In this paper, which aims to find out first-language related barriers in accessing healthcare, we found multiple barriers in each stage (perception of HC needs, HC seeking, reaching, utilization); as previously indicated in the literature [1, 2]. For the perception of HC needs and desire for care, access to health information and inadequate health literacy emerged as the main themes [33] Access to health information is an important component of access to healthcare particularly as knowledge to desire for care [33], as well as having more control over decisions about health and well-being [34]. For HC seeking and reaching, postponement of seeking healthcare emerged as the main theme. Particularly, patients with chronic diseases were vulnerable to losing their companions/interpreters due to regular need for healthcare which led to postponement. For HC utilization, decreased effectiveness of utilization emerged as the main theme. Due to the use of interpreters -particularly unprofessional- loss of information and miscommunication emerged as a significant barrier between patient and provider. As a consequence, language barrier was found to be associated with low adherence to treatment and dissatisfaction with services. Most of these findings have been previously discussed in the literature [1,2,3,4]. Contrastly, we found that all these processes become overly complicated in the context of political oppression and its internalization. In the following section we will discuss our findings about how oppression and its internalization complicate language-related access to healthcare.
One of the impacts of internalized oppression was the reluctance to seek healthcare. The paramount example of this was when a participant stated that “why would I bother an ambulance”. The participant did not intend to call an ambulance not only because he couldn’t speak Turkish, but because he thought that he was not worthy of the service. Because in his mind the ambulance belonged to a superior structure that when he called for it, he would be a ‘bother’. This form of self-depreciation is a characteristic of the oppressed populations, mentioned by Paulo Freire, which derives from internalization of the opinion the oppressors holds of them [11].
The pattern of internalized oppression was seen in the patient-provider relationship as well. When talking about their experiences with doctors; with a Turkish doctor, the general mood was discomfort, shyness, silence, and strict compliance; with a Kurdish doctor it was comfort, confidence, chattiness, non-compliance (negotiation) and a sense of humor. A similar pattern of internalized oppression was also seen in the form of discrimination. The main form of discrimination was not explicit discrimination but rather the implicit feeling of being devalued by healthcare providers. We believe that not mentioning explicit discrimination might be due to two reasons. First, explicit discrimination might be happening in rare occasions, second, discrimination might not be reported during the interviews because of the perceived consequences of structural discrimination.
The indicators of internalized oppression were also noticeable throughout the interviews, hidden in the participants’ language. The participants were using a self-directing tone in their answers. The main pattern of speech was: “I wish I could speak Turkish” rather than “I wish healthcare services were provided in my language”. This is a characteristic of the oppressed, mentioned by Freire, in which the oppressed are convinced of their own unfitness to the system [11]. However, this undermines the autonomy and dignity of individuals and communities, which in turn destroys their agency and potential for making change [11, 35,36,37,38]. Because in their mind, the one should change is not the system, but the oppressed themselves [11]. This is against the basic rule of health promotion: enabling people to increase control over and improve their health [39]. Wishing to speak Turkish can also be an ‘adaptive preference’, namely a preference based on the options available [40]. Since Kurdish is not an available option, it makes the participants wish to learn Turkish out of neccesity. Because, in present circumstances, speaking Turkish could be empowering and help individuals navigate the state bureaucracy while making political demands in favor of bilingualism and provision of public services including education and healthcare in their first language.
Another impact of oppression and its internalization was that it voided commonly used coping strategies against language barriers. One of the main coping strategies for dealing with language barriers is ethnic matching [1, 41]. In other words, people who do not speak the official language attempt to find a healthcare provider who speaks their language. In situations where they can find a match, language barrier becomes less pronounced [1, 41]. However, we found that ethnic matches avoid speaking if the language in question is an oppressed language. As one of the participants (RW51) mentioned, some health professionals, despite being able to speak Kurdish, avoided speaking, because of political implications and the devalued status of Kurdish. New studies also show that Kurdish is gradually being less spoken in the public sphere outside the family [18, 19].
Another main strategy to deal with language barriers is the provision of interpretation services. Despite its shortcomings, such as information loss during interpretation, and not being able to share private information with the interpreter [42], it has been a commonly used technique to deal with language barriers [2]. This is again a service that the Kurdish population is deprived of, because of political oppression. Consequently, the Kurdish population who are not provided HC services in their language; are not provided interpretation services; and also who are not able to easily find an ethnic match, are left to their own resources to cope with language barriers in accessing healthcare.
We found that, for our participants, social resources were almost the only resource in accessing healthcare. These social resources were being converted into cultural resources sometimes in the form of health knowledge; sometimes in the form of language skills for interpretation; other times, to economic resources, in case of a financial need to seek healthcare outside the region. These types of contributions of social resources are seen in other populations having similar problems [43]. However, the prominence of utilizing social resources in accessing healthcare in our study is mainly due to their inequitable access to economic and cultural resources which is also rooted in political dynamics. Similar to other populations having language barriers [43], the main social resource the participants mentioned was family members and neighbors rather than collective engaged communities. As such, they are dependent on their weak and fragile resources. Therefore, they can easily lose their resources which significantly interrupts their access to healthcare.
A concrete example of losing social resources is the case of referral to or preferences for (because of dissatisfaction with local HC services) cross-city HC services. This is also related to political dynamics and inequitable distribution of resources and services. The Southeast region of Turkey, which is predominantly Kurdish, has the poorest healthcare infrastructure in the country. For instance, it has the lowest number of nurses, general practitioners, and specialists [3, 44]. Inequitably distributed health equipment/infrastructure, and shortage of healthcare staff and resources have been found in other oppressed populations as well [43]. As a result, people in these regions are regularly referred to other provinces for further investigation of their health conditions and their treatments. This makes people leave their close neighborhoods where their social resources are concentrated and leads to further despair while they search for better health outcomes.
Strengths and limitations
This is the first study that examines how and in what ways first-language affects access to health services for the Kurds in Turkey. Given that the Kurds have been politically oppressed for almost a century, it is an important population that can reveal the effects of oppression on access to healthcare. One of the strengths of the study is also using a patient-centered theoretical framework that assesses both individual and structural dimensions of accessing healthcare.
There are also some limitations of our study. The first one is about sampling. We interviewed a sample of Kurdish-speaking-only people in a geographically determined region. Therefore, our findings may not reflect the experiences of the Kurdish people living in other parts of Turkey. Moreover, although we used a maximum variation strategy in sampling, we reached some participants using snowballing method, therefore it might reflect the opinions of a group sharing similar socioeconomic and political backgrounds. Also, the contribution of women in this study was relatively lower because we couldn’t find a Kurdish-speaking female researcher to interview women. As such, the younger female participants were less communicative during the interviews. Given that gender gender modifies the effect of ethnicity for health behaviors [45], and the rate of illiteracy (consequently not speaking the Turkish) is 1.8 times higher among women than that of men in the Eastern region of Turkey [46], they are probably those who need the most but talked the least (inverse care law). Therefore, conducting further research with a higher contribution of women might add different dimensions (such as intersectionality) to this subject. The second important limitation might be related to interpretation of data. Given that oppression can be in other forms than language or ethnicity (such as race, gender, sexual orientation, socioeconomic status etc.) [29], some findings from this study might be due to other forms of oppression. For instance, we do not know about the experience of Turkish-speaking Kurds in the healthcare system; or the experience of Turks who have similar socioeconomic status as our sample. However, we are convinced that this study provides adequate evidence regarding ethno-linguistic oppression being an independent barrier in accessing healthcare. Therefore, this study point that future research may focus on the other forms of oppression in accessing healthcare. Another prospect for future studies can be conducting a similar study with younger generations who speak Turkish fluently to see ethnicity related health accessibility problems beyond language. Because despite speaking Turkish very well, racial discrimination and otherization regarding Kurdish ethnic background may sustain in a way that speaking Turkish may not buffer the accessibility barriers.