Demographics of the participants

A total of twenty-four participants (sixteen females and eight males) ranging from 21 to 80 years of age were interviewed (Table 1). Sixteen participants were first-generation Pakistani immigrants, and eight were second-generation immigrants. More than half of the participants were females. The mean age of 1st generation participants was 50 years and 29 years for the 2nd generation participants, respectively. All the 1st generation participants were married. Two 2nd generation participants were married, and others were single (n = 6). All participants were living with their families in Norway. Less than half of the participants were retired. Others were self-employed or students. Diabetes (n = 5), digestive problems (n = 8), and cardiovascular problems (n = 6) were the most frequently reported health complaints by the participants. The number of different TM modalities used by the participants ranged from 6 to 27, with a mean of 14 different TM modalities per participant. Table 1 shows the participants’ demographic data and the types of TM modalities they used.

Table 1 Demographic data of the participantsThemes

The analysis of the interviews revealed three main themes: (a) House of Knowledge, (b) Choosing the best possible approach for health restoration, and (c) Adverse effects of TM use. We divided these themes into six sub-themes (see Table 2 for the Overview of themes and sub-themes). We did not recognize any pattern of differences between the views of 1st and 2nd generation immigrants.

Table 2 Overview of themes and subthemesHouse of knowledge

Under this theme, we explained the participants’ extensive knowledge of TM for specific illnesses. We gained insight into the use of TM while living in a family system and how family influenced TM use. We explored the importance and role of family in sickness and cure.

Influence of family in TM use

Most participants talked about the importance of family in the lives of immigrants when they were sick and how the family influenced their TM use. All the participants lived with their families in Norway and shared that the source of knowledge regarding TM is their home (mothers and grandmothers). Some of the participants expressed that the Pakistani family system influenced their lives in Norway. For instance, one participant (F16) explained it this way: The family system is very strong in Pakistan. If you live in a family, you learn these things automatically. They used to apply these things [TM] to you and your siblings, and their parents did the same with them. So, when you live in such a society, you learn these things from your family life. This quote explains how living with and observing the family helped the participants learn about TM. The participants’ belief in the healing power of TM and these learned behaviors reinforced the notion that TM could benefit their health because of living with the family. A second-generation participant (F23) who was a frequent user of TM with various health complaints stated: It is because of the environment we have at home. I was also always observing my parents, and they just took Paracetamol as a last resort. They always tried to recover their body using natural things. This explains how the family environment transferred one generation’s beliefs regarding TM to another.

There were also participants who mentioned that discussing with family members is essential when they experience mental or physical health complaints and deciding on TM to be used. A participant (F3) stated: As a family first, I take suggestions from my wife that I have this problem and ask what I should do now. So, I take her suggestions; whatever she recommends, like some medicine or any remedy, herb, kawa, then I take it. Another participant (F1) who received family care in the past stated: My family helped me so much during this time [with schizophrenia]. Everyone took great care of me at home and behaved very well with me. So, it shows how living with the family and family care provided physical, emotional, and mental support in illness. Some participants also stated that they always contacted their mothers when they experienced a health complaint because they were sure their mothers would suggest a remedy for every problem. F17 explained: I call my mother, and then, of course, she would bring out a remedy. So, trust in the family and receiving their help and solutions seemed important, even for adults. It shows the connection with the family, family care, and dependence on the traditional knowledge of the family to recover from the health complaints.

Knowledge about TM for specific illnesses

Participants shared their extensive knowledge about TM and how they use it for specific illnesses. The information they shared included common names of TM, preparation methods, dosage, adverse effects, and lifestyle advice. We identified 96 different TM modalities used for 44 different health complaints. Most reported TM modalities were medicinal plants, animal products, and food items, but the participants also reported using some minerals, ritual remedies, and commercial herbal preparations (Table 2). Generally, the women and participants with chronic illnesses used more TM modalities than the men and other participants. Table 3 shows TM used for various health complaints and the participant-reported adverse effects of TM. An extended list with more information about TM, including traditional names, English names, scientific names, preparation methods, dosage, adverse effects, and lifestyle advice, is available as supplementary material (additional file 1: Table 4).

Table 3 TM used for specific health complaints and participant-reported adverse effects of TM usedChoosing the best possible approach for health restoration

Throughout this theme, the participants described how they chose the best possible option for restoring health while living in Norway and what factors govern this decision. They explained how living in Norway influenced their attitudes and behaviors toward health-seeking. Three subthemes were identified under this theme: health-seeking behavior for restoring health, reasons for using TM, and the exchange of health practices between Pakistan and Norway.

Health-seeking behavior for restoring health

We identified different health-seeking behaviors of the participants for restoring health in illness and their beliefs behind these behaviors. Many of the participants reported using both TM and conventional medicines to recover from health complaints. The decision about which modalities to use could depend on factors such as their belief in TM, the nature and severity of the illness, access to the healthcare system, the response from the healthcare providers, and the availability of TM at home. They also expressed that using TM was their first approach to any health complaint. However, two of the participants (F23, F20) stated that the approach they used to manage the illness depended on their problem. In addition, a couple of participants (F1, F13) mentioned that their first approach was using conventional medicines. Some participants suffering from chronic diseases expressed the importance of taking conventional medicines to maintain their quality of life.

A few participants preferred to use TM for minor illnesses but usually visited the conventional doctor in case of serious diseases. Various reasons were identified for this health-seeking behavior. Some participants believed that TM could cure the problem entirely with few adverse effects rather than eliminate the symptoms. F19 explained that keeping it natural positively helps your body because painkillers can have negative effects. What it [painkillers] can do is that the problem will be there, but your pain will not be there. But the problem can still be there, if you know what I mean. So, it depicts a strong belief in the healing power of TM. Some participants (F20, F21) used TM because of the Islamic faith that Allah created natural things that are better to use. It included the fact that the food items specified in the Quran and Hadees (teachings of the prophet) can cure the illness. A female respondent (F21) said: It’s more related to my belief in Islam, and I want to use the natural things which God gave us instead of all these chemically produced things [conventional medicine].

Another reason for using TM was the belief that the long-term use of conventional medicines is not suitable for the body. One of the participants (F14) managed her problem of chronic constipation through diet changes and household remedies because she found it better to avoid conventional medicine prescribed by her doctor. The difficulty in assessing the healthcare services in Norway was another reason for the preference for TM in illness. A female informant (F2) said: I have a lot of these things [TM] at home because here [in Norway], it is very difficult to reach the doctor when you are sick. As they have a very long procedure, first you have to talk to the doctor, and then he will give you an appointment. Others preferred TM due to the low probability of getting conventional medicines from the healthcare system compared to Pakistan. All the participants who had children under five years of age reported frequent use of TM for their children, and they believed that it helped them. A worried mother (F15) of three small children who frequently suffered from seasonal allergies and infections stated: The doctor just gave her [child] paracetamol because there is no other medicine like cough syrup for a child in Norway who is under two years of age. Apart from paracetamol, the remedy I use is adding black pepper powder or nutmeg to honey and mace powder to honey and giving it to her. These quotes depict that barriers in assessing the Norwegian healthcare services contributed to using TM for themselves and their families.

Some participants (F13, F1) also preferred to use conventional medicines as a first choice, even for minor health complaints, as they wanted quick relief. In addition, some participants reported using conventional over-the-counter medications before accessing the Norwegian healthcare system and in the waiting time to see the doctor. F15 stated: I always want a quick solution. I always start with paracetamol for me and my daughter. I don’t visit the doctor immediately when the problem starts. The participants (F16, F5) revealed they were using more conventional medicines after migration because of the lack of TM in Norway. Regarding this, the participant (F16) stated: In Norway, it is difficult to get those things from which we do the remedies in Pakistan. So, I didn’t do anything. In short, although TM was the first choice to treat illness for most participants, several combined this with conventional medicine or entirely used conventional medicines due to the lack of availability of TM in Norway.

Reasons for using TM

We identified that the participants used TM often in combination with conventional medicine to manage acute and mild health complaints, chronic problems, adverse effects of conventional medicines, and undiagnosed health complaints. Participants reported using different herbal remedies, food items, and commercial herbal preparations for acute and mild health complaints such as flu, seasonal allergies, and gastrointestinal problems. Several participants (F15, F4, F23, F8, F14) mentioned that they preferred TM for minor complaints because the doctors in Norway usually don’t prescribe any medication for minor complaints (cold and viral infections).

The participants (F4, F6, F7, F2, F3) also expressed that they combined TM with conventional medicine for chronic conditions such as diabetes, arthritis, and cardiovascular problems. For instance (F2): Sometimes it happens, and you are taking medicine, but your sugar level is still not under control. Then, in this case, I use black cumin and fenugreek seeds, mix them in the water, and drink them. It makes the sugar level better. Another participant (F6) mentioned using TM to control her blood pressure after taking conventional medicines. She stated: I used to drink cold drinks after adding ice and psyllium husk to them. It lowers my blood pressure, and I also keep the seeds of black cardamom in my mouth. It is very effective.

Some participants (F10, F11, F4, F3) reported using TM to manage chronic problems after experiencing adverse effects of conventional medicines. A participant (F10) had gastric problems due to extensive use of conventional medicines, so she started using TM (turmeric and seeds drinks). She (F10) found that TM could improve her quality of life: That [turmeric drink] is so soothing, and I sleep like a baby, and I wake up without crying like a baby because it relieves my pain. Another participant (F11) mentioned that she didn’t use conventional medicines because they make her drowsy, while another one (F4) avoided them to sleep peacefully.

Two participants used TM to manage autoimmune diseases because they knew that conventional medicines couldn’t cure their problem, so they preferred to use various home remedies and ritual remedies to manage their condition. F5 reported using TM to treat stomach problems that his doctor was unable to diagnose after multiple medical tests. He stated: I had very severe burning in my stomach, and they (doctors) always said that everything was fine. But then my sister told me to add psyllium husk to milk at night and to drink it in the morning. I used it for just one week, and I don’t have any problem now after 30 years. These data demonstrate the extensive dependence of first and second-generation participants on TM use in various types of health complaints.

Exchange of health practices between Pakistan and Norway

Participants reported the exchange of TM, conventional medicines, food items, and knowledge regarding health and TM between Pakistan and Norway. Some participants developed medical practices that were a mix of traditional and conventional medical practices. It was also expressed that they learned how to take care of their health through diet, exercise, and hygiene while living in Norway, and they continued practicing this when they visited Pakistan. For instance, a participant (F19) avoided eating in restaurants in Pakistan because of hygiene problems. Another participant (F21) continued eating in restaurants in Pakistan after eating raw red onion (quercetin: anti-bacterial) before eating anything else. She reported that she never got sick from food after she started this practice. It shows how the participants practiced their new (Norwegian) and traditional (Pakistani) knowledge of health for their well-being.

Participants (F8, F15, S2, F6, F3, F24) contacted herbalists and traditional healers in Pakistan while living in Norway through some family member or when visiting Pakistan due to family recommendations and the belief in TM. Some participants searched for remedies on the internet when they experienced some health complaints (F10, F14, F2, F24). Participants also reported bringing TM from Pakistan, Sweden (F4), and Turkey (F5, S2) because they were not available in Norway. Others took conventional medicines (F9, F10) and food items from Norway (F7) to Pakistan, doubting the quality of medicines in Pakistan. Some participants (F10, F1) reported that the medicines available in Pakistan are not “first-class medicines.” A participant (F1) with chronic illness explained it: It means true and false. In Pakistan, false medicines (author’s comment: low quality) are very common and have fewer effects. A participant (F7) who has been living in Norway for 35 years and has a gluten allergy always brings gluten-free flour to Pakistan as he can’t eat the flour available in Pakistan. These data depict how the exchange of TM and health practices between Pakistan and Norway occurred at different levels and contributed to practicing the best approach to health restoration.

Adverse effects of TM use

Under this theme, we explored the participants’ knowledge, experiences, and beliefs regarding the adverse effects of TM. Most of the participants were unaware of the adverse effects of TM and seemed confident that it could never happen. Few participants (F14, F21, F22) experienced minor adverse effects from honey, ginger, salt, and turmeric, such as an unpleasant taste or odor, bloating, and irritation (Table 3). However, one participant (F1) reported serious adverse effects. He experienced renal failure because of using TM recommended by a healer in Pakistan. He said that a religious healer advised him to eat sugar. He continued: It harmed me significantly, so I was close to the death point many times. He also reported a negative interaction of TM with conventional medicines in this way. It happened that they (TM) lowered my sugar level so much. My doctor told me this is the problem with these remedies and that other medicines also stopped working after using them. It depicts participants’ experiences regarding the adverse effects of TM and drug-herb interaction.

After experiencing adverse effects of TM, some participants (F1, F14) stopped using them, while others continued using the TM after changing their method of use and preparation. F14 stopped using honey and lemon because of the warm effect of honey on the body. She stated: By a warm effect, I mean that you feel a burning in your stomach. A participant (F21) had skin burns because of using concentrated lavender oil. She continued using it after mixing it with another oil. Two participants (F10, F4) reported allergic reactions (sore throat, breathing problems, and watery eyes) after eating almonds and figs. They continued using them after soaking the almonds and figs in water overnight and eating small portions of such food items as recommended by their healers. It led to no allergic reactions, according to the participants. It shows that participants had their ways of managing adverse effects, and many participants who experienced adverse effects continued using them despite experiencing these harms.

Some participants (F16, F12) were concerned about the adverse effects of TM before use. They used Google to search the pros and cons of TM, but none reported using scientific sources for this purpose. One participant (F12), the mother of two children, mentioned that she used to search on Google for remedies that were considered safe for her children. She believed that because of this counterchecking, her children never experienced any adverse effects of TM.

Participants believe that natural is always safe and effective

Most participants considered TM safe because they believed “Natural is always safe.” They said they never experienced any adverse effects of TM because of their natural origin and lack of chemicals. F11 argued: Because these are all natural things, they don’t have any adverse effects. Another participant (F5) said: These things don’t have any adverse effects. They don’t have any chemicals, and chemicals are responsible for the adverse effects. Because of a firm belief in TM’s healing power and effectiveness, most participants shared that they did not countercheck the information about TM before using it. A female participant (F15) shared that she didn’t seek information before using TM because of her beliefs. She stated: Because these are remedies that have been used in our houses for centuries, we firmly believe they are correct. It shows that participants’ information-seeking before using TM was dependent on the patient’s beliefs regarding the safety of TM. These beliefs and perceptions may be understood as indirect risks of TM modalities.