Specialist Dr. Tevfik Bayram with Prof. Dr. Sibel Sakarya has conducted a scientific study on the access to health services of Kurds and the study was published in the International Journal for Equity in Health.
The title of the study is “Oppression and internalized oppression as an emerging theme in accessing healthcare: findings from a qualitative study assessing first-language related barriers among the Kurds in Turkey”.
Dr. Tevfik Bayram was a guest of Botan Times before the publication of this study and answered Semiha Yildiz’s questions(The program is in Kurdish).
Some parts of the article
We found that Kurds who do not speak the official language face multiple first-language related barriers in accessing healthcare. Poor access to health information, poor patient-provider relationship, delay in seeking health care, dependence on others in accessing healthcare, low adherence to treatments, dissatisfaction with services, and inability to follow health rights were main issues. As an unusual outcome, we discovered that the barrier processes in accessing healthcare are particularly complicated in the context of oppression and its internalization. Internalized oppression, as we found in our study, impairs access to healthcare with creating a sense of reluctance to seek healthcare, and impairs their individual and collective agency to struggle for change.
Perception of needs and desire for care
We found that the participants had limited information about their health conditions and healthcare system, for example: whether they need to see a doctor or not; and when and whom they should visit. They reported their main source of health information as their social circles (mainly relatives, majority of whom also have low education and limited comprehension of Turkish). They stated that they are generally not able to ask questions to their healthcare providers. In cases where they have a Kurdish family physician or nurse, they sometimes visit Family Health Centers to ask questions from them.
“If I don’t ask someone, I don’t know [what specialist I should visit] and I don’t know who [specialist] is where. (RW51)”. If they [the doctors] are Kurdish… For instance, the one [family physician] here is Kurdish, like you and me, I go and ask him. (RW51)” “Everybody goes to him. Even those who have no problems go and ask something. (RW33)”.
Healthcare seeking and reaching
Most of the participants stated that they have never visited a doctor on their own. And those who visited health care services generally did it when their health condition became serious. They described a dependence on a trustworthy Turkish-speaking person (generally a relative) to accompany them. However, they stated that their relatives are not always available, and even if they are available, especially for the participants who have chronic conditions, they don’t feel comfortable calling them regularly.
“I have never been to a doctor on my own. I haven’t been able to do that (RW49)”. “Once I went on my own, but I came back the way I went (UM68)”.
“If they [my kids] are home [I can ask them to accompany me]. But I feel guilty when my son misses a class because of me. I am their mother but still… (UW66)”.
“Last year I went to the doctor. He put me in that closed cabinet [MRI machine]. I waited for the results for one year. I waited until my grand-daughter [who is a university student in another city] returned home… If I could do it by myself, I would visit the doctor 1-2 times in a month. (UM68)”.
We also found that they are not able to make an appointment and again are dependent on a Turkish-speaking person. After the appointment, they still need a person to complete their registration at the health facility and take them to the doctor’s/nurse’s office or diagnostic test rooms.
“It is very hard. They will ask you to take a blood test or a tomography… If someone is not with you, you will just go back and forth. (RW49)”.
At this stage, we also found a pattern of behavior that went beyond language and rooted in internalized oppression. In response to the question about the use of emergency services, most of the participants stated that they woudln’t call (or haven’t called) an ambulance, not only because they couldn’t speak Turkish, but because they had a low self-worth for the service.
“The other day I had excruicating pain in my kidneys. I asked my son to call his uncle to rush me to the hospital (RW51)”.
“I don’t speak Turkish, it [ambulance] would never even come to my mind. (RM60).” “And why would I bother an ambulance in the middle of the night. (RM62).” “Why would an ambulance come for me, such a poor guy.(RM67)”.
Health care utilization
We found that the communication between patients and healthcare providers is done through an interpreter who is generally a relative and also has a limited comprehension of Turkish. There is a (perceived) loss of information between patient and provider through the interpreter. There are also sensitive issues that are not discussed because of the presence of the interpreter.
“I go with my daughter. If she is not with me I will never go, even if I die here… (UM68)”. “[The doctor] asks the person [interpreter], he then asks me and I tell him… I am not comfortable with that at all. You don’t know if he [the interpreter] said everything as you explained or not. And sometimes there are things that you can’t say. [RW51].” “For instance you have pain in your private parts, you can’t say it. [Normally] you would say it to your doctor, there is no shame with the doctor, but you are ashamed when your children or your neighbor is there. (RM60).” “I would prefer a person who I don’t know [personally]… (UW37).”
We found that the participants are not able to build a dialogue with health care providers. The patient-provider relationship is generally a ‘monologue’, rather than a ‘dialogue’. Based on the experience of our participants, it appears that they are almost exclusively ‘receivers’ of transmitted information, rather than being an active part of discussion or treatment decisions. We found that this type of patient-provider relationship is not only related to language, but also internalized oppression. When the participants talked about their experiences with doctors; while with Turkish doctors their general mood was discomfort, shyness, silence, and strict compliance; with Kurdish doctors it was comfort, confidence, chattiness, non-compliance (negotiation) and a sense of humor. Therefore, they preferred health providers who speak Kurdish.
“When it’s your language, it is like eating on your own. But when it is not your language, it is like being fed with a spoon by someone else” (UM59).
“I have no relationship with them [doctors], nothing. (UM68)” “Once he [the doctor] gave me a pill, it was red. After taking two pills I felt dizzy. So I stopped taking it. The next time I went to him I didn’t mention it. (RM67).” “If it was in my own language, I would say everything that was on my mind. I would say hey Mr. or Mrs. Doctor, look I have this and this. (RM60).” “For instance, our family physician is Kurdish, whenever I go he would say ‘hey uncle! Welcome! Is your blood pressure high again?’ I would say yes of course… [laughing] [describing a conversation with a sense of humor] (RM67).
Another indicator of oppression and its internalization at this stage was the reluctance of Kurdish-speaking health professionals to speak Kurdish with their patients. RW51 mentioned that some health professionals, despite being able to speak Kurdish, don’t speak Kurdish with them.
Health care consequences
One of the common consequence of the language barrier was that the participants often postpone or cancel their treatments. They also have low adherence to treatmet and regular check-ups (particularly those who have chronic conditions).
“If I don’t feel very bad I don’t go to doctors (RW49)”.
“It would be nice to know what medication [prescribed] is for what problem. I don’t know what it is for and what is inside it. I just take it, even if it would be poisonous. (RW51).” “Sometimes you take a pill, and you feel worse [adverse effects], you don’t know what to do. Sometimes you tell [your doctor], but most of the time you don’t. (RW51)”.
Another consequence of language barrier was the inability to pursue health rights. Moreover, the participants were using a self-directing tone for not being able to pursue their health rights which indicates internalized oppression. The main pattern of speech was: “I wish I could speak Turkish” rather than “I wish the services were provided in my language”.
“Once a car hit my daughter, they took her to the hospital. I went there and the police called me. They blamed my daughter. I couldn’t say anything. I was saying [to myself], ah ah, I wish I could speak Turkish! Then you would see who is guilty and who is innocent. But you can’t claim your rights, they do whatever they want. (UM63)”.
In regard to stigma and discrimination, the majority of the participants stated that they haven’t experienced it. Most of them supported the general idea that “all doctors want to treat their patients”. However, some participants said, on some occasions they felt ‘devaluated’ because of not speaking Turkish. Consequently, this has led to the emotions of feeling sorry for themselves, anger or guiltiness. We posit that this perceived feeling of being devaluated is an indicator of internalized oppression.
“I haven’t directly experienced [stigmatization or discrimination]… but they [doctors] probably think why these people are so illiterate. (RW51).” “Because I don’t speak Turkish, they would consider themselves superior, they would say [internally] ‘look at this, he doesn’t speak Turkish, he can’t even reply to my questions’, and then I would feel sorry for myself. (UM68)”. “I wish I could talk to them on my own. This [not being able to communicate with doctors] makes me angry. (RW49)”. “I hate myself, I want to explode. (UM59).”
Another language related consequence was when the patients are referred to other cities for their treatments, they lose their social support, and feel more desperate.
“Cizre [a district in the province] is ours, it’s our language, I can talk with someone, I can see someone who I know of. (RM60).” “In Diyarbakir [a neighboring metropolitan city], we suffered a lot. I would go to the parks [in the area] and cry until our appointment time. (UW66)”.