Language, perceived discrimination and barriers to complaint use: sub-Saharan African immigrants' healthcare experiences in Oslo, a qualitative interview study

Universal coverage alone does not ensure equitable healthcare. Racism is consistently associated with poorer healthcare experiences, but not consistently with lower healthcare use. What patients do after an encounter they interpret as discriminatory therefore remains unclear. This study examined how sub-Saharan African immigrants in Oslo interpreted such encounters, how language shaped comprehension and participation, how those experiences related to later service use, and what their accounts indicated about rights and accountability. We interviewed 15 first-generation immigrants from five sub-Saharan African countries, individually and in English, in 2021. Recruitment was purposive and referral-based. We analysed the data using reflexive thematic analysis. A working definition of discrimination was provided before participants described events. Awareness of the Equality and Anti-Discrimination Ombud and Tribunal was prompted rather than spontaneously recalled. We applied candidacy and a right-to-health framework, covering availability, accessibility, acceptability, quality, participation and accountability, abductively after initial theme development. Ten participants reported encounters they interpreted as discriminatory, including dismissive conduct, an explicitly group-based remark, ambiguous double-gloving and inadequate language support. All five contrasting accounts included communication described as adequate in a shared language, which we advance as a tentative linguistic recognition hypothesis rather than as evidence of cause. Inadequate communication affected reported comprehension and participation, and troubling encounters were followed by continued attendance, avoidance or self-medication. When prompted, all participants agreed that discrimination violated human rights. None described making a formal complaint, and their accounts point to five overlapping mechanisms of non-use: anticipated futility, emotional conservation, normalisation, procedural uncertainty and relational risk. Attendance can therefore record clinical need or absent alternatives rather than acceptable care. Healthcare use is an inadequate equity indicator. Complaint mechanisms that go unused generate institutional records showing no problem. Integrating candidacy, a right-to-health framework and the naming, blaming and claiming sequence, the study proposes language accessibility as a testable determinant of recognition, participation and accountability. It does not establish legal violations or causal effects.