Perceptions about Iranian-Kurds’ ethnic-inequality in health

Based on the different existing ethnicities, each country has its own specific ethnic classification criteria, which bring about difficulties when conducting studies related to this particular variable [1]. In recent years ethnicity has been under the spotlight as an aspect of social health and numerous articles have been published in this regard [2].

Some ethnic groups around the world have inferior health compared to other groups [3]. Ethnic-inequality in health is a situation where people from different ethnicities that share similar needs, receive unequal health care benefits and / or have higher morbidity and mortality rates which are not fair and can be avoided [4]. In both developed and developing countries, many minority groups receive lower income [1, 3], while also having inappropriate working conditions and live in environmentally and economically poorer areas with high dense populations [5]. Ethnic discrimination is a one of the causes for stress in these people’s lives which in turn also affects their health. This problem has been given much more attention during recent years [6, 7].

With a population of close to 80 billion, Iran has a vast ethnic variety [8]. Social aspects such as educational needs [9‐11], marital patterns [11, 12], and gender inequality [13, 14] in different ethnicities have been given more attention in recent years.

Iran’s Kurdistan province is in the west and shares borders with Iraq. Figure 1 shows the Kurds’ habitats that are mostly living in the 4 countries of Iran, Iraq, Turkey and Syria. Kurdistan of Iran is of the less developed among the provinces with the lowest life expectancy rates [15] and human development index after Sistan and Baluchistan in south east [16]. The ethnic Kurd in Iran has almost two main sub-ethnic groups namely Sourani and Ourami.

Based on reviewing available studies, it can be concluded that the social aspects of ethnicities in Iran have been given more attention than health. Considering mass migration and changes in ethnic groups’ interactions in the modern era, the question is that do ethnicities still affect the health of the population? On the other hand, the perception of inequality is of significant importance regardless of the actual differences (whether they exist or not). Thus, knowing how people perceive ethnic inequality and its effect on their health is crucial.

Considering the ethnic diversity in Iran and the significant importance of the Kurd ethnicity, this study was conducted to understand the people’s perspectives about Iranian-Kurds’ ethnic-inequality in health and examines its determinants.

This study was conducted in the 3 cities of Marivan, Sanandaj and Tehran during 2011–12. These cities have different variety of ethnic compositions and subsequently varied sensitivity to ethnicity. Marivan is in the Iran’s Kudistan located on the Iran-Iraq border. This city population consists of Sourani and Ourami, equally. So, the issue of difference between the two sub-ethnic groups has importance in this city. The majority of Sanandaj’s (the capital of Kurdistan province) population is Sourani. Here, the differentiation is between Kurds and non-Kurds. Tehran, the capital of the country, has drawn many Iranian ethnicities to itself and caused them to intermingle. The later city was chosen because it is where Kurds, as an ethnic minority group, live among a population with diverse ethnic mixes. In summary, in Marivan sub-ethnicities of one ethnic group, in Sanandaj Kurd ethnicity as a majority group and in Tehran Kurd ethnicity as a minority group were investigated.

This qualitative study was conducted using in-depth interviews and Focus Group Discussions (FGDs): 17 in-depth interviews and 5 FGDs in Marivan; 7 in-depth interviews and 2 FGDs in Sanandaj; 10 in-depth interviews and 3 FGDs in Tehran. In total, 34 in-depth interviews and 10 FGDs were conducted that are shown in Table 1. Purposeful sampling with maximum variation was applied to choose participants continuing the point of data saturation. The interviews were conducted in 3 separate groups of health delivery service personnel (HDSP), academic graduates (AG) and finally, healthcare services users (HSUs).

The HDSP were chosen from the district health centers and one urban healthcare center in every city studied. In the formation of every FGDs, it was noted that all of the participants verbally confirmed their consent. An effort was made in all the three groups to interview both men and women of different socio-economic classes.

In case the number of interviewees reached the required minimum for a focus group discussion and provided they gave their consent to participate, the group discussion was conducted.

The interview was conducted using a questionnaire guide designed by an expert in the field of the given research with the aid of two qualitative study researchers. Interviewers were the researcher that has enough knowledge about the implementation of the study. Discussions’ guide for in-depth interviews and FGDs were developed according to the target groups (AGs, HSUs and HDSP) and the status of each city including language. It was pretested beofer the field work. The following issues were discussed and questioned from the interviewees: to what extent study subjects consider ethnicity in their identity; the effects of ethnicity on health; health inequality among various ethnic groups and the reasons behind it. The interviews were audio-recorded and transcribed verbatim.

Thematic analysis was used to analyze the data using the ‘Opencode’ software. Relevant codes and categories were extracted. The context of each interview was first considered as a whole, and then the general or fundamental meaning of the context was explained in one or more clauses. Primary codes and categories were designed and after numerous analyses, those that repeated were merged. Furthermore, to verify the study’s, two individuals coded the interviews. Finally, the codes were modified, merged and or removed by two other individuals.

An introductory question was asked in the FGDs: “how would you introduce yourself?”. The purpose of this question was to discover the significance of ethnicity in persons’ identity. Among the participants from AGs and HSUs in all three cities, seldom someone introduces her/him-self through their ethnicity. Only one person in Marivan addressed herself as a Kurd among ten interviews held with the HDSP, while most others spoke about their family, social matters and employment.

Since the main objectives of the study were recognizing the perception of people regarding health inequalities in Kurds and its determinant factors, the results section is accordingly divided to two parts of the participants’ views on health inequality and then the determinant factors. While presenting the study’s results, in addition to the explanations, certain quotes given by the interviewees along with the geographical location of study and group have been included in italic fonts.

The present study’s findings show, based on perception of the study subjects, there is no concern on inequality of physical health, different points of view exist regarding mental and social health, but there is a common belief about AHS inequalities.

The first point is that practically no one mentioned her / his ethnicity during the briefings. This could be because of the lack of ethnic differentiation. The ethnic-inequality in lifestyle, which is a risk factor for health in different dimensions, was clearly pointed out. In other parts of the results, inequalities is in due to various social and cultural characteristics; the effects of tradition, hygiene and nutrition were mentioned which can be the source inequality in life style as well. Other studies on health inequalities on cardiovascular diseases, diabetes, asthma and cancer found social determinants as the most prominent reason behind these differences [17‐19].

Although there was no general consensus on mental and social health inequalities, but the fact remains that they were given more attention. But some believe that the state of mental health for the Kurds to be unsatisfying. One study shows the rate of violence against women to be significant in Marivan [20]. According to a National Health Survey, the prevalence of mental illnesses in individuals older than 15 years of age in Kurdistan was 21.8%, ranking 13th among 30 provinces [15].

The present study shows that what people perceived is inequality in AHS. This inequality is obviously associated with health outcomes and affects the ethnic groups’ sense of prejudice and dissatisfaction of healthcare services [21, 22]. This perception of inequality can be classified into 3 groups: A) Problems and issues that cause an actual perception of deprivation backed by logical aspects. For example, the participants pointed out the AHS inequalities between Kurdistan and neighboring provinces. B) Although certain inequalities exist, some of them are not due to the public sectors’ mismanagement. For example, the absence of a private hospital is associated with the lack of private sector interest. C) A number of demands that are not realistic and may be considered false; for example, some expect high-tech medical facilities to be set up in small cities, which is not rational considering the population size and subsequently the number of patients. After the World Health Organization’s 2008 report on primary health care, equity in affordable HCU was recognized as a significant challenge in the current health systems, for which the ‘universal health coverage’ targets were proposed [23]. The most prominent step in Iran’s health system was the ‘family physician program’ and later on the Health Transformation Plan. This program was yet another solution to the aforementioned problem, designed to increase access to quality health services and backed by a desirable insurance policy [24]. Nevertheless, the rational issues put forth by the people must be taken into careful consideration by the authorities. In order to eliminate the perception of prejudice, people must be informed about the justifiable issues (such as the absence of a private hospital or other irrational demands).

According to the present study’s findings, another reason responsible for health inequalities was the human resources’ lack of interest, physicians in particular, to be in the deprived regions of Iran. Kenneth Wells says, considering the inequalities in health accessibility and uncertain need and quality of mental healthcare, we lay emphasize on the importance of general education, intervention on physicians performances and other HDSP in order to improve the quality and situation of ethnic minorities’ healthcare [8]. By intervening in the country’s healthcare system’s operation in delivering equal services to regions with specific strategic conditions, and paying attention to ethnic differences, the feeling of inequality can be reduced.

In this study, people considered a social network as a socio-cultural characteristic that led to the bondage or support of similar groups. Nazeroo and Karlson have also shown that the formation of social networks in various ethnic groups may lead to interpersonal or organized prejudice, affecting personal health [5].

Another finding in our research was the health inequality existent among various ethnic groups, which is mainly because of the ‘different’ acceptance of new health issues. Lack of information, low level of education, cultural incompatibility between ethnic groups and HDSP and socio-cultural barriers and differences are why new issues are accepted and comprehended differently. Research has shown the relationship between HDSP and patients to be directly related to the patients’ satisfaction, obedience and side effects of their health [25, 26]. As the studies show, when a country has a vast variety of ethnicities and cultures, the HDSP face a range of patients from different ethnic groups, where each have a unique understanding of the health system [19, 27‐29].

In conclusion, this study provides evidence to policymakers, especially those who have concern over UHC, to informed design interventions on AHS and HCU by considering ethnic and sub-ethnic perceptions. The people’s lack of awareness, their undesirable culture regarding the acceptance of health services, poor AHS, the service delivery system’s problems and the unequal distribution of human resources were stated as factors affecting HCU. The perceptions behind inequality and inappropriate AHS were the unsuitable financial status of the province of Kurdistan and also the reputation of political disputes. It seems that ethnic variables should be considered as an essential element of the Iran’s health information system for monitoring health inequality to be used in further interventions.