Predisposing characteristics
Beliefs about healthcare services
Respondents made a clear distinction between the Turkish and the Dutch healthcare system. None of the respondents were satisfied with the referral system in the Netherlands, because they felt it impeded their access to specialist care. Respondents mentioned this referral system as a motive for seeking healthcare in Turkey, and believed that the Dutch government or health insurance companies pressured the GP to keep costs down by refusing or delaying a referral to which the patient felt entitled. Some respondents then bypassed the system by utilizing healthcare in their country of origin. For example, a patient with a weight-gain problem said the following:
“I don’t think it was assessed properly. Only some diagnostic blood tests, they said the results were good … they’re just GPs, and it’s not easy to get referred to a hospital. That’s why more people from the Netherlands tend to go to Turkish hospitals.” (R03).
Others utilized healthcare in Turkey in addition to their healthcare utilization in the Netherlands. They took the diagnosis to their GP in the Netherlands and asked for a referral to specialist care. Respondents who had previously utilized healthcare in Turkey said their Dutch GP always referred them to a specialist when they gave them the medical information obtained in Turkey. For example, one respondent said the following about his wife:
“She had a herniated disk. They looked at it [in Turkey], took X-rays and 3D scans, and we took them with us. Actually, our main problem in the Netherlands was the waiting time. It can take 6 to 12 months, and in the meantime the pain is still there. So we came here, had the X-rays taken, and showed them to our GP. The GP started treatment immediately and discussed with us what he could do.” (R02).
There was also a group who bypassed or postponed a visit to their GP in the Netherlands because they perceived the GP as being passive, and perceived the seemingly common recommendation to use acetaminophen (a standard over-the-counter painkiller) as a lack of attention. They waited for their complaints to either disappear or worsen, so that the GP would be more likely to take action (i.e., physical examination, medication other than acetaminophen, or referral) or, when it was convenient, they would wait until a planned visit to Turkey. One patient had complaints for two years and had visited her GP only twice, but because acetaminophen had been prescribed, the patient and her family decided to go to Turkey for care.
“When they don’t give you any attention, you don’t feel like going back. You think you're going for nothing, so why go? And they always suggest taking acetaminophen. You can take up to six tablets a day.” (R06).
Respondents had ambiguous views about the GP as the first line of contact with healthcare services. Even though they were dissatisfied at not being referred to specialist care, most respondents praised their own GP and how the first line of care was organized. The respondents saw the GP as vital, and as someone who viewed them holistically—that is, looking not only at their health problems, but also at how they were living and their well-being.
Respondents had mixed feelings about how GP care was organized. One patient appreciated the fact that it was appointment-based, which meant there was no waiting time on the day of the appointment. However, another patient complained about the fact that when she was ill, she could not see the GP immediately but had to make an appointment. One second-generation migrant said the following:
“Making appointments, that’s really great. For example, if we make an appointment with the GP for 9:15 and we arrive at 9:10, there will be a maximum of two people ahead of you— there isn’t much waiting time. Within five minutes the GP comes out, greets you, and takes you to his office. It’s a wonderful thing.” (R08).
The respondents’ beliefs about the Turkish healthcare system were often the opposite of their beliefs about the Dutch healthcare system. Almost all respondents reported that the way in which the healthcare system in the Netherlands was organized was clear and structured, but quite slow with regard to waiting times and referral to specialist care. However, they reported the opposite for the healthcare system in Turkey, where the respondents perceived healthcare as being organized in a way that was neither structured nor standardized. Even so, respondents praised the swift provision of services in private hospitals and direct accessibility of specialist care.
All respondents had a strong preference for private hospitals in Turkey because they perceived state hospitals as being slower at providing services and inferior in terms of quality of care. For example, with regard to the services in a private hospital, a patient with cancer of the biliary system said the following:
“My appointment was on Thursday at 1 p.m. Around 4 or 5 p.m. everything that needed to be done was done. I slept in the hospital that night. The next day, the results slowly started coming in. On Saturday they told me there was a tumour that needed to be surgically removed because it might keep growing. The physician told me to tell my wife the news and after that we could talk again. Then they told me I could have the operation on Wednesday. So, on Wednesday I had the operation. I went to the hospital on Thursday for a check-up, and by the following Wednesday [within 6 days], I already had the operation.” (R10).
Private hospitals have special care pathways for patients insured abroad in which appointments, diagnostics, and insurance forms can be arranged, and which allow the respondents to see the specialist on the same day. The respondents were very appreciative of the hospitality, atmosphere, and swiftness of the care provided in these hospitals.
Beliefs about good care
Beliefs about both healthcare systems and meeting the respondents’ healthcare needs were often mentioned as “defining” good clinical practice. The Turkish healthcare system was closer to the respondents’ beliefs and healthcare needs than the Dutch system, which lead to a preference for the Turkish system. Moreover, some older respondents (who were accustomed to the Dutch healthcare system) said they perceived a decline in quality of care in the Netherlands due to healthcare budget cutbacks, which reinforced this preference. They perceived good care as being admitted to the hospital, whereas nowadays patients are more often seen on an outpatient basis, as expressed by the following respondent:
“In the past, when something happened, they immediately admitted you to the hospital [in the Netherlands]. Now, for example, I call the GP on the nightshift and he doesn’t do anything but write a prescription for acetaminophen.” (R07).
However, respondents were unable to give a clear definition of what type of care they perceived as being good clinical practice. A respondent whose daughter was sick changed his views on good clinical practice depending on which healthcare system met his perceived need for care. He said that a physician who “took action” on your health complaints was perceived as being a better physician. Yet, at the same time he said it would also be better to wait and see, as his Dutch GP generally told him previously:
“In the Netherlands there is a tendency not to give medication when it isn’t needed. I like that, but, in general, Turkish people are used to going to a doctor and getting something. If you don’t get medication, an injection, or a referral to the hospital, a doctor hasn’t examined you properly.” (R05).
Still, the same respondent perceived treatment as being necessary, even though his Dutch GP would not continue the treatment that was given in Turkey:
“We’re giving the medication by injection. We’ve given her two already, and tomorrow will be the last one. They only gave us three syringes instead of five, because we’re going back to the Netherlands tomorrow. The doctor didn’t give us five because when you go back to the Netherlands, the doctors there don’t use this treatment. They will not continue the treatment we were getting in Turkey. So the doctor did not want to give us five syringes for nothing, but gave us three, until the day we go back. The treatment should be continued—you should have all five of them.” (R05).
Another factor, respondents linked to good clinical practice, was the amount of time a doctor invested in a consultation or operation. A physician spending more time on a consultation, was seen as both positive and negative. Some respondents said this was better because it meant additional attention, while others saw it as an indication of lack of experience. However, none of the respondents mentioned experience with a disease or a medical specialist’s reputation as a marker of quality of care.
Enabling resources
The following themes emerged from the interviews as enabling resources: social network, visiting Turkey, health insurance, and waiting times in Turkey. As a predisposing characteristic, the social network influenced respondents’ motives to seek healthcare in Turkey. As an enabling resource, the social network provided assistance as informal caregivers, companions, and/or guides through the healthcare utilization process. One second-generation migrant even stated that without the help of her social network, she would not have utilized healthcare in Turkey:
“I live at my brother’s home in the Netherlands. I couldn’t see myself coming to Turkey and doing this on my own [without his help].” (R06).
Other enabling resources were a planned vacation to Turkey, being insured with a Dutch insurance company that had a contract with the Turkish hospital they visited, and having no waiting times for diagnostic work-ups at the Turkish outpatient clinics. It is important to emphasize that almost all respondents stated that their decision to visit a Turkish hospital was made after arriving in Turkey. Healthcare services utilization in Turkey therefore seems to be opportunistic in nature rather than deliberately planned.