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.

BACKGROUND: Language has been well documented to be a key determinant of accessing healthcare. Most of the literature about language barrier in accessing healthcare is in the context of miscommunication. However, it is critical to consider the historical and political contexts and power dynamics underlying actions. The literature in this matter is short. In this paper we aimed to find out how first-language affects access to healthcare for people who do not speak the official language, with a particular focus on language oppression. METHODS: We conducted this qualitative study based on patient-reported experiences of the Kurds in Turkey, which is a century-long oppressed population. We conducted 12 in-depth interviews (all ethnically Kurdish, non-Turkish speaking) in Sirnak, Turkey, in 2018-2019 using maximum variation strategy. We used Levesque's 'Patient-Centred Access to Healthcare' framework which addresses individual and structural dimensions to access. RESULTS: 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. CONCLUSIONS: A human-rights-based top-down policy shift, and a bottom-up community empowerment approach is needed. At the system level, official recognition of oppressed populations, acknowledgement of the determinants of their health; and incorporating their language in official capacities (particularly education and healthcare) is crucial. Interventions should include raising awareness among relevant professions and stakeholders that internalized oppression is an issue in accessing healthcare to be considered. Given that internalized oppression can be in other forms than language or ethnicity, future research aimed at examining other aspects of access to healthcare should pay a special attention to internalized oppression.

Evaluation of Arterial Functions and Carotid Intima Media Thickness in Children During Mid-Term Follow-Up After Kawasaki Disease.

OBJECTIVE: Kawasaki disease (KD) is a multisystemic vasculitis of medium- and small-sized arteries. The involvement of the coronary arteries may lead to long-term cardiovascular sequelae. We studied the elasticity of the aorta and the common carotid artery (CCA), flowmediated dilatation of the brachial artery, and carotid intima media thickness, as well biomarkers such as high-sensitivity C-reactive protein (hs-CRP) and elastin, as useful indicators of cardiovascular risk in patients, following KD. METHODS: The study group consisted of 26 patients with a history of KD, and 26 healthy children. Echocardiography, and carotid and brachial ultrasound studies were performed. Plasma hs- CRP and elastin levels were studied in both groups. RESULTS: The stiffness indices (SI) obtained from the aortic arch, abdominal aorta, and the CCA were increased in the patients, compared to the controls. Distensibility was decreased at the sinus of Valsalva, the sinotubular junction, the aortic arch, and the ascending aorta, compared to the control group. Flow-mediated dilatation (FMD) was lower in the patients than in the controls. The age of the patients had a negative correlation to distensibility of the aortic arch and abdominal aorta, and a positive correlation to the stiffness of the aortic arch. Follow-up duration correlated positively to stiffness of the aortic arch. Carotid intima-media thickness (CIMT), serum hs-CRP, and elastin levels did not differ between the groups. CONCLUSION: Increased aortic and carotid stiffness and decreased aortic distensibility suggest impaired arterial functions following KD. Long-term follow-up and monitorization early in cardiovascular disease is needed.

Experiences With Health Care Services in Switzerland Among Immigrant Women With Chronic Illnesses.

Introduction: Descriptive data indicate a high burden of chronic illness among immigrant women in Switzerland. Little is known about how immigrant women with chronic illnesses experience healthcare services. This paper presents a methodological approach theoretically informed by Sen's capability approach and Levesque's framework of access to healthcare to study patient-reported experiences (PREs) of Swiss healthcare services among immigrant women with chronic conditions. Methods: We conducted 48 semi-structured qualitative interviews in Bern and Geneva with Turkish (n = 12), Portuguese (n = 12), German (n = 12), and Swiss (n = 12) women. Participants were heterogenous in age, length of stay, SES, and educational attainment, illness types and history. We also conducted semi-structured interviews with healthcare and social service providers (n = 12). Interviewed women participated in two focus group discussions (n = 15). Interviews were transcribed verbatim and analyzed using Atlas.ti software, based on Gale et al.'s framework approach. Findings informed three stakeholder dialogues in which women as well as healthcare providers and policymakers from various territorial levels participated. Results: Our methodological approach succeeded in integrating women's perspectives-from initial data collection in interviews to identify issues, focus group discussions to increase rigor, and stakeholder dialogues to develop tailored recommendations based on PREs. Discussion: This is one of the first studies in Switzerland that used PREs to research healthcare services and healthcare needs among immigrant women with chronic illnesses. This paper provides new insights on how to better understand existing challenges and potentially improve access to and quality of care.

Determinants of health behavior inequalities: a cross-sectional study from Israel.

Health behaviors are shaped by the opportunities people have; and the choices they make according to these opportunities. Inequality in economic, cultural and social resources causes disparities in health and health behaviors. Jerusalem has a multiethnic structure, mainly made up of Jews and Arabs. Arabs and Ultra-Orthodox Jews are disadvantaged in terms of socio-economic and health indicators. The purpose of this study is to determine the factors associated with three health behaviors: physical activity (PA), fruit and vegetable consumption, and smoking. This cross-sectional study was conducted among 1682 adults from a stratified sample by age, sex and neighborhood from 2011 to 2015, in accordance with the Healthy Cities project. Univariate analyses were conducted by Chi-square test of independence; and multivariate analyses by logistic regression models. Of the total population, 12% do adequate amounts of PA; 17.6% consume adequate amounts of fruits/vegetables; and 19.4% are current smokers. Multivariate analyses indicates for both genders: ethnicity/religion and education level is associated with doing PA; ethnicity/religion, education and income level is associated with fruit/vegetable consumption; and ethnicity/religion, and age is associated with smoking. However, gender significantly modifies the effect of ethnicity/religion for all the three health behaviors. Gender disparities regarding health behaviors are higher among Arabs and Ultra-Orthodox Jews. In similar economic, cultural and social circumstances, men and women have similar health behaviors; and unequal opportunity to education and income creates a vicious gender inequality cycle. Therefore, to reduce health behavior inequalities, besides economic and cultural inequalities, social and gender inequalities should also be reduced.

A clinical scoring system to predict the development of intraventricular hemorrhage (IVH) in premature infants.

OBJECTiVE: The aim of this study is to develop a scoring system for the prediction of intraventricular hemorrhage (IVH) in preterm infants in the first 7 days of life. METHODS: A prospective, clinical study was conducted in Bahcesehir University, Medical Park Goztepe Hospital Neonatal Intensive Care Unit, with the enrollment of 144 preterm infants with gestational age between 24 and 34 weeks. All preterms were followed up for IVH after birth until the 4th week of life. The demographic characteristics and clinical risk factors were noted. Risk factors were analyzed. The score was established after logistic regression analysis, considering the impact of each variable on the occurrence of IVH within the first 7 days of life. The IVH scores were further applied prospectively to 89 preterm infants as validation cohort. RESULTS: Low gestational age (GA), low Apgar score, and having bleeding diathesis were the most important risk factors for IVH. According to these risk factors, a scoring system was developed for IVH ranged from 0 to 5. According to the risk ratios (RR) obtained from the logistic regression model, low GA (≤ 28 gestational week), presence of bleeding diathesis within 7 days, and low Apgar score increased the risk of IVH (RR = 3.32 for GA ≤ 28 gestational week, RR = 6.7 for presence of bleeding diathesis in 7th day, RR = 3 for having low Apgar score). The score was validated successfully in 89 infants. The area under ROC curve was 0.85 for derivation cohort and 0.807 for validation cohort. The predictive ability of the IVH score for derivation and validation cohort was calculated. The negative predictive values of a score less than 4 were 96.4 and 59.1%. CONCLUSiON: Concerning IVH-related sequelae which continue to be a major public health problem, we have developed a feasible predictive model for evaluating the risk for developing IVH for preterm infants in the first 7 days of life.