsp;million) in 2024. During the same period, the Nepali migrants grew from just six individuals to ten thousand, with a substantial proportion (76%) aged between 20 and 45 years [37]. More recently, the share of Asian communities such as Chinese, Vietnamese, and Nepali has been rising rapidly, while the growth of Baltic and Middle Eastern language-speaking groups has slowed. This trend has contributed to increasing demographic diversity in Finland, particularly in the capital region [38].\u003c/p\u003e\u003cp\u003eThis diversity makes understanding the distinct cultural and healthcare practices of the migrant population particularly pertinent, especially given the sharp contrast with Finland's digitalised, patient-centred healthcare model [39]. For example, Nepalis culture is deeply rooted in values where healthcare decisions are often made collectively by families or household heads, with women and children typically having limited autonomy [40\u0026ndash;42]. Similarly, doctors in Nepal are revered as figures of authority and care, with their presence alone often perceived as a form of healing [43]. Further underscoring these differences, healthcare services in Nepal are predominantly provided face-to-face, as the digital infrastructure remains underdeveloped despite a recent increase in internet access and social media use.\u003c/p\u003e\u003cp\u003eIn Finland, the law allows to handover attorney in handling personal matters including accessing healthcare information in various situations [44]. Research has shown that the expansion of digital services can reduce direct support from public sector workers and increase reliance on third-sector organisations [33]. This shift may also raise the risk of individuals relying on others (referred as proxy users\u003cem\u003e)\u003c/em\u003e to access digital services, potentially compromising privacy and autonomy. These drastically different healthcare systems and medical practices between the countries of origin and destination create an interesting study setting.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy objectives\u003c/h2\u003e\u003cp\u003eThis study aims to examine the digital healthcare challenges from the perspectives of Nepali migrants in Finland. The following research questions guide this investigation:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eWhat challenges do Nepali migrants encounter while using digital healthcare services in Finland?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWhat are the consequences of digitalisation in healthcare in Finland for Nepali migrants?\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThrough investigating these questions, the study provides recommendations for policies and future research.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eResearch design\u003c/h2\u003e\u003cp\u003eThis study adopted a qualitative research design, utilising semi-structured interviews to examine the experiences of Nepali migrants residing in the Helsinki (capital) region of Finland. Qualitative method was selected to enable a detailed exploration of participants\u0026rsquo; perspectives and to gain in-depth understanding of their interactions with the healthcare system [45]. To adequately reflect the diversity within the migrant community and enrich this exploration, the study aimed to include individuals from varied socio-demographic backgrounds.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRecruitment of participants\u003c/h3\u003e\n\u003cp\u003eParticipants were selected using a combination of convenience, purposive, and snowball sampling techniques [46]. This approach ensured variation in socio-demographic characteristics and the inclusion of individuals with relevant experiences. The inclusion criteria required participants to have used healthcare services in Finland, to have resided in the country for a minimum of one year, and to belong to the working-age population.\u003c/p\u003e\u003cp\u003eFollowing the establishment of these selection criteria, recruitment was conducted through multiple channels. An invitation to participate was posted in a Facebook group widely used by the Nepali community in Finland. While some participants responded directly to this post, others were recruited through snowball sampling or via the researcher\u0026rsquo;s personal network. In total, 31 individuals were contacted. Of these, four were excluded due to not meeting the inclusion criteria, resulting in a final sample of 27 participants.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe author was involved throughout the data collection and analysis process. Prior to scheduling interviews, participants were fully informed about the study\u0026rsquo;s objectives and their expected role. Once participants agreed to take part, interview times and venues were arranged based on mutual convenience. In adherence to ethical guidelines, each participant received a printed information sheet in Nepali before data collection commenced. This sheet outlined the study's aims, the voluntary nature of participation, the right to withdraw without providing a reason, and the confidentiality of the data. Written informed consent was obtained from each participant for both participation and audio recording. The Research Ethics Committee in the Humanities and Social and Behavioural Sciences at the University of Helsinki reviewed and approved the study protocol.\u003c/p\u003e\u003cp\u003eData were collected between February and August 2023. To foster an environment where participants felt comfortable expressing themselves more freely, all interviews were conducted in Nepali, their native language. The researcher\u0026rsquo;s shared background with the participant community further contributed to this setting, facilitating open discussions on sensitive issues and supporting the accurate interpretation of responses. An interview guide [47] was developed based on prior research and revised iteratively in response to emerging insights from initial interviews. Additionally, the researcher maintained a field notes throughout the data collection process to document observations and reflections. Interviews were conducted in various settings such as public libraries and residents to accommodate participants' preferences.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e\u003cp\u003eThe study included 27 participants (13 men, 14 women). Their mean age was 44 years (range: 31\u0026ndash;67), and their duration of residence in Finland averaged 12 years (range: 4\u0026ndash;29 years). Participants' educational attainment, reported as attended in Nepal, showed varied levels: nine (33%) had completed a basic level (up to 10 years), five (19%) had attained higher secondary education (11\u0026ndash;12 years), and the remaining thirteen (48%) had received university-level education. Participants digital skills were also collected as the background information and categorised into three levels: 12 participants (45%) reported poor skills, 9 (33%) indicated average level, and 6 (22%) identified as having advanced skills.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe interview data were transcribed verbatim and analysed using reflexive thematic techniques [48]. This approach was selected for its structured process and its capacity to integrate reflexivity in qualitative research based on textual data [49, 50]. Consistent with the emphasis on reflexivity inherent in this approach, the potential for insider bias was recognised due to the researcher\u0026rsquo;s shared background with the participant group, which simultaneously supported the collection of in-depth data. To address this, additional strategies such as peer debriefing and a field journal were employed throughout the analysis [51].\u003c/p\u003e\u003cp\u003eThe analysis began with a familiarisation phase, during which the transcripts were read multiple times to gain a thorough understanding of the content. A summary of each interview was prepared to capture key observations. Initial codes were then assigned to these summaries, focusing on salient features and recurring patterns. These codes were grouped into broader categories, which were iteratively reviewed and refined into preliminary themes. This process involved examining the coherence of each theme, identifying overarching patterns, and exploring conceptual links between categories to ensure alignment with the study\u0026rsquo;s objectives. Through this iterative approach, a set of overarching themes and subthemes was developed, providing the foundation for detailed thematic analysis. Participants were assigned pseudonyms to ensure anonymity during data analysis.\u003c/p\u003e\u003cp\u003eWhile the analysis was predominantly inductive, emerging directly from the data, insights from prior research also served as a guiding lens during the thematic development and refinement. Particular attention was given to themes related to digital skills and knowledge, barriers encountered utilising digital healthcare, and previous experiences with medical practices, especially in relation to digital healthcare services.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe digitalisation of healthcare services in Finland presents a complex and layered experience for migrants, shaped by multiple, interrelated challenges. Analysis of the data revealed four key themes that reflect the digital healthcare experiences of Nepali migrants: limited digital skills, language barriers, reliance on proxy users and the resulting loss of autonomy, and a strong preference for in-person care. These themes are closely connected, and participants\u0026rsquo; accounts often touched on more than one area simultaneously, making it difficult to present them as entirely separate. For instance, discussions of digital skills were frequently intertwined with collective practices, such as involving family members in managing healthcare tasks, while language barriers often reinforced the need for proxy support. This overlap highlights the interdependent nature of these experiences and the challenge of placing them within fixed thematic boundaries.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDigital skills and healthcare use\u003c/h2\u003e\u003cp\u003eA common challenge identified in the study was limited digital literacy, which influenced how participants engaged with Finland\u0026rsquo;s digital healthcare systems. Although nearly all participants owned smartphones, their use was often limited to basic tasks such as messaging or video calls. Only a few were confident using digital tools for health-related purposes. For instance, some participants described Maisa as a \u0026ldquo;pocket calculator,\u0026rdquo; appreciating its convenience for those who could navigate it. However, most participants struggled with functions beyond everyday communication.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t open the computer. I have not used these things for using services in Finland. I can manage normal things like duty list, use messenger and video call on mobile but nothing more.\u0026rdquo;\u003c/em\u003e (P7, male)\u003c/p\u003e\u003cp\u003eDespite recognising the potential benefits of digital systems, many participants lacked prior experience with such tools and found them difficult to use independently.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is very hard through the digital system to use healthcare services. For example, saying hello and using messenger does not mean that I know the method of using available healthcare services.\u0026rdquo;\u003c/em\u003e (P6, female)\u003c/p\u003e\u003cp\u003eSeveral participants expressed a willingness to learn, recognising that digital skills could save time and reduce dependence.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have seen the booking option in Maisa but haven\u0026rsquo;t learned how to use it\u0026hellip; if I learn, I can book lab time and appointments from home.\u0026rdquo;\u003c/em\u003e (P8, female)\u003c/p\u003e\u003cp\u003eAge and previous exposure to technology influenced their use behaviour, with older participants especially feeling left behind. For instance, a participant of sixties reported:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Not everyone knows how to use these digital things. I\u0026rsquo;m too old for new things. I prefer the paper system we used before.\u0026rdquo;\u003c/em\u003e (P10, male)\u003c/p\u003e\u003cp\u003eMany participants were reluctant to use digital tools, instead relying heavily on family members to manage healthcare tasks. This behaviour may not be solely due to a lack of knowledge, but also reflects a practical trust in family members, who were perceived to be more familiar with Finnish systems and more proficient with digital technologies as part of a younger, digitally fluent generation. For example, a participant reported how the devices are shared in a family as:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know much about it. My Wife reads the report sent by them. Now they have apps, something called maas\u0026hellip;., it is downloaded into\u003c/em\u003e \u003cb\u003eour mobile\u003c/b\u003e, \u003cem\u003ebut I don\u0026rsquo;t know anything. My wife takes care of it.\u0026rdquo;\u003c/em\u003e (P11, male)\u003c/p\u003e\u003cp\u003e Some participants felt discomfort with repeated dependence and bothering them. As a participant added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not easy for me to book an appointment online. I always ask my son to help, but I don\u0026rsquo;t want to bother him all the time.\u0026rdquo;\u003c/em\u003e (P3, male)\u003c/p\u003e\u003cp\u003eMany participants viewed the lack of digital training as a systemic failure. One participant remarked highlighting a sense of exclusion despite fulfilling civic responsibilities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;..but at least they should provide training and teach about new systems to make fair use of digital health technologies. Otherwise, waste of our tax money.\u0026rdquo;\u003c/em\u003e (P16, Female)\u003c/p\u003e\u003cp\u003eThis frustration was not unique to migrants and echoes concerns expressed by the general population. However, participants felt disproportionately limited in their ability to fully exercise their healthcare rights, leading some to feel like second-class citizens despite contributing equally through taxes. Such experiences indicate that digital solutions are not just about owning a phone or computer. They involve a lack of skills, experience, and support. Even when participants wanted to use the systems, many felt left out because there was no proper help to guide them. In addition, participants had trust to their younger children more than themselves in using smart phones, web portals and digital Apps.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLanguage barriers and digital healthcare use\u003c/h2\u003e\u003cp\u003eLanguage skills emerged as another key factor limiting access to digital healthcare. Although some participants had sufficient digital skills, the dominance of Finnish on platforms such as Omakanta made navigation difficult.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no English in these platforms which is a big problem. I copy content and convert it to Google Translate... Sometimes, Google provides odd words.\u0026rdquo;\u003c/em\u003e (P17, male)\u003c/p\u003e\u003cp\u003eAnother participant described uncertainty when using translation tools:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes I find it very hard to understand what they are asking in Omakanta. I have to translate everything in Google, and I am not sure if I get it right.\u0026rdquo;\u003c/em\u003e (P9, male)\u003c/p\u003e\u003cp\u003eSome participants received training in their workplace about digital healthcare, but that was often ineffective due to the language of instruction.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They provided us the training, but it was given together with other Finnish colleagues. How can the same method be catchable to us foreigners?\u0026rdquo;\u003c/em\u003e (P15, female)\u003c/p\u003e\u003cp\u003eThis mismatch between language of instruction and participant needs reduced the potential impact of such efforts. Similarly, private healthcare providers were seen as more accessible due to the use of English and user-friendly interface in their digital systems.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In private hospitals, everything is in English, so I use both Maisa and their own Apps. Omakanta is not available in English, except for the front page.\u0026rdquo;\u003c/em\u003e (P9, male)\u003c/p\u003e\u003cp\u003eHowever, not everyone could afford private services, contributing to unequal access. Participants also shared views on usability. Browser-based platforms such as MyKanta were seen as harder to access, especially for those without regular use of computers. In contrast, app-based platforms like Maisa were more widely used due to their availability on mobile phones.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The issue with MyKanta is that I need to open the computer and web but for Maisa there is an App, and it\u0026rsquo;s on mobile. Also, no need to worry about the language since they are also in English.\u0026rdquo;\u003c/em\u003e (P20, male)\u003c/p\u003e\u003cp\u003eThese narratives point to the need for linguistically inclusive design and user-friendly interfaces that accommodate users\u0026rsquo; everyday practices. Participants who were fluent in Finnish and possessed strong digital skills were able to make extensive use of healthcare platforms, while others struggled with even basic functionalities. The following notes illustrate this further.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t use Google anymore. Apart from Maisa and Omakanta, I use the official websites (like THL-Finnish Institute for Health and Welfare) and other portals (for example Terveysportti) for\u003c/em\u003e \u003cb\u003eresearch-based information.\u003c/b\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e (P22, female)\u003c/p\u003e\u003cp\u003eWhereas some participants accepted digitalisation as an unavoidable reality. As participants noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eDigital is nice, but only to smart people\u003c/b\u003e. \u003cem\u003eHowever, development should not be stopped because of us. Let us go ahead with technology, we will manage anyway.\u0026rdquo;\u003c/em\u003e (P11, male)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It has gone to the digital age. I am not the only one to suffer. It is my fault that I can\u0026rsquo;t use the system. I ask daktor saheb (respected doctors) to communicate me through papers so that my children can help.\u0026rdquo;\u003c/em\u003e (P17, male)\u003c/p\u003e\u003cp\u003eThese narrations illustrate that language barriers often make digital healthcare even harder to access. Without proper translation and support, many participants had to rely on others. The digital healthcare system appeared to lack certain features necessary to meet the needs of migrants, making it difficult for them to use services independently.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eReliance on proxy users and loss of autonomy\u003c/h2\u003e\u003cp\u003eFor many Nepali migrants, healthcare tasks were managed collectively within the wider family rather than individually. Children, spouses, or other close relatives often handled digital healthcare responsibilities, such as reading medical messages or booking appointments. This reflected both cultural norms around shared responsibility and practical needs related to language barriers or limited digital skills. One participant explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;umm..I don\u0026rsquo;t use digital things. I watch TV, I know YouTube, and I use my phone and Facebook. But I don\u0026rsquo;t use a computer. Whatever is needed, my daughter does. I don\u0026rsquo;t know or care about these things.\u0026rdquo;\u003c/em\u003e (P24, female)\u003c/p\u003e\u003cp\u003eAnother participant noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I gave consent and my login details to my kids\u0026hellip; we don\u0026rsquo;t have privacy in our family.\u0026rdquo;\u003c/em\u003e (P16, female)\u003c/p\u003e\u003cp\u003eThis kind of support offered emotional comfort and familiarity, especially in a new healthcare environment. Sharing information was seen not as a violation of privacy but as part of caring for one another. Highlighting how open communication within families helped manage uncertainty, a participant noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The more we share, the more relaxed we feel. If we share, they suggest, and we can avoid the bad. Why should we worry about sharing with our son or husband? It may burst, if we don\u0026rsquo;t share.\u0026rdquo;\u003c/em\u003e (P26, female)\u003c/p\u003e\u003cp\u003eIn contrast to Finland\u0026rsquo;s healthcare system, which emphasises privacy and self-management, many participants viewed shared access as normal and even necessary. Yet this shift from individual to family-based decision-making was not always a matter of personal choice. In many cases, it resulted from barriers to independent use, such as language, lack of training, or unfamiliarity with digital systems. This created a situation where individuals had little control over their own healthcare. One participant shared that their daughter received digital notifications before they did and regularly accessed their health information:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;She knows my login ID and even gets the notifications before I do\u0026rdquo;\u003c/em\u003e (P8, female).\u003c/p\u003e\u003cp\u003eThese practices raise questions about autonomy and privacy in contexts where the system assumes individual control, but users rely on others to navigate it. These experiences also highlight how Nepali migrants manage digital healthcare through family support, reflecting cultural norms but also pointing to structural barriers. While this approach offers emotional and practical benefits, it reduces individual autonomy and raises concerns around privacy, especially in a system designed for self-managed care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePreference for in-person care\u003c/h2\u003e\u003cp\u003e Across interviews, participants consistently expressed a strong preference for face-to-face healthcare interactions. In-person visits were seen as more trustworthy, easier to understand, and more emotionally supportive than digital consultations. Describing the emotional comfort of being physically present, a participant shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a\u003c/em\u003e \u003cb\u003esky-earth difference\u003c/b\u003e \u003cem\u003e(aakash jaminko farak) between online and face-to-face services. We understand everything when we see each other. When we have eye contact, half of the illness feels cured.\u0026rdquo;\u003c/em\u003e (P1, male)\u003c/p\u003e\u003cp\u003eParticipants often felt that online or phone-based consultations failed to convey the seriousness of their symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Online, I feel like they don\u0026rsquo;t understand me properly\u0026hellip; it\u0026rsquo;s just not the same.\u0026rdquo;\u003c/em\u003e (P12, male)\u003c/p\u003e\u003cp\u003eOthers found it difficult to explain their condition without visual cues or gestures, which they believed helped doctors take them more seriously. They even applied the technique of falsifying or exaggerating the stories to get the appointment which is not possible to do over online mediums.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is difficult to get an appointment online, but if we go there, we can\u003c/em\u003e \u003cb\u003eexaggerate the situation\u003c/b\u003e \u003cem\u003ethrough different gestures.\u0026rdquo;\u003c/em\u003e (P5, female)\u003c/p\u003e\u003cp\u003ePhysical presence was also linked to a sense of reassurance and care. Participants believed that seeing the doctor, being touched, or reading facial expressions contributed to healing. As one participant said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When we go in person, there is a better chance of getting an appointment. Doctors understand us better when they see us. On the phone or online, how can we explain? There, they understand through gestures. It\u0026rsquo;s easier when they see and touch us.\u0026rdquo;\u003c/em\u003e (P14, female)\u003c/p\u003e\u003cp\u003eIn this view, the body itself played a role in communication, something digital platforms were seen to limit or exclude. Some also felt discomfort with video consultations, especially when asked to show parts of their body on camera. A participant reflected cultural discomfort with visual exposure in remote care settings as:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor wanted to assess my knee and asked me to point to the pain area over the video. I was so embarrassed\u0026hellip; I wouldn\u0026rsquo;t have felt this in a physical meeting.\u0026rdquo;\u003c/em\u003e (P23, female)\u003c/p\u003e\u003cp\u003eDespite the participants reported part as \u0026ldquo;knee\u0026rdquo;, her expression was clearly referring over the lower body part that was needed to access. This statement also indicates the trust issue of sensitive information over online platforms.\u003c/p\u003e\u003cp\u003e Participants expressed a clear preference for face-to-face care, citing emotional, cultural, and practical reasons. Digital consultations were often perceived as impersonal, difficult to navigate, or less trustworthy, particularly when symptoms were hard to communicate or when cultural norms influenced expectations of care.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated how Nepali migrants in Finland engage with digital healthcare services and the challenges they encounter in doing so. It also explored the broader implications of the rapid digitalisation of healthcare in the Finnish context. The empirical findings indicate that digital technologies have made healthcare more accessible and convenient [2, 13] for those migrants who possess higher levels of education, proficiency in digital tools, and command of the local language. For most participants, however, the benefits of digital healthcare were limited due to several barriers potentially extending pre-existing social inequalities.\u003c/p\u003e\u003cp\u003eSome participants in this study reported reduced travel time, 24/7 access to healthcare information, and the convenience of digital applications and wearable devices, which enhanced their autonomy in managing health [9, 10]. The study also revealed a preference for mobile applications, particularly Maisa, over web-based portals like Omakanta, underscoring the critical role of usability and interface design [2]. Furthermore, few participants actively utilised translation tools to overcome language barriers and searched for more reliable and research-based information, through portals other than MyKanta and Maisa indicating a gap within minority migrants. These intragroup disparities reflect findings from other contexts, such as among Pakistani migrants in Norway [52] and African migrants in Portugal [23], where acceptance of digital healthcare was influenced by factors such as education, gender, and digital competence. In many cases, acceptance was not based on preference or perceived benefit but rather on the absence of alternative options [11, 20].\u003c/p\u003e\u003cp\u003eThe study finds that possessing smartphones and using digital tools in everyday life, was not enough to translate this competence to use healthcare-specific services [15, 17, 20]. Participants extensively discussed the additional challenges including language barriers, weak knowledge of digital technologies and their traditional practices in seeking healthcare. This reinforces the need of incorporating language and cultural familiarity to use digital healthcare service equitably [2, 10, 23].\u003c/p\u003e\u003cp\u003eThe study also confirms previous findings that digital healthcare tools are often developed with the general population in mind, leaving minority groups with limited support [2, 12, 53]. The unavailability of digital platforms in English or other minority languages increases health inequalities [15, 54] and further distances already marginalised users. In contrast, private healthcare providers were perceived as more accessible due to their multilingual options, highlighting inequities between public and private healthcare systems in Finland. While digitalisation in public services including healthcare also pose challenges among general population, migrants face significance additional obstacles [8, 20]. Participants\u0026rsquo; experiences suggest that the digital training delivered alongside their Finnish colleagues was neither sufficient nor effective for migrants, leading to calls for separate training tailored to their specific needs and circumstances.\u003c/p\u003e\u003cp\u003eAnother key finding of this study is that many participants relied on family members to manage digital healthcare tasks, such as booking appointments or reading medical messages. While previous research has highlighted the risks of using proxy users to access digital services [33, 55], the participants in this study did not view such reliance as problematic. Instead, they considered it a helpful and routine part of daily life. Unlike Russian speaking migrants, the largest migrant community in Finland, who have been reported to use external agencies to navigate digital healthcare [33], such practices were not observed among Nepali participants. It was common for Nepali migrants to share login credentials and delegate health-related tasks to trusted family members. While this reflects a strong culture of shared decision-making [41], it raises concerns about privacy, autonomy, and accountability. Entrusting healthcare tasks to untrained family members carries risks, particularly if relationships change or if sensitive information is not managed appropriately.\u003c/p\u003e\u003cp\u003eParticipants did not express concern about maturity of minors accessing parents\u0026rsquo; healthcare information. Instead, they were more curious about the age limit at which parents could access their children's health records. This reflects family norms in Nepal, where household responsibilities, including healthcare matters, are often managed collectively. In contrast, Finland\u0026rsquo;s healthcare system grants minors increasing autonomy from the age of 10, based on maturity and care context [56]. However, these criteria are often unclear and difficult for many parents, to interpret particularly for communities like Nepali. Many participants appeared unaware of a legal framework, including procedures for authorising another person [20, 44], for accessing health records. Importantly, some routinely relied on underaged children to assist with digital healthcare tasks, indicating both a lack of awareness and a gap in support.\u003c/p\u003e\u003cp\u003eBeyond legal and privacy concerns, this dependency had emotional implications. While some viewed sharing digital access as a form of emotional support, others described feeling anxious, embarrassed, or disempowered due to their inability to manage healthcare independently. This loss of autonomy may impact confidence in navigating healthcare and runs counter to the principles of patient-centred care that digital systems aim to promote [5, 57]. While video consultations in primary healthcare have been found effective and are expected to increase rapidly in high-income countries [58], they were perceived as inappropriate by Nepali migrants, largely due to cultural considerations. Participants expressed discomfort with video-based interactions involving physical examinations.\u003c/p\u003e\u003cp\u003eThe preference for face-to-face care is not unique to migrants, but also among the general population [59]. However, among Nepali migrants, the reasons for preferring in-person care appear as a solution to overcome language barriers and cultural norms. Some valued the opportunity to use gestures to convey urgency, while others connected care directly to physical presence and communication. The frequent use of the term \u0026ldquo;\u003cem\u003eDaktor Saheb\u003c/em\u003e\u0026rdquo; illustrates the deep respect afforded to doctors in Nepali culture, reflecting their perception as trusted and authoritative figures [43]. These cultural values help explain the strong preference for in-person consultations over digital alternatives, despite broader trends toward digitalisation. In the context of a welfare state like Finland, recognising and incorporating these cultural differences into healthcare design is therefore essential to address the diverse linguistic, social, and behavioural needs of migrant communities [2, 60].\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e\u003cp\u003eTo the best of my knowledge, this study is the first in Finland that explores the digital healthcare experiences of a relatively younger, economically active migrant community from South Asia. It contributes a new perspective to the academic literature and offers practical insights for policymakers. While previous research has examined migrants\u0026rsquo; general engagement with digital public services, this study focuses specifically on their experiences with digital healthcare. This focus is particularly timely, given that Finland, like other EU countries, is expanding its digital healthcare systems to advance Universal Health Coverage (UHC) under the Sustainable Development Goals. By drawing on participants\u0026rsquo; lived experiences, the study provides more detailed insights than population-based surveys, allowing for a deeper understanding of individual-level challenges. This depth was further enhanced by the researcher\u0026rsquo;s affiliation with the Nepali community, which facilitated a more contextualised interpretation of the data and a deeper interpreting of participants' narratives.\u003c/p\u003e\u003cp\u003eHowever, the study has several limitations, many of which are common to qualitative research with a small sample size. The possibility of researcher bias, for instance, may have influenced the interpretation of findings. In addition, participants self-reported digital competence and educational background from their country of origin, may not fully reflect the skill levels expected in Finland\u0026rsquo;s highly digitalised welfare state. This competence was further compounded by the overlap between digital and language barriers, making it difficult at times to determine whether certain challenges stemmed primarily from digital literacy or language proficiency.\u003c/p\u003e\u003cp\u003eAdditionally, participants frequently reported sharing devices and healthcare information, but the implications of this sharing were not always clear, and therefore require cautious interpretation. A further limitation of this study is its narrow scope, as it focused digital healthcare experiences solely on the use of certain online platforms and service calls. A more comprehensive representation of healthcare digitalisation would encompass various new tools and technologies, including wearable devices. Therefore, while the study provides valuable insights, these limitations should be carefully considered when interpreting and generalising the findings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe main aim of this research was to identify the challenges migrants face in using digital healthcare in Finland and to understand the effects of these challenges. This study illustrates the complex relationship between technology, migrants\u0026rsquo; behaviour, and healthcare access, reflecting broader concerns about the digital divide in welfare states. Supporting existing research, the findings show that for migrants, digital tools have introduced new forms of dependence and increased vulnerability. Furthermore, the study mirrors that access to digital tools alone does not ensure meaningful engagement with digital healthcare for migrants.\u003c/p\u003e\u003cp\u003eAlthough digital tools are designed to promote self-management, many participants, due to limited knowledge, frequently transferred this responsibility to proxy users. While this strategy may be practical in the short term, it carries increasing risks over time, including long-term privacy concerns and reduced individual control over personal healthcare. This study also highlighted how the \u0026lsquo;digital by default\u0026rsquo; approach in high-income countries may deepen existing social inequalities by creating new barriers within already disadvantaged groups.\u003c/p\u003e\u003cp\u003eTo overcome these challenges, this study recommends efforts such as providing multilingual support, developing user-friendly interfaces, and tailored digital literacy training. Crucially, while digital healthcare continues to develop, in-person services must remain available to support those who cannot or do not wish to use digital tools. Further research is needed to explore the experiences of other migrant groups in different contexts, to support the development of inclusive digital healthcare policies that recognise diverse needs and capabilities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e: World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee-ID\u003c/strong\u003e: Electronic identification\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSDGs\u003c/strong\u003e: Sustainable Development Goals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEU\u003c/strong\u003e: European Union\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTHL\u003c/strong\u003e: Finnish Institute for Health and Welfare\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Research Ethics Committee in the Humanities and Social and Behavioural Sciences at the University of Helsinki (12/2023) reviewed the study protocols to ensure ethical standards and granted approval for the study. All participants provided written informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated and analysed during this study are not publicly available but may be obtained from the corresponding author upon reasonable request and subject to appropriate ethical approval.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Kone Foundation and the Strategic Research Council at the Research Council of Finland [grant numbers 327145, 327148, 352501, 352504]. The Article Processing Charge was covered by the Helsinki University Library.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll aspects of the research were undertaken by SKK.\u003cstrong\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to express my sincere gratitude to all the research participants who generously shared their valuable experiences through interviews. I am especially thankful to my PhD supervisors and colleagues, for their insightful comments and support during the development of this article. I also gratefully acknowledge the financial support provided by the Kone Foundation, the Research Council of Finland, and the University of Helsinki. I also acknowledge the use of ChatGPT-4.0 to support language refinement and editing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor\u0026rsquo;s information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoctoral Researcher, University of Helsinki, Faculty of Social Sciences, Social and Public Policy, Helsinki, Finland\u003c/p\u003e\n\u003cp\u003eShrwan Kumar Khanal\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStachwitz P, Debatin JF. Digitalization in healthcare: today and in the future. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2023;66.\u003c/li\u003e\n\u003cli\u003eMatlin SA, Hanefeld J, Corte-Real A, da Cunha PR, de Gruchy T, Manji KN, et al. Digital solutions for migrant and refugee health: a framework for analysis and action. The Lancet Regional Health - Europe. 2025;50:101190.\u003c/li\u003e\n\u003cli\u003eEU. 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British Journal of General Practice. 2019;69:e586\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eHeponiemi T, Jormanainen V, Leemann L, Manderbacka K, Aalto AM, Hypp\u0026ouml;nen H. Digital divide in perceived benefits of online health care and social welfare services: National cross-sectional survey study. J Med Internet Res. 2020;22.\u003c/li\u003e\n\u003cli\u003eBetancourt JR, Green AR, Carrillo JE. Cultural competence in health care: Emerging frameworks and practical approaches. 2002.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digital healthcare, digital literacy, proxy users, in-person care, Nepali migrants, migrants’ health, Finland, social exclusion","lastPublishedDoi":"10.21203/rs.3.rs-6949319/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6949319/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of digital technologies in healthcare has been expanding rapidly. While these tools have improved service delivery by increasing efficiency and convenience, they have also introduced barriers for certain groups, including migrants. As a result, digitalisation may deepen existing social inequalities, particularly for vulnerable populations. Despite these concerns, there is limited understanding of how migrants engage with digital healthcare in their everyday lives. This study addresses this gap by examining the challenges and consequences of digital healthcare use among Nepali, a minority migrant community in Finland.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThe data comprise semi-structured interviews with 27 Nepali migrants. The study identified four key challenges: limited digital skills, language barriers, reliance on proxy users, and a strong preference for in-person care. Although most participants had access to smartphones and digital platforms, many lacked the confidence or ability to use them independently for healthcare-related tasks. This, combined with language barriers, often led to a reliance on proxy users, with healthcare tasks frequently assisted by family members, including underage children. While these practices sometimes reflected cultural norms of collective care, they also raised significant concerns about privacy, autonomy, and the overall accessibility of digital healthcare systems for migrants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nAccess to digital tools alone does not guarantee meaningful engagement with healthcare. Reliance on proxy users and complex digital interfaces can reinforce inequality, particularly under the ‘digital by default’ model of high-income countries. To support inclusive access, the study recommends multilingual interfaces, user-friendly design, tailored digital literacy training, and the continued availability of in-person services. Further research is needed to inform policies that reflect the needs of diverse populations.\u003c/p\u003e","manuscriptTitle":"“Digital is nice, but only to smart people”: a qualitative analysis of barriers to digital healthcare for migrants in high-income countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 04:28:06","doi":"10.21203/rs.3.rs-6949319/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-27T10:36:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T17:59:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T16:21:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T09:38:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171350431536060525176066484369234358878","date":"2025-08-06T12:08:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62305006938878123074688909071092980409","date":"2025-08-05T22:54:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171685618130223560528287242245554814641","date":"2025-08-05T13:52:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T13:18:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277434660690907913967520106283815804806","date":"2025-07-04T10:35:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31499825292077392593586184714508210151","date":"2025-06-30T23:15:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-28T22:58:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-28T21:57:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-26T07:27:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-25T07:29:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Digital Health","date":"2025-06-25T07:26:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84b452e8-64e7-4121-8f86-f4901b1414e7","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T18:11:41+00:00","versionOfRecord":{"articleIdentity":"rs-6949319","link":"https://doi.org/10.1186/s44247-025-00220-1","journal":{"identity":"bmc-digital-health","isVorOnly":false,"title":"BMC Digital Health"},"publishedOn":"2025-10-28 00:00:00","publishedOnDateReadable":"October 28th, 2025"},"versionCreatedAt":"2025-07-30 04:28:06","video":"","vorDoi":"10.1186/s44247-025-00220-1","vorDoiUrl":"https://doi.org/10.1186/s44247-025-00220-1","workflowStages":[]},"version":"v1","identity":"rs-6949319","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6949319","identity":"rs-6949319","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}