Traditional Meals and Sense of At-Homeness – Finnish Immigrants with Dementia in Bilingual Residential Care in Sweden

Introduction

This study focuses on the food culture in a Finnish-speaking or a bilingual dementia care unit in Sweden. One of the most frequent activities in residential care is related to food. Meals are served several times during the day to keep the residents in a good physical and nutritional status. Besides nutritional reasons, meals are playing an important role as a social event and it is related to culture (Lam & Keller, 2015; Sidenvall, 1999). The food traditions of individuals are often shaped by the individual upbringing and social environment in where food is served and eaten (Andersson, 2005; Chaudhury, Hung & Badger, 2013, Evans, Crogan & Shultz, 2005; Fjellström, 2004; Meiselman, 2008). Meal in this study is defined as both the food/dishes and the social situation in which food is served and eaten and the physical environment where eating takes place.

The large global immigrant transitions of today, have brought along food and meal traditions and thus added to the variety of the food choice that we have today. For healthy individuals there are most often a large variety of foods to choose from whether it is nutritious or not. But for a person who is suffering from some kind of disease or health condition, eating can be a challenge. Older adults with cognitive decline, or diagnosed with dementia is a group at risk of developing malnutrition due to their condition. They may forget to eat or do not know how to eat or have problems swallowing food (Di-Maria Galilli & Amella, 2005; Stockdell & Amella, 2008; World Alzheimer Report, 2014). There is also a risk of developing malnutrition if the person cannot feed him/herself (Westergren, Unosson, Ohlsson, Lorefalt, & Hallberg, 2002). A report by Alzheimer’s Disease International, (2014) has recommended strategies to prevent malnutrition in persons with dementia, such as stimulating the appetite by regular snacks and meals, try food that the person with dementia likes, naturally soft food, chopping up the food of necessary or giving ‘finger food’ and/or keeping the food hot. Also the social interactions during mealtime, for example nursing staff eating together with the person with dementia and if necessary help with the meal are important, as well as giving the person with dementia time to eat and be observant to non-verbal clues such as body language. According to studies by Chaudhury, Hung & Badger (2013), and McDaniel, Hunt, Hackes & Pope, (2001), the dining room or place with a relaxed atmosphere is important for a positive meal experience.

As meals are part of an individuals´ culture, older adults with other ethnic backgrounds may have other food preferences, regarding what, when and where to eat than those in the hosting country. According to a study on South Asian immigrants in the UK, it was reported that food and dieting also had religious meanings, as different religions have restrictions regarding what kind of food is allowed and not allowed (Rauf, (2011). Another study conducted in Norway on the Sami population, indigenous people of Northern Scandinavia, showed that when being served Sami food, the Sami patients with dementia appetite and nutritional intake improved, as well as that traditional food brought joy and a sense of belonging (Hanssen, 2013; Hanssen & Moene Kuven, 2015). As such, cultural food preferences need to be considered when providing care for immigrant persons with dementia.

Among several conditions of dementia symptoms, the most common and well-known is Alzheimer’s disease according to World Health Organization [WHO], (2019). Globally there are an estimated 50 million people living with dementia in 2018 and this number will more than triple to 152 million by 2050 (World Alzheimer Report, 2018). In Sweden with it´s over 10 million citizens there are many nationalities and there are also about 150 000 people diagnosed with dementia out of which approximately 20 000 have other ethnic origins (National Board of Health and Welfare, 2017). The exact numbers of immigrant persons with dementia are unknown, as culture can be a barrier for health seeking for dementia (Daker-White, Beattie, Gilliard & Means, 2002; Wezel, 2014). According to the American diagnostic and statistical manual for mental disorders (DSM-5) (American Psychiatric Association, 2013), dementia is a symptom complex including impaired memory function and reductions in one or more cognitive abilities such as language impairment, executive ability and visuospatial ability. The impaired memory makes it difficult to remember names of people, places and events and the person with dementia may have difficulties in focusing, communication difficulties and a disturbed sense of direction in places familiar to the person. One of the consequences of the language impairment for a bilingual or immigrant person with dementia, is that the later learnt language is lost first and as the condition progresses, also the native language (Divita, 2014; Ekman, 1994). The language impairment makes communication for an immigrant person a challenge, when having to communicate one’s needs and wishes for example in receiving health care in the hosting country. The memory impairment and gradual loss of physical and psychological abilities affects the person’s confidence and the sense-of-self is threatened. Experiencing all these losses, dementia can be described as being in a state of homelessness (Zingmark, Norberg & Sandman, 1993). The person with dementia therefore needs care, which supports the personhood and sense-of self. Other than that, basic nursing care should be as supportive as possible to enhance the person’s with dementia well-being (Kitwood, 1997; National Board of Health and Welfare, 2017).

When dementia has progressed into advanced stages and the person can no longer take care of her/himself and not manage normal daily activities, professional and residential care is needed. Dementia care in Sweden is provided in larger care homes where there are older adults with multiple physical conditions mixed with older adults with dementia or in special care units/group homes only for people with dementia: These care units are small-scale units for 10-12 residents with the idea that the unit should look ’home-like’ and have more nursing staff than in larger care homes (National Board of Health and Welfare, 2017; Trydegård, 2000.) Immigrant persons with dementia in Sweden, are generally admitted to Swedish-speaking care homes or a dementia unit. For an immigrant person with dementia the transfer to a Swedish-speaking care unit can be a challenge as it may be a culturally foreign environment, (Ekman, 1994; Heikkilä & Ekman, 2003). However, there are also ethnic or culturally profiled dementia care units in Sweden, where the nursing staff is bilingual and speak the residents’ native language, for example for the older Finnish immigrants (Berg, 2001). In the areas of Sweden with a larger amount of older Finnish immigrants, there are care services in Finnish and also care units with Finnish-speaking nursing staff. Besides the benefits of being able to communicate in one’s native language, cultural features such as food can play an important role for the residents. Nutrition and meals in ethnic dementia care units for immigrants with dementia has not been given much attention in earlier studies. Therefore, this study takes its’ departure from a Finnish-speaking dementia care unit in Sweden.

Aim: to explore the food-culture in a Finnish-speaking care unit for Finnish-speaking immigrants with dementia in Sweden from the perspectives of bilingual nursing staff and family members.

Material and Methods

A qualitative approach and design were chosen to gain a deeper understanding of the studied phenomenon from a subjective point of view, namely that which is personally experienced by the participants. The design and method are intended to cover a variety of personal experiences (Graneheim & Lundman, 2004; Krippendorff, 2004), as in this study of the care provided to Finnish immigrants with dementia in the Finnish-speaking care unit. This sub-study is part of a research project which explored how Finnish culture was expressed in bilingual residential dementia care.

The setting

This Finnish-speaking care unit was situated in a larger Swedish-speaking care home consisting of several care units. The Finnish-speaking care unit had rooms for 10-12 residents with dementia and had Finnish/Swedish-speaking nursing staff. The residents had their own small one-room apartments with a small kitchenette and bathroom. These were furnished with the residents’ own furniture and decorations. The common areas consisted of a large living room furnished for meals as well as it was a place for socializing. There was a kitchen where the meals were prepared and sometimes cooked. Otherwise the meals were cooked in the central kitchen of the whole care home. The interior decorations in the day/living room were Finnish pictures, a calendar with weekdays in Finnish and Finnish artworks. On a bookshelf, there were Finnish books, newspapers, music CD: s and old Finnish films available for the residents. By the time of the data collection of this study, there were 11 Finnish residents aged 70-90 years. he residents showed symptoms of middle or advanced stage of dementia. All, except one or two could eat by themselves, the two residents who could not eat by themselves were fed by the nursing staff or family members.

Participants

The 18 professional caregivers and family members were chosen by purposive sampling and consisted of 10 enrolled nurses and eight family members. The family members were spouses, daughters and sons and the nursing staff consisted of registered nurses, enrolled nurses and a nurse aid (table 1). All the nursing staff, aged 20-58 years, had emigrated from Finland to Sweden in the 1970s. The enrolled nurses had a two-year education and the nurse aid 20 weeks. The nursing staff had worked in this care unit for several years. The participating family members were fluent in Swedish and Finnish and visited their spouse/parent with dementia with various frequency depending on the geographical distance to the care unit.

Table 1. Participants

Data collection

After having got permission from the operations manager to conduct the study, the participants received written information and thereafter they were called to give additional information about the study. The interviews were conducted individually with the participants at a quiet place in the care unit. The interview questions were based on a semi-structured interview guide, with questions like: What is Finnish culture in this care unit? How is it expressed? Can you give examples of what kind of food you serve here? When and how? By using semi-structured questions, the participants were encouraged to talk freely and not being limited to structured responses. The interviews were audio-recorded and lasted approximately 45 minutes. All, except one interview was conducted in Swedish. One interview was conducted in Finnish by the author of this study who speaks both Finnish and Swedish.

Analysis

The interview material was transcribed verbatim and analyzed using qualitative content analysis. The analysis method is a widely used method to analyze interview data in nursing research. The analysis here was done on a descriptive level, meaning working with the text based on what is clearly spoken in the text (Graneheim & Lundman, 2004; Krippendorff, 2004). After having read through the interviews several times to get a sense of the whole content. The next step was to identify sentences in the interview text related to the aim of the study, i.e. meaning units. A meaning unit consists of a part of a sentence, a whole sentence or several sentences related to the aim of the study. The step thereafter implied condensation, i.e. removing unnecessary words, but keeping the core content of the meaning unit. In the next step, the condensed meaning unit was labelled with a code and the next step implied categorization of coded meaning units based on commonalities and differences in the content of the meaning units. The final categorization was done in several steps and on different levels of abstraction which finally emerged into main categories with respective sub-categories. In the analysis of this study, two main categories were identified: meals stimulating the appetite and meals as a cultural reminder with respective sub-categories: Traditional food for physical well-being/ Food for memory, Food associated with cultural holidays/ Finnish dishes rekindling identity, which are presented in the findings section.

Ethical considerations

Oral and written information was given to the participants about the study and that all participation was voluntary and that they could withdraw from the study any time without having to explain the reason. The participants were informed that the interview material would be kept confidential and the material stored in a secure place not being available to anyone who was not been working with the study. To ensure confidentiality the real names of the participants would be changed into fictive names so that no participant could be identified. The participants also signed an informed consent. The study was approved by the ethical committee at Linköping University, Sweden (Dnr 02-053).

Findings

The food culture in the Finnish-speaking dementia unit was in fact both Swedish and Finnish in the sense that Swedish food was prepared in the care home’s main kitchen. Swedish dishes were served during lunches and Finnish dishes at the evening meals. Although the Scandinavian dishes have similarities, it was considered important to serve traditional Finnish foods several times a week. Being served traditional meals which according to the nursing staff were physically and psychologically beneficial for the residents with dementia, and a cultural reminder of the traditions in the country where they came from (table 2).

Table 2. Categories

Meals Stimulating the Appetite

The Finnish-speaking nursing staff were able to observe and compare the differences of when the meals served were Swedish or Finnish food. The food was cooked by the nursing staff at the kitchen in the care unit or it was bought in from a Finnish grocery store nearby. Examples of Finnish dishes served were Finnish sausage soup, macaroni casserole, Karelian Pirogues, and Finnish Rye Bread.

. . . and then we buy Finnish sausage and bread, the traditional Finnish loaf-bred, it’s popular (nursing staff)

Traditional food for physical well-being

The nursing staff had noticed that traditional or familiar food seemed to stimulate the residents’ appetite so that they ate enough and with a good appetite. From a medical point of view, it was considered important that the residents were served dishes that they were familiar with so they should eat with a good appetite and enough to keep a good nutritional status. Enough food would keep the residents in a good health, make them more resistant to infections and pressure-sores. The evening meals often consisted of Finnish traditional food, a bit heavier and filling than the evening meals served in the Swedish-speaking units in the same care home according to nursing staff and family members. An explanation was that there were many hours between the evening meal and next day´s breakfast and that no one should have sleeping problems caused by hunger.

We prepare a somewhat more filling food for the evening since so many hours will pass before they get to eat their breakfast, and we have noticed that when they get proper, nourishing food, they have no pressure-sores (nursing staff)

Mother eats better and more when she gets Finnish foods . . . . I sense that she prefers that which she use to eat… Finnish food, it is more like at home (daughter)

The nursing staff had observed that when the residents did not like the food, they played with it, ate slower or needed support with their meal. As a contrast it was also noticed that some of the residents were more prone to eat independently and could function more adequately from their physical abilities when they were served traditional food or food that they really liked.

There was this lady that always complained about her bad teeth and that she could not eat the hard-bread, but one day when she was given Finnish Rye Bread, she ate it all, yes it was all consumed, even the bread-crust! (nursing staff).

Not only the particular dish itself was important, but also the social interactions during the meals. Most of the time the residents were eating all meals together, while the nursing staff first served the food to the residents and then sat down to eat together with them. Even though the conversations between nursing staff and residents were short and mainly focused on the food, the residents were able to respond, either verbally or non-verbally, as they understood the questions in their own language. It also happened that family members of the residents brought something to eat and had a meal or coffee together with the residents, which stimulated the residents to function from a more adequate capacity.

……yes we have a lady here, she is now over 90 years of age and some years ago when her children from the south of Sweden came to visit her, we sat down at the round table [in the day-room] and had a meal together or coffee, they always bring coffee and pastry….so then she was able to eat so neatly with knife and fork and all, but otherwise she might not even eat at all on her own….she probably sensed that it was something special….

Some of the participants had problems swallowing the food and even if the food had to be run through the food-processor and looked unappetizing, the taste and smell might still be there, and perhaps giving a familiar taste experience according to the nursing staff.

Finnish foods were also considered trigger memories according to family members and nursing staff.

Food for Memory

The residents with an advanced stage of dementia, were often unable to communicate verbally and had moments of enlightenment where they seemed to take in impressions and conversations, only these moments did not last for too long. Family members reported that, residents being served food triggered memories and moments of enlightenment:

….when we, 14 of us, sat at the kitchen table at Christmas, she commented that, and I thought all of us brightened up when Mom said…- It is Christmas Eve!...but then when we left the table, it was just as if it was not Christmas any more, but it was at that instant when she saw the Christmas food…a light came on (daughter)

Birthday celebrations could also trigger memories as each resident´s birthday was celebrated with a cake, flowers and singing according to the nursing staff. It was considered important and meaningful to give special attention to the birthday person and a way of making the resident visible and feeling appreciated.

..Yes, when they have their birthday we all celebrate, on the day when someone has a birthday we go and buy a flower or something else, and birthday cake...then we sit down together and try [to celebrate] as best as we can (the nursing staff)

Traditional Meals as Cultural Reminders

Holidays or festive food traditions were mentioned by all participants, not as much as how holidays were celebrated, as what kind of traditional food were served on each holiday. Although Swedish and Finnish food traditions have similarities, the differences between Finland and Sweden seemed to come to the participants´ mind easily. Experiences from the war was another strong reminder of the Finnish cultural identity.

Traditional food was associated with cultural holidays

Responses to what Finnish food culture is, was strongly related to food traditions on holidays, like Christmas, Easter and Midsummer.

Everyone may have their personal food preferences even when it comes to holiday celebrations, but special foods served during these festivities seemed to be strongly rooted in the national culture and traditions:

They [the residents] remember this…if we talk about Christmas…it is the Christmas ham, turnip casserole, carrot casserole, she remembers all this…it is very important to stimulate that part too (daughter)

Yes, then we ate carrot casserole and Karelian pirogues for Christmas….and mämmi¹ for Easter! (nursing staff)

Finnish dishes rekindling cultural identity

The Finnish National Holiday, the 6^th of December, was mentioned as an important day since many had experienced the War. The Finnish National Holiday was celebrated with Coffee, Cake and the presence of the Finnish flag and was considered enhancing a feeling of belonging and cultural identity.

Yes, we bought a cake, and we laid the table extra nice and sat down at a long table. We have several persons that endured the Second World War and they appreciate it when there is some special occasion (nursing staff).

Discussion

In exploring the food culture in this Finnish dementia care unit, there was much focus on the kind of traditional foods that were served. The nursing staff who had daily encounters with the residents could notice and reflect on the benefits of having Finnish food more clearly as the family members who did not make daily visits to the care unit. But, as family members they could contribute with information about a residents’ personal food preferences, which also is important to consider in serving meals, as one can never take for granted that all traditional food is preferred by everyone. All interviewed nursing staff however agreed to that serving traditional Finnish meals were well-liked by the residents and beneficial from various aspects, first and foremost from health aspects, but also from psychological and cultural aspects. The focus on health aspects of traditional meals, is probably a natural reflection considering the characters of caring, i.e. to prevent disease and particularly in this study, malnutrition, and to give good care in order to maintain a good health status (Swenurse, 2017). The risk of developing malnutrition in persons with dementia is well-known and has been described in several studies (Di-Maria Galilli & Amella, 2005; Stockdell & Amella, 2008; World Alzheimer Report, 2014; Westergren, Unosson, Ohlsson, Lorefalt, & Hallberg, 2002), as well as strategies to prevent malnutrition (Alzheimer’s Disease International, 2914). Some of these strategies were used in this care unit. By serving traditional Finnish food, the residents’ appetite was stimulated, and they seemed to prefer that kind of food, because it was something that they were familiar with and liked. The meals were also served in a homelike atmosphere in the sense that the unit was small-scale, but also with decorations that reminded the Finnish residents of their home country, Finland. This is consistent with the studies by Chaudhury, Hung & Badger (2013), and McDaniel, Hunt, Hackes & Pope, (2001), which pointed to the importance of a positive homelike atmosphere when dining. Also, the findings of this study, indicated that even though the conversations during mealtimes were somewhat sparse, there were social interactions when the residents and nursing staff had the meal together. The conversations between the nursing staff and the residents were in the residents’ native language and therefore understood by both, which could have contributed to a good food intake. From a health perspective those strategies seemed to have contributed to keep the residents in a good nutritional status and health according to the nursing staff, who claimed that there were no pressure sores, which can be one of the consequences of malnutrition.

Even though, there was much focus on food for nutritional and health reasons, other aspects, such as tastes, smells and appearance of traditional food were mentioned as triggers of memories in the Finnish residents with dementia. Memories of their home country and even memories strong enough to motivate the person with dementia to eat by themselves or behave in an adequate way at the dining table, when they did not do that otherwise. The study by Hanssen and Muene Kuven (2015), exploring Sami, Norwegian and African residents with dementia reported similar findings, that traditional food awakened memories in the residents, and they spoke words, that they did not normally do.

Other aspects of serving traditional food were related to culture and identity. Being in a Finnish-speaking dementia care unit in a Swedish care home one would think that language and communication should be good enough care, but the Finnish-speaking nursing staff went further. They made efforts in trying to keep some of the Finnish traditions alive, as they had realized and observed that by providing the residents with e.g. traditional food not only on normal weekdays, but also on festive and national holidays was a reminder of their home country bringing the residents back to their roots, cultural background and identity. This is consistent with earlier studies, showing that meals have an important role in shaping a cultural identity (Lam & Keller, 2015; Sidenvall, 1999). If dementia is seen as a state of homelessness (Norberg, Ternestedt & Lundman, 2017; Zingmark, Norberg & Sandman, 1993), due to the fragmentation of the effected person’s personality, this homelessness needs to be countered on several levels; to the sense of self, the people in the environment and the objects or the social context in which they are cared for. In the Finnish unit of this study there were cultural features which could be viewed as an interface which helped the residents to relate to their roots and cultural background and in their kind of home-less state, enhance their sense of at-homeness.

Limitations

This study was explorative to its nature as there are not many studies conducted on meals and meal situations for immigrants with dementia. More studies on the subject are needed. A limitation of this study is that the residents´ with dementia perspective is missing. The Finnish immigrants however were in an advanced stage in their condition and it would have been difficult interviewing them. Observations of persons with dementia can add to further aspects of the meal situations. As the aim of this study was to explore the perspectives of the nursing staff and the family members, it was considered enough to answer the research question.

Conclusions

In conclusion, the Finnish persons with dementia in this study were fortunate in being surrounded by Finnish cultural expressions, where they were being served traditional Finnish meals. There were also nursing staff willing and able to prepare it. Traditional foods were beneficial from several aspects, for nutritional and health reasons, as well as psychological and cultural reasons. As for an immigrant person with dementia experiencing a state of homelessness, traditional meals were a reminder of their cultural roots, identity and contributed to enhance their sense of at-homeness. Since this study showed that traditional food to immigrants with dementia was important from several different aspects, health and elder care need to consider the importance of the diet in order to maintain a good quality of care as well as an equal care.

References