Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination?

Figures & data

Table 1. Composition of focus groups.

Focus group	N	Gender	Ethnic background	Age group	Educational level	Duration of stay in the Netherlands
1	5	Female	Turkish-Dutch	Range 53–71 (M = 61; SD = 7.8)	4 Lower, 0 intermediate, 1 higher	Range 16–37 (M = 27.80; SD = 9.2)
2	6	Male	Turkish-Dutch	Range 55–75 (M = 65.67; SD = 7.6)	2 Lower, 3 intermediate, 1 higher	Range 38–45 (M = 40.50; SD = 2.4)
3	5	Female	Turkish-Dutch	Range 43–52 (M = 47.40; SD = 4.3)	1 Lower, 3 intermediate, 1 higher	Range 25–33 (M = 29.40; SD = 3.4)
4	6	Male	Turkish-Dutch	Range 48–56 (M = 51.83; SD = 3.5)	2 Lower, 3 intermediate 1 higher	Range 25–35 (M = 31.75; SD = 4.6)
5	6	Female	Dutch	Range 66–90 (M = 78; SD = 8.3)	3 Lower, 3 intermediate 0 higher
6	5	Male	Dutch	Range 55–74 (M = 64.60; SD = 8.8)	0 Lower, 5 intermediate, 0 higher
7	6	Female	Dutch	Range 46–53 (M = 50.33; SD = 2.4)	0 Lower, 4 intermediate, 2 higher
8	7	Male	Dutch	Range 45–49 (M = 46.71; SD = 1.7)	0 Lower, 6 intermediate, 1 higher

Table 2. Perceptions of barriers of patient participation among indigenous dutch and Turkish-dutch participants.

Main theme	Perceptions of barriers	Description of barriers	Sample quotes indigenous Dutch patients	Sample quotes Turkish-Dutch patients
1. Enabling factors	Language proficiency	Barrier to participate because of low Dutch language proficiency	Not applicable	“In Dutch, I’m able to point to for instance my kidney or something else and then say that it hurts. But I can’t be more specific than that.” (Older Turkish female) “I find it difficult [explaining the health problem], because I don’t speak the language.” (Older Turkish female) “If I would go without an interpreter, then I would only be able to say pain.” (Older Turkish male)
	Communication style	Barrier to participate because of differences in preferred communication style between patient and GP: direct and to the point versus indirect and implicit	“I can ask everything you know. Everything.” (Older Dutch female) “When you finish your story and he gives you those pills or whatever, then you’re done right?” (Older Dutch female) “I just tell [the GP] what is the matter, and then I start talking.” (Older Dutch female). M: “I understand that nobody has problems [with expressing complaints]?” P1: “No, I don’t.” P2: “No.” (Older Dutch females) “I can say everything to him [GP].” (Older Dutch female) P1: “Well, the GP appreciates her [other patient] for it. An elderly that is so assertive.” P2: “Well, I do forgot things sometimes.” P3: “But you have become as assertive as can be!” (Older Dutch females) M: “What is needed to do so? To take up an active role [during doctor-patient communication]?” P1: Well, that you are assertive and take the initiative.” (Older Dutch male) M: “So, you can stand up well for yourselves?” P1: “ Yes, I uhm..I ehm can do so…at the GP.” P2: “Certainly.” M: “…” P3: “But we are quite assertive.” (Laughs) (Younger Dutch females) P1: “If you are not sufficiently quick-witted, you will receive less quality care than someone who is quick-witted.” P2: “Yeah, that’s true.” P3: “Yes, that’s true […]” (Dutch younger males) “If I don’t understand, I will continue to ask questions.” (Dutch younger male).	“When I have a good conversation with my GP, I do not have any worries anymore. Perhaps it is because of the good conversation that we feel better; it diminishes the stress. I have a beautiful day that day.” (Older Turkish female) P1: “Some people can, although they do not speak the [other’s] language.. P2: ..by just gesturing.. P1: ..still communicate.” (Older Turkish females) “The doctor’s assistants are not very kind to us. They ask a lot of questions. Why are you calling? What do you want?” (Older Turkish female) “My doctor laughs a lot. […]. He is very kind.” (Older Turkish female) “They [Turkish-Dutch patients] rather choose a female doctor. Why? They look more friendly, and they give you more time.” (Older Turkish male) “A Turkish doctor is able to satisfy a patient with words only. A Dutch doctor focuses on stress or pain killers.” (Younger Turkish female) “A doctor should not be like a remote control, from a distance asking where does it hurt, I’ll write you this or that, and then bye. That’s unacceptable.” (Younger Turkish male) “He [GP] could have asked his question in a different manner.[…]. He could have asked by grabbing his [patient in film fragment] arm and moving it to find out whether it hurts and what kind of pain it was..he could have understood.., but the GP did not not bother.” (Younger Turkish male). “I am worried about my health, and there is no end to his questions! I think he [doctor’s assistant] puts a list before him: do you have this, do you have that?” [Younger Turkish male)
2. Predisposing factors	Individualism/ Collectivism	Barrier to participate because of different cultural values: individualistic (Dutch) versus collective goals (Turkish), independence versus strong relationships	“When something needs to be done… Well no problem of course. In most cases, I decide for myself what I prefer anyway.” (Older Dutch female) “Being a bit assertive is pretty good.” (Older Dutch female). M: “How would you describe the relation with your GP?” P1: “Good.” P2: “Business like.” P3: “Yes.” M: “Business like?” P2: Yes. P4: “Yes.” P1: Yeah, ehm..” P2: “ And also uhm..not like friends or something.” (Older Dutch males).	“Sometimes he [former doctor] said some Turkish words, he let us feel he was close to us. When you left his room, you left it with a smile.” (Older Turkish male) “You just feel better [with her Turkish dentist]. How are you? Yeah, how is the little one and your husband, and so on. It is like visiting an acquaintance, something like that…And with my GP, I don’t have that.” (Younger Turkish female) “I think ten minutes for an appointment is just minimal, it’s no good. The doctor cannot really know his patient this way.” (Younger Turkish female) M: “How should a GP behave towards you? P1: Like family.” (Younger Turkish male)
	Power distance	Barrier to participate because of different values regarding distance to GP: low (Dutch) versus high (Turkish)	“But that person is being overruled by her doctor. And, she does not have a good doctor. And I think that.. I think that that is uhm wrong.” (Older Dutch female) “I remember that I used to have a tremendous amount of respect for my GP. Yes, that is, of course, a long time ago [laughing].” (Older Dutch female) “Some people think well the doctor knows best. Right, cause I’m sick and that man is going to make me better. Well, I don’t have that, that’s… no, never had it.” (Older Dutch male)	“In the end he is a doctor. He has studied for it. Ultimately uhm…he sees ill people every day. He has more knowledge. How can I say ‘no’ to the doctor? I accept everything he says.” (Older Turkish female) “My daughter was sick and the doctor asked what she wanted and what the doctor should do. Then my daughter answered if I knew what to do and what you should do I wouldn’t be here, then I would look for a solution myself!” (Older Turkish male) “ If there is something the matter with me, he [the doctor] has to find out what it is.” (Younger Turkish female)
	Uncertainty avoidance	Barrier to participate because of different values regarding dealing with tolerance for uncertainty and ambiguity: low (Dutch) versus high (Turkish)	“Before you visit the doctor, then it’s been a couple of days or sometimes weeks and also with the children, you first go along with it for a while to see what happens and ..uhm try to solve it yourself.” (Younger Dutch female)	“Go home today and come back tomorrow. When you use this medicine it will disappear, over and over again. Why don’t you give me what’s really necessary in the first place?” (Younger Turkish male)
3. Physicians’ responses	Perceived discrimination	Barrier because of feelings of being treated differently because of ethnic/linguistic background	“When I visit [the GP] with my [health] complaints, then I am being listened to, I am taken seriously…” (Dutch younger female) “I don’t visit [the GP] often, but when I go, I am taken seriously…” (Dutch younger female) “When I am with him or her [GP], I feel that I am being taken seriously.” (Younger Dutch male) “He [GP] pays attention.” (Younger Dutch male)	“They [GPs] will not refer you to the hospital if you cannot express yourself well enough.” (Older Turkish female) “Hidden or open…everywhere in the Netherlands or in other countries, there is discrimination.” (Older Turkish male). “I feel betrayed here [in the Netherlands]…that is why I do not trust them [doctors]. They use us as guinea pigs…as guinea pigs…that’s how I feel.” (Older Turkish male). “Something has to go seriously wrong first, before they start listening. That is my experience.” (Younger Turkish female). “And ehm..at a certain moment [..] I started to cry and I said: ‘I will not leave until you have referred me [to the hospital].” (Younger Turkish female) “ I do not visit my GP often, but it is always the case that you do not get the answers that you want or uhm…the medication that you want.” (Younger Turkish female). “Is it because I cannot explain my problems or because of the indifference of the GP? He did not take me very seriously.” (Younger Turkish male) “These people [Dutch doctors] did not take us seriously. Maybe because we are foreigners.” (Younger Turkish male)