Introduction
One of the top priorities of the United Nations Sustainable Development Goals 2030 is to reduce inequalities within and between countries for disadvantaged populations. The basis of this goal is the necessity of accepting health as the most basic human right, regardless of the gender, race, religion, social class and political orientation of the individual (1). Despite all regulations in the world and Turkey, it is reported that especially women who migrate experience barriers to accessing this right. When these barriers to accessing the service are evaluated holistically, the individual characteristics of asylum seekers, the health system, health policies, the geographical location of the country, and cultural social factors and discrimination are emphasized (2). Studies trying to explain migration from the perspective of asylum seeking women benefiting from health services have focused on asylum seeking women’s health problems, prenatal and postnatal care experiences, migration experiences and the effects of migration on women’s health (3,4).Studies on the effects of migration on women’s health focused on maternal health and emphasized that the access of pregnant women who migrated to antenatal care was often delayed (5,6). Additionally, these studies focused on the negative experiences of asylum seeking women during their pregnancy (7,8).
When evaluated in terms of health care providers to asylum seeking women, it is quite difficult to provide adequate and culturally appropriate gynecological and obstetric health care services to minority ethnic groups. In order to overcome this difficulty, it is imperative to examine and understand the views of health professionals on the care of asylum seeking women. So far, research in this perspective has focused on the barriers healthcare professionals face in providing services. These obstacles are; inability to coordinate care, cope with cultural diversity, and communication barriers (9-11). Studies generally focused on communication barriers, were carried out with a single group of health professionals or were carried out in a descriptive design. However, a multidisciplinary perspective and qualitative design are very important in revealing the experiences of health professionals holistically.
This study aimed to describe the experiences of healthcare professionals providing women’s health services to asylum seeking women. The results of the study, which examines the experience of providing women’s health to asylum-seeking women from a multidisciplinary perspective, present the process not only in terms of obstacles, but also in a broader framework. It is thought that it will contribute to the development of women’s health services, especially in the regions where refugee women live and in the hospitals they are admitted to.
Methods
Study Design, Participants, and Setting
This study aimed to phenomenologically describe the working experiences of doctors, nurses, and midwives health care for asylum seeking women through a qualitative design. A snowball sampling method was used. The inclusion criteria for this study were (a) being a nurse, a midwife, or obstetricians and gynecologists working on the frontline, (b) providing women’s health care services to asylum seeking women and working at obstetric and gynecology service and delivery room (c) having more than six months of experience. Other healthcare professionals who had less than six months of experience were excluded. Following the literature for phenomenological studies, the absence of new information in the interviews was accepted as an indicator of data saturation (12). The study was completed with 34 healthcare professionals (12 nurses, 15 midwives, and 7 physicians). This study was carried out in four state hospitals, each with a capacity of 150 beds, located in the border districts of Şanlıurfa, where temporary accommodation centers were located, and a training and research hospital with 500 beds in the city center.
Ethical Considerations
Approval was obtained from the Istanbul University Social Sciences and Humanities Research Ethics Committee to conduct the study (date: 26.06.2018, number: 66934). The participants were provided with necessary explanations about the study (objective, content, and the data obtained would be used only within the context of this study; they had the right to leave the study). Consent was obtained from the participants who agreed to participate in the study. The participants were given a number, and data confidentiality and anonymity were ensured. The data obtained from the interviews were kept in encrypted files that only the researchers could access. This study was carried out in line with the Declaration of Helsinki, 1964.
Interview Guide
Following the objective and question of this study, a semi-structured interview guide, which was prepared with support from the literature, was used (3,13,14). Two experts on qualitative research methods evaluated the interview guide, and the questions were tested with two pilot interviews. The required revisions were made following expert views and pilot interviews, and the interview guide was finalized (Table 1).
Data Collection
The semi-structured, face-to-face and individual in-depth interview methods were used to collect data. The first participant who met the inclusion criteria in the study was reached by contacting the managers of hospitals and the other potential participants were determined in line with snowball sampling.The participants were informed about the study’s aim, scope, and process. Interview time and place were determined by the participants who agreed to participate in the study. The first researcher conducted the interviews, and each was recorded with a voice recorder with the participant’s consent. The duration of the interviews varied between 32 and 53 minutes (41 minutes on average). In this study, data collection and analysis processes were conducted in parallel, and a codebook was created to help determine the time to reach data saturation. In the 34th interview of the study, it was decided that data saturation was reached. There weren’t repeat interviews carried out. The interviews were carried out between January 2019 and April 2019. All researchers on the research team were academics in nursing and had Ph.D. degrees, and they were female.
Statistical Analysis
In analyzing the data obtained from the study, Nvivo 12 software package and (15) Colaizzi’s seven-step method (1978) were used (Table 2). Within the scope of trustworthiness, this study tried to meet four criteria: credibility, transferability, dependability, and confirmability (16). In this context, the NVivo12 software package used to analyze the data ensured credibility. The researchers discussed the confirmation of the participants, the process of the research through frequent meetings, and the inclusion of the qualifications of the researchers in the text. The research sample, environment, and process were presented clearly and precisely to ensure transferability. Statements of the participants were directly quoted in the text. For reliability, the researchers created the codes and themes using Colaizzi’s seven-step method (15). An expert outside the research evaluated the consistency between the researchers and the suitability of codes and themes, and the results were validated. Different researchers coded data to ensure confirmability. Lastly, the consolidated criteria for reporting qualitative research checklist was followed in reporting (17).
Results
In the study group, 30 of the 34 healthcare professionals were females, and their ages varied between 23 and 48. Twelve participants were nurses, 15 were midwives, and 7 were obstetricians and gynecologists. While the participants’ experiences in their current institution varied between 6 months and 11 years, their total experience varied between 6 months and 30 years. Thirteen of the participants were married. All participants worked in the gynecology/obstetric units (Table 3).
As a result of data analysis, reached the three main themes: (1) Challenges, (2) reflections, and (3) needs. Table 4 shows each theme’s sub-themes, codes, and example quotations.
Discussion
The experience of caring for asylum seeking women is full of uncertainties and obstacles. The risk of experiencing these problems will continue due to rapid changes in world dynamics and forced migration movements. This study aimed to describe the working experiences of doctors, nurses, and midwives in health care for asylum seeking women through a qualitative design.
Discussion section is presented by discussing under each theme.
Challenges
According to the participants, the physical structure of the hospital they worked in and the equipment when providing women’s healthcare services to asylum seeking women was insufficient. The participants emphasized that they had problems, especially with the delivery room, operating room, inpatient units, blood bank, and neonatal intensive care unit, and beds were insufficient for the patients referred to the hospital. Another study conducted in Turkey stated that almost half of the healthcare services in public hospitals in cities close to the Syrian border experienced capacity problems in terms of physical conditions and healthcare professionals because of the services provided to asylum seekers (18). Other causes of the problems are that most asylum seekers ignore the chain of referrals and refer to hospitals by skipping primary healthcare centers due to insufficient resources, equipment, and beds (19). Asylum seekers receiving health services in Sweden, on the other hand, expressed their dissatisfaction with emergency services (20). This information can be considered as an indication that hospitals are not ready for the dense population of asylum seeking patients with different health backgrounds.
The participants emphasized negative working conditions as an essential source of problems experienced when providing women’s healthcare services to asylum seekers. Especially, nurse and midwife participants reported that they worked more than normal working hours, experienced a lack of healthcare professionals, and could not maintain their professional development during this process. Following these results, different studies also showed that after Syrian asylum seekers came there was an increase in patient circulation, lack of nurses and increase working hours, and a decrease in the time allocated to patients (18,21). In a similar study, physicians working in areas with too many asylum seekers stated that professional development training, career, and promotion opportunities were insufficient and they tended to leave the region in which they worked (22).
The participants described the women’s healthcare services they provided to asylum seekers women as unsafe healthcare and treatment. The participants emphasized that patient and employee safety were not provided with the effect of an unsafe healthcare service environment when providing women’s healthcare services to asylum seekers women. Also, in terms of patient safety, they stated that experiencing problems while getting information for anamnesis and informed consent due to the insufficiency of translator services caused problems in making the correct diagnosis, applying, and completing effective care treatment.
Participants stated that they had difficulty in getting information for anamnesis and had problems obtaining informed consent for cesarean section and hysterectomy operations. In a study with similar findings, problems were experienced in receiving informed consent from patients who would undergo an operation or interventional procedures (23). Lastly, the participants reported that asylum seeking women referred to institutions using the identities of other women, and this situation was a significant threat to patient safety. According to the literature, the lack of identity numbers and identity impersonation to get medication by many patients create suspicion in healthcare professionals (23). The demand for identity information correctness gives healthcare professionals the responsibility of bureaucratic procedures such as checking identities (24). In addition to its adverse impacts on patient safety, it can be said that this situation is reflected in the relationship between the patient and the healthcare professionals, with healthcare professionals losing their confidence in patients.
Regarding employee safety, the participants stated that they were afraid of being exposed to violence and that there was a risk of infectious diseases since they did not know the patients’ anamnesis. In the literature, violent behaviors against healthcare professionals have been closely associated with communication with patients and their relatives and the language barrier (14). Another issue the participants mentioned relating to their safety was that they were at risk since asylum seekers had infectious diseases frequently, but since they could not learn their anamnesis, the diagnosis of these diseases made after the intervention put them at risk. In the literature, the infectious diseases of asylum seekers who experience migration under negative conditions and struggle for their lives under unsuitable conditions are among the situations that scare the host country most (25).
Reflections
While the participants described their experiences in providing healthcare services to individuals from different languages and cultures as unhealthy communication with translators, they also stated that they felt insufficient and unsafe. Similarly, in a study conducted on nurses providing care to asylum seeking women, nurses stated that they felt insufficient (21). In a study that examined the difficulties experienced by healthcare professionals providing women’s healthcare services to pregnant women with different languages and cultures, it was concluded that healthcare professionals felt insufficient since they could not communicate with women (26).
While the participants stated that they experienced different emotions when providing service to asylum seeking women, they described these emotions as astonishment, sadness, anxiety, and despair towards different practices and beliefs of women. However, they emphasized that their emotions did not affect their service. In their study, Dias et al. (27) found that healthcare professionals had positive emotions and attitudes toward asylum seekers, while Zhou et al. (28) expressed that the negative emotions nurses developed for asylum seeking patients were due to workload and communication problems. In a study conducted in Iran, nurses stated that they felt hopeless, anxious, and fearful while providing care to patients from different cultures (29).
Lastly, the participants stated that providing healthcare services to asylum seekers contributed positively and negatively. The participants mostly evaluated dealing with patients from a different society as positive in terms of having increased self-confidence, gaining experience in managing crises and patients, and getting rid of biases. In contrast, they evaluated the fatigue and burnout created by negative working conditions, getting impatient with people, and having decreased tolerance as negative. Following these results, it was found in the literature that nurses working in regions where Syrian asylum seekers lived intensely had increased self-confidence, acted more patient and careful, were cautious and courageous, had increased awareness about creativity, and cared about different patients during this process (21). According to the results of studies that focused on the negative impacts of this experience, it was found that nurses and midwives who lived in an area where Syrian asylum seekers lived intensely had higher burnout levels (22,30).
Needs
Participants stated that they needed to effectively provide women’s healthcare services to women from different cultures. First, they thought that it was essential to ensure their individual motivation and that this could not be achieved only with financial motivation sources. Many factors such as political, economic, social, cultural, and technological factors affect the motivation of health workers. However, most work motivation theories focus on micro factors (31). These reflections are also seen in practice. However, it is necessary to determine health professionals’ working conditions and focus on these conditions and motivation factors specific to individuals.
They expressed their education and training needs that would enrich the transcultural health service provision professionally. Studies continue to make these training programs compulsory in disciplines such as business administration, medicine, and nursing.
The name and content of intercultural courses in medicine and nursing undergraduate programs in Turkey differ, and there is no standardization (32,33). The situation in the world is no different. It was found that intercultural nursing course was compulsory in only 31.6% of nursing programs in Korea (34). It has been reported that medical curricula in Europe are culturally inadequate and that the programs do not evolve in line with the increasing migration (35). It is recommended that the barriers, strengths, weaknesses, and opportunities associated with the different cultures that health professionals serve are determined by SWOT analysis. In other words, what is the process in practice besides the theoretical information? Answering the question is of vital importance.
Finally, they mentioned that the importance of working as a multidisciplinary team in addition to their individual and professional needs and stated that the presence of a professional translator in this team was vital. In the literature, the most difficulties are experienced in the process of giving care to patients from different cultures (36). Aygün et al. (37) stated that physicians providing healthcare services to asylum seekers were unsure whether translators could tell the problems correctly and to what extent they could translate the recommendations and treatment they gave. It is thought that translations not made by professionals are not generally accurate, symptoms are not explained correctly, and essential details are skipped (38). In a different study, it was emphasized that the lack of professional translators, healthcare professionals not having language education, and language barriers when providing health services to asylum seekers were obstacles to patient rights including reproductive rights (39). Patients from different cultures create uncertainty and anxiety for healthcare professionals. Although the presence of an interpreter is considered the gold standard in ensuring intercultural communication, it should not be forgotten that the essential point is health communication. Linguistic and cultural knowledge alone is not sufficient to decide an individual’s situation. While it has been suggested that individual efforts cannot overcome language barriers, professional steps should be taken by including the parties receiving and providing service. Also, it is advocated that the presence of effective translators will provide a correct medical interaction, thereby contributing to patient outputs (40,41).
Study Limitations
The data were collected with in-depth interviews, which limited the findings to the expressions of the participants. The majority of the study participants were females (n=30); only four males were recruited for this study. Thus, the experience of the males may not have been adequately explored in this study.
Conclusion
This study narrows the gap in the literature and expands the scope of existing knowledge concerning the healthcare professionals’ experience with asylum-seeking women’s health care. The results obtained in the study were collected under three themes (1) challenges, (2) reflections, (3) needs. Our results revealed that many factors, especially the language barrier, cultural differences, and ignorance, affected the effectiveness of these services. In addition to the effectiveness of the service provided, the meanings attributed by health professionals to their experiences during this process differ. In conclusion, it was found that the healthcare professionals thought providing healthcare to individuals with different languages and cultures created inadequacy and professional insecurity, they experienced adaptation problems during the whole process, and they had problems with the physical structure and equipment of the hospital they worked in, they worked under negative working conditions, they evaluated the whole process as an unsafe healthcare and treatment service process, they thought the host country was not ready to provide healthcare services to patients with different language and cultures. They stated they should be supported personally, professionally, and as a health team in improving this experience. Our results may help health institutions, managers and policymakers understand healthcare professionals’ challenges, emotions, needs and also determine strategies for improving healthcare delivery.
Ethics
Ethics Committee Approval: Approval was obtained from the Istanbul University Social Sciences and Humanities Research Ethics Committee to conduct the study (date: 26.06.2018, number: 66934).
Informed Consent: The participants were provided with necessary explanations about the study (objective, content, and the data obtained would be used only within the context of this study; they had the right to leave the study).
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: G.T.Ü., Ü.B., Design: G.T.Ü., Ü.B., Data Collection or Processing: G.T.Ü., Analysis or Interpretation: G.T.Ü., Ü.B., Literature Search: G.T.Ü., Writing: G.T.Ü.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.