UNIVERSITY OF AMSTERDAM
Nederlandse Gesondheidsorg
vir Suid Afrikaanse
Immigrante
Perceptions of Dutch health care by South African
immigrants, living in the middle and Western part of
The Netherlands
Name: Karlijn van der Reest10/8/2014
Student number: 10495746
Track: Migration and Ethnic Studies First reader: Martha Monteiro-Sieburth Second reader: Patrick Brown
Content
Introduction………3
Purpose of the study and research questions………..6
Operationalization of terms………....9
Background………13
Dutch health care system………...………16
Theoretical framework………..20
Methodology……….31
Findings………36
South African health care system……….52
Discussion and conclusion………54
References………..……62
Appendix A………..…..68
Introduction
The aim of this study was to explore the perceptions of a sample of South African immigrants of the Dutch health care system. The reason for this study was my personal interest in the Dutch health care system and the way this system is reviewed by immigrants. I had access to a group of South African immigrants, so I decided to focus on their perceptions. I focused on their perceptions to be able to grab their personal feelings about the way the immigrants feel they are being treated when using the Dutch health care system. By perceptions I mean the way the South African immigrants evaluate the Dutch health care system and how the immigrants value the health care they receive in The
Netherlands. To be able to study the perceptions of South African immigrants in The Netherlands, I divided my research into three steps.
First, I researched the perceptions and experiences of a selected group of South African immigrants in The Netherlands. I focused on their personal experiences and on the feelings they have developed towards the Dutch health care system since they have moved to The Netherlands. My main focus during this research was the trust they have or have not developed in the Dutch health care system and the way they are being treated when using Dutch health care. When using the term trust related to health care, I am referring to the definition of Calnan and Sanford (2004), who mention that
definitions of trust vary, but “all embody the notion of expectations: expectations by the public that health care providers will demonstrate knowledge, skills and competence; further expectations that they will behave in the patients’ best interest and with beneficence, fairness and integrity”. I chose to use trust, because trust is of main importance in explaining how people feel when using public services (Calnan and Sanford, 2004).
using health care in South Africa with the feelings they have developed about the way they are being treated in The Netherlands. I chose to make this comparison because previous experiences influence current perceptions (Gray, 2007). This is due to culture, habits and beliefs (Gray, 2007). In this study, this would mean that the experiences of the South African immigrants in South African health care influence the way they perceive the Dutch health care system. Besides, the comparison between their treatment in South Africa and their treatment in The Netherlands can explain possible feelings of discrimination and incomprehension.
Thirdly, I performed three interviews with professionals working in different fields in the Dutch health care system, to find out how they perceive the Dutch health care system from the inside. Besides, I interviewed them about their experiences with serving immigrants in general and South African immigrants particularly. I used these interviews to be able to present a perspective from another point of view. Since these interviewees are professionals working in the Dutch health care system and have their personal experiences with immigrants as well, it was relevant to include them in my study (Harvey, 2011).
When I selected my sample, I tried to select an as diverse group as possible. I kept in mind that South Africa is a diverse country, with people of diverse backgrounds and cultures (Cejas, 2007). This diversity can lead to differences in perceptions and opinions about the Dutch health care system (Gray, 2007). It was important to me that in my sample, the main populations of South Africa were represented, as well as people from different economic and educational backgrounds. Because of the small sample I used, this was difficult to achieve, but I managed to find a varied group with people of different color, originating from different parts of South Africa and with different economic and educational backgrounds.
After interviewing my respondents, I analyzed the data and tried to find overarching themes that explained the opinions of my respondents. I analyzed the interviews I performed with the experts as well and took themes from these interviews to find out more about the professional opinions about Dutch health care. I combined these themes with my literature research, in order to develop
conclusions from my research. I described the entire process in the paper below.
The main goal of this study was to bring a deeper understanding of how South African immigrants in the Netherlands experience the Dutch health care system, the barriers they notice and the trust in Dutch health care they perceive. The purpose of this study was fourfold.
1. To identify the health care services that South African immigrants in the Netherlands access and what their experiences are in terms of the advantages and barriers they face.
2. To describe the processes South African immigrants in the Netherlands go through in accessing health care and the responses they receive from doctors and other health care professionals, particularly in terms of trust factors.
3. To interpret the experiences of South African immigrants in the Netherlands in the light of what it shows about health care and trust.
4. To consider what these experiences can reflect about the Dutch health care system.
My interest in this topic was both personal and academic. Having lived in South Africa for half a year myself, I noticed the major differences that exist in the country and started to wonder how this could change. Besides, I am convinced that health care is one of the most important pillars of a country. When thinking about a topic for my thesis, I decided to combine these interests and start a research about the way South Africans in the Netherlands perceive Dutch health care. The way people, whether they are residents of a country or immigrants, are being treated in the health care system of a country, can tell a lot about the way a country deals with its inhabitants. I would like to find out whether South Africans in the Netherlands are experiencing health care here in the same way as they do in South Africa. Of major importance in this research will be whether there are noticeable differences between different racial and ethnic groups in the way they are being treated in Dutch health care. Since I am studying in the Migration and Ethnic Studies track, I aim to contribute to the
already existing knowledge about Dutch health care for immigrants.
The research questions guiding this study are:
1. Among South African immigrants in the Netherlands, what is known about the Dutch health care system?
A. What processes do South African immigrants in the Netherlands use to obtain information about Dutch health care?
B. What are some of their assumptions and perceptions of Dutch health care?
C. What are their reported experiences in accessing and using Dutch health care?
D. What do health care providers state about their experiences with South African immigrants regarding their health care?
2. What are the cultural issues that are raised by South African immigrants in accessing health care? How important are they in determining what care they get and how they evaluate it?
A. What do South African immigrants understand about Dutch cultural issues and what role does this understanding play in their using medical services?
B. What do healthcare professionals understand of South African culture and do they speak about it in their delivery of services?
3. What are the reasons given by the immigrants to explain their feelings of trust and concern by the Dutch health care system?
A. What does trust mean in a health care context?
B. What prior experiences regarding trust of health care have they had, and from where? C. For how long and to what extent have they used their prior experiences to access health care in the Netherlands and how have they been received or rejected?
D. What have been their experiences regarding misunderstanding or discrimination in using Dutch healthcare? How have these been overcome or not?
Operationalization of terms
To support my research questions, I operationalized the following concepts, in order to cover a common understanding. I shortly explained the most important terms that were present in my research questions. These terms are ‘culture’ and ‘experiences’.
Culture
Culture is a fluid concept, a concept that contains several definitions. Goodenough (2005) explains that a definition of culture consists of several criteria: “-criteria for categorizing phenomena as
meaningful stimuli; -criteria for deciding what can be; -criteria for deciding how one feels about things; -criteria for deciding what to do about things; -criteria for deciding how to go about doing things, and; -the skills needed to perform acceptably”. This definition means that there is not one
single definition of culture; each individual will set a personal definition of culture, leading from personal experiences (Goodenough, 2005).
Although there is not a single definition of culture, this does not need to be a problem in interaction. As long as the variation in people’s knowledge and understanding does not interfere with their ability to interact readily with each other, they will have the sense that they have shared knowledge and understanding and for these reasons, have a common culture (Goodenough, 2005). It can be explained in the same way as common language; no one speaks a language exactly the same as anyone else, and no one has exactly the same ideas about shared ideas within a community; their culture (Goodenough, 2005). As long as these differences do not get in the way of people living and working together, it might happen that people do not even notice these differences (Goodenough, 2005).
according to the definition of culture by Goodenough (2005), caused changes to the Dutch culture. On the other hand, the differences between the major population and minority groups have increased, which has led to difficulties in society (Collyer, 2005). In this study, I used culture as an indicator to be able to explain differences in experiences in Dutch and South African health care.
When looking at a multicultural society, like the society in The Netherlands, the differences in culture might cause problems. As mentioned before, differences in culture can lead to different opinions about shared ideas within a community (Goodenough, 2005). When these differences in ideas cause problems in the shared environment, cultural issues might appear (Collyer, 2005). Immigrants need to integrate into a new society and have to adapt to a new culture than the one they are used to (Tandogan & Incirlioglu, 2004). When a person is permanently migrating to a different country, like the respondents I used in this study, this person needs to adapt to a new culture in social, economic and political ways (Collyer, 2005). This adaptation is possible, since cultures are fluid systems (Ritzer, 2011).
On the other hand, the people already living in the country the migrants moved into, have to get used to the influences of new people moving into their country and the consequences of a different culture besides their own (Maxwell, 2010). Over the past years, the European and Dutch political climate has changed in a negative way towards immigrants (Metselaar, 2005). Due to these developments, a part of the Dutch population has developed a negative attitude towards immigrants (Metselaar, 2005). In this study, I tried to find out whether my respondents are affected by possible negative attitudes towards them and whether they meet these negative attitudes when they are using the Dutch health care system.
Experiences
Just like the concept of culture, the concept of experience is a concept that contains several definitions. Most commonly, experience is spoken of in terms of adventure and travelling (Lash, 2006). Another way of talking about experience can be the years of practice a person has had in its profession (Lash, 2006). However, there are a few official definitions that I will discuss now. Kant (in Lash, 2006) states that experience is epistemological. This means that experience originates from knowledge and science (Lash, 2006). This is the case when a person has encountered a number of cases of a similar type (Lash, 2006). Another definition is the case in the current society; in which, according to Lash (2006), everyone is searching for excitement and more challenging experiences.
Experience has been taken up into social sciences through ‘gender’, ‘ethnic’, and ‘cultural’
experiences and thus depend on a person’s background and life (Lash, 2006). This is the case in this study as well. Since experience is a personal issue, it will depend on one’s background, personality and life experiences how an event is experienced (Ritzer, 2011). I used experience in my research to find out how people feel when they use the Dutch health care system. I kept in mind that experience is a very personal issue and that this research is about opinions. Therefore, this research is not an objective research. All conclusions that I set in this research are based on opinions and therefore, cannot be generalized as standards for an entire society. However, I do believe that personal experiences can tell a lot about actual happenings, in this case, when using the Dutch health care system.
Background
The aim of my research was to explore the Dutch health care system and the perceptions of this system by a specific group of immigrants, the South African immigrants. The existing knowledge in this field often stems from reports of the Dutch government and research institutes which are
subsidized by the Dutch government (Scheffer, 2000). However, the majority of these reports focus on so-called problematic groups within Dutch society, like the Turkish, Moroccan and Surinamese
groups (Knipscheer & Kleber, 2005).
The 25th article of the Universal Declaration of Human Rights, by the United Nations states that ‘everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control’ (United Nations, 1948). As can be seen, every individual has the right to receive health care.
Promoting and protecting health is essential to human welfare and sustained economic and social development (World Health Organization, 2010). The World Health Organization (2010) concludes that a high quality of health care contributes to a better quality of life as well as to global peace and security. In research, conducted by The World Health Organization (2010), people rate health and health care as one of their highest priorities, only preceded by economic concerns. Despite the high importance of health and health care, the global contradictions in health care have been increasing over the first decades of the 21st century, due to economic and political issues (World Health Organization, 2010). Although health care is becoming more available all over the world, it remains hard to access for certain groups of people. The issue of accessibility has to do with lack of money and lack of knowledge about health services being offered. A well-functioning health financing system all over the world needs to be achieved, in order to make high-quality health care available for everyone (World Health Organization, 2010).
Due to political, social and economic changes, the quality of global health care has decreased over the last decade (World Health Organization, 2013). The economic crisis that has influenced all countries worldwide has influenced the health care systems as well (Catalano, 2009). In times of
crisis the well-being of residents can be compromised due to budget cuts and diminished services (Catalano, 2009). The quality of health care is often one of the first items that is being influenced by welfare reductions (Catalano, 2009). It is found that in a situation of economic crisis, governments value the health and well-being of their own citizens over that of immigrants in their country (Gushulak & MacPherson, 2011).
When focusing on The Netherlands, it is found that the climate for immigrants has become more restrictive over the last decades (Metselaar, 2005; Boswell, 2003; Schuster, 2000). The political climate has changed and the centre-right parties rule the country now (Metselaar, 2005). As a consequence of this, it has become more difficult for immigrants to enter the country, to stay and to achieve a legal status in The Netherlands (Schuster, 2000). Although refugees are still allowed into the country, for economic migrants, it is more difficult to achieve a legal status than it used to be (Boswell, 2003).
For this specific research, it was relevant to find out whether a specific group of immigrants, who has been living in The Netherlands for a certain amount of time, feels attended to and/or mistreated by the Dutch health system. There are a limited number of studies that focus on feelings of trust in the Dutch health care system among immigrant groups (Knipscheer & Kleber, 2005). Particularly when focusing on those immigrants who have legal access to health care and who pay insurance for receiving health care. The importance of this study is to contribute to already existing knowledge by adding the perspectives of users in the system for whom services back home may have been different or even similar to the services in The Netherlands. Besides, I added the perspectives of experts in the field, in order to create an as complete as possible image of the Dutch health care system for a specific group of immigrants.
My study addresses the experiences of South African immigrants in the Dutch health care system and describes their perceptions and the way they deal with their experiences at the moment they require health services. I compared their perceptions about South African health care with their perceptions about Dutch health care in order to be able to explain their feelings about Dutch health care more thoroughly. In this way, I targeted the shared source of their (dis)satisfaction and the reasons behind these feelings, as well as opinions and experiences of a very specific group of immigrants, which could be useful for further research about this topic.
Dutch Health Care System
To be able to contextualize the perceptions and experiences of the South African immigrants in The Netherlands, I explained how the Dutch health care system is equipped. According to the World Health Organization (2010), the Dutch health system is a system of scenario building and planning. This is essential to determine long-term orientations and requires specific capacities that lend
through several changes (World Health Organization, 2010). In the next parts, I explained more about these changes and the consequences of them for the people who use Dutch health care.
First of all, there are two developments that cooperate next to each other. On the one hand there is the development of scientific progress; physicians have to stay up with their field of knowledge, keep developing themselves and make sure they do not fall behind (World Health Organization, 2010). On the other hand, physicians need to be close to their patients, act like a family doctor and as the
interface between clients and the health system (World Health Organization, 2010). Essential in the developments in the medical field is to keep in mind that health care has to do with people and personal feelings. According to the World Health Organization (2010), the technical and scientific developments can lead to a different kind of health care in which the needs of the patients do not have the highest priority any more.
A possible issue in this system is the option that patients start to fear to visit their doctors (Bright, 1994). Although they might have some serious issues with their health, because they do not feel personally related to their physicians anymore, they might feel objection visiting them (Bright, 1994). This is mainly so for older people, who are used to get all the time they need at a physician and now suddenly notice that they do not get this time anymore. It increases the level of people who walk on with an untreated issue; sometimes an issue that would require immediate doctors attention (Bright, 1994).
Another issue in Dutch health care is the change in priorities (Enserink, 2005). Where the needs and problems of patients used to be the main issue in health care, due to changes in policy, physicians do not always have enough time to examine their patients and listen to their entire story (Enserink, 2005). According to the World Health Organization (2010), the Dutch health care system is trying to
prevent the overuse of medication. Recent discoveries about the possibility of a worldwide problem because of resistance against antibiotics and the consequences of this have increased these tries (World Health Organization, 2010). However, this development can lead to patients feeling mistreated and mislead by their doctors (Enserink, 2005).
Due to policy changes over the last decades, the Dutch health care system has changed in more ways besides the ones I described above. Among others, this is due to the demographic changes in the Dutch society (Boot & Knapen, 2005). The Dutch society is aging and this development brings new issues in health care (Boot & Knapen, 2005). Because it has been proven that older people need more health care than younger people, and the group of older people increased over the last decades, the Dutch health care system needs to reinvent itself (Boot & Knapen, 2005). There is more pressure on general practitioners (GP’s); they have to measure the seriousness of people’s health complaints and decide whether or not people need to be referred to specialists (Boot & Knapen, 2005). As a
consequence of this, people sometimes feel that they are not taken serious by their GP and resent the health care they receive (Boot & Knapen, 2005).
Besides, health care has become more expensive (Mooij, 2006). Due to the above mentioned aging of the Dutch population, there is more pressure on the welfare state and the public expenditures increase (Mooij, 2006). This leads to financial issues for the Dutch government and tension in the Dutch society between a growing group of aging people, who depend on collective health care, arranged by the Dutch government, and a decreasing group of younger people who pay for this health care
through taxes (Mooij, 2006). Besides, the current welfare state is not adapted to recent developments in the Dutch society, such as the labor participation of women, higher educational levels and more heterogeneous forms of cohabitation (Mooij, 2006). This gap between law and actuality undermines the legitimacy of the Dutch health care system as it is now (Mooij, 2006).
To be able to solve the above mentioned issues, the Dutch government is taking measures to make the health care system less dependent on the taxes of the Dutch population (Mooij, 2006). Since 2014, the Dutch health insurances have changed their policies (Rijksoverheid, 2014). Health insurance is mandatory in The Netherlands, so people have to adapt to the changes that are made in these insurances (Mooij, 2006). The mandatory personal risk, that is included in each health
insurance in The Netherlands has gone up to 360 Euros per person, which means that people are required to pay themselves for a part of the health care they use (Rijksoverheid, 2014). Besides, the treatments that are included in the basic insurance are reduced (Rijksoverheid, 2014). People can choose themselves whether they want to take an extra insurance to cover their extra health care expenses and their dental costs. If they decide to have only the basic health insurance, they will have to pay for their health care expenses themselves (Rijksoverheid, 2014).
Besides, the new introduced system means that people have to pay for their health accounts themselves at first, and then have to claim back their money from the insurance (Rijksoverheid, 2014). They are made responsible for their own expenses and declarations, in order to make them more aware of the costs of health care (Boot & Knapen, 2005). Because of the introduction of the new health insurance system, there are no differences between private and public health insurances; everyone is made responsible to take care of their own health care (Rijksoverheid, 2014).
Following from this, the Dutch health system is trying to save money in different ways as well (Mooij, 2006). Like mentioned before, the GP has to function as the gate between patients and specialists who are working in the hospitals. GP’s decide whether patients’ issues are serious enough to be looked at by specialists (Mooij, 2006). Besides this, GP’s have to economize on the prescription of medication (Mooij, 2006). Health insurances have decided that they will not cover all medications people need, so GP’s, and other doctors as well, are forced to prescribe less medication or other
brands than they are used to, due to the power of the health insurances (Mooij, 2006).
Overall, it can be stated that the Dutch health system has gone through many developments over the last decades (World Health Organization, 2010). Since the system is not fully adapted to the current population of The Netherlands, changes have to be made in the way the system works. However, it has to be clear that the focus of doctors needs to be on their patients and that they have to try to prioritize the needs of the patients over the mandatory protocols that are part of their profession (Enserink, 2005; Bright, 1994).
Theoretical Framework
To support this study, I used three main theories. First of all, I described some issues that exist around trust. Trust is a main issue in people’s health care experience and because of this, relevant in this study (Brown, 2009). The second theory I used in this study is Granovetter’s theory about strong and weak ties, to be able to explain feelings South African immigrants in The Netherlands might have according to Dutch health care, compared to their feelings towards South African health care (Ritzer, 2012). Finally, I used Habermas’ theory about public sphere (Ritzer, 2012). This theory can explain why South African immigrants perceive the Dutch health care system in their specific ways. These three theories are interconnected. I explained these connections throughout the theoretical framework. A conceptual map of the theory can be found in appendix A.
TRUST
There are several definitions of trust related to health care. Dibben and Davies (2004) mention that the term ‘trust’ is often used in order to make general statements about the relationship between
groups and their service providers. Trust can be explained as a set of expectations that is held by one party about another party’s likely behavior in a situation entailing risk to the first party (Dibben & Davies, 2004). Brown, Alaszewski, Swift and Nordin (2011) conceptualize trust in health care as facilitating positive dispositions towards health care providers at the micro- and macro-levels as well as emotional inoculation against anxiety. Mollering (2001) defines trust as a mental process of three elements: expectation, interpretation and suspension. Finally, Gilson (2006) defines trust as the optimistic acceptance of a vulnerable situation, in which he suggests that trust has to do with faith and commitment.
As can be found in the different definitions of trust, there is some overlap between them. Trust has to do with expectations and dispositions (Brown et al., 2011; Gilson, 2006; Dibben & Davies, 2004; Mollering, 2001). In this study, I researched trust in health care. The role of trust in health care has been receiving increased attention over the past decades (Dibben & Davies, 2004). Public trust and confidence in health care services are related to perceptions about these services and to how these services manage and deal with potential risks (Dibben & Davies, 2004). On the contrary, personal trust relates to people’s experiences of care delivery, their concerns about the interpersonal aspects of care and the moral choices they have to make in their uncertainty (Dibben & Davies, 2004).
There are two levels of trust; micro and macro (Robb & Greenhalgh, 2006). Trust at a micro level reflects the experiences of people in transactions with other people (Uslaner, 2007). Trust at the macro level is more about the functioning of institutions and the faith people have in these
institutions (Uslaner, 2007). At the macro level, trust is a cipher, a place-holder for the effectiveness of institutions; in this study the effectiveness of health care institutions (Uslaner, 2007). The trust in health care systems in general has to do with the macro level trust relationships, while the trust in personal physicians or nurses have to do with micro trust relationships (Robb & Greenhalgh, 2006).
The macro and micro levels of trust are interconnected and reinforce each other in the experience of health care (Robb & Greenhalgh, 2006). This interconnection can be explained, because a single positive or negative experience on the micro level can influence a person’s feeling of trust in the entire health system, the macro level (Robb & Greenhalgh, 2006). The other way around is possible as well, reading about positive or negative developments in the health system might influence the feelings of trust on the micro level as well (Uslaner, 2007).
Contrary to feelings of trust in health care, are the feelings of distrust in health care (Armstrong, 2008). In this case, the patient feels like he is not in control of his experiences and someone else is making decisions about sensitive subjects (Brown, 2009). In this case, experts will be blamed for their failing and the patient will lose its trust in the health care system (Brown & Calnan, 2012). Public trust in the health care system can be strongly influenced by scandals in the media (Calnan & Sanford, 2004). This happens especially when there is, according to the public opinion, not enough openness about incidents and the way the health care system dealt with these (Calnan & Sanford, 2004). Openness and the sharing of information are of major importance in the experience of trust (Calnan & Sanford, 2004). However, sharing too much information can lead to higher levels of distrust (Legemaate, 2011). Some information is useless for patients and will only make them
worried and suspicious towards their physicians (Legemaate, 2011). It is up to the physicians and the health care system in general to decide which information to share and which not in order to receive an as high as possible trust level and, at the same time, make patients feel comfortable and provide them with the feeling they are taken seriously (Legemaate, 2011).
Following from the above mentioned distrust in health care, there appears to be a racial difference in trust in health care (Armstrong, 2008). In a study, performed by Armstrong (2008) in the United States of America, he found that black people have a higher level of distrust in the health care system
than white people. These differences might have implications for racial differences in health care and health outcomes. Distrust in health care decreases the visits of patients to their physicians and
increases the costs of monitoring vulnerable groups in society (Armstrong, 2008). Distrust in health care can lead to lower rates of used health care and higher levels of testing and unnecessary
interventions (Armstrong, 2008). A similar research in The Netherlands by Dahhan (2007) confirms the results of Armstrong (2008). Dahhan (2007) found that immigrants in The Netherlands have difficulties trusting the Dutch health system, due to several cultural issues and misunderstandings between physicians and their patients. Immigrants in The Netherlands state that they would have higher feelings of trust in the Dutch health system if their needs and issues would be taken more into account (Dahhan, 2007). At the moment, immigrants often feel like they are not taken seriously, partly due to differences in culture and language issues, which cause them to trust the Dutch health system less than could be possible (Dahhan, 2007).
As noted above, trust in health care is important for people to feel comfortable enough to open up to their physicians (Dibben & Davies, 2004). They need to have confidence that all actions are in their best interest and that the health care system in general will do everything to help them. However, when there have been incidents that cause distrust, these issues are not easily solved (Brown & Calnan, 2009). It has to be kept in mind that only one bad experience can lead to distrust and that is not easy to win back the trust of a person (Armstrong, 2008; Dahhan, 2007). It can be concluded that a certain amount of trust is necessary when using health care and that health care staff has to try their best in order to help people trust them.
Strong and Weak Ties
Social network theory deals with social relationships and focuses on a range of micro to macro structures (Ritzer, 2012). I explained the micro and macro levels of trust in the part above (Robb & Greenhalgh, 2006). Micro and macro structures can be used in all levels of society (Uslaner, 2007). Micro structures are about interpersonal transactions, while macro structures deal with the
relationships of people with institutions (Uslaner, 2007). To be able to look at strong and weak ties in relation to micro and macro structures, I will first explain the differences between strong and weak ties. Granovetter’s theory focuses on strong and weak ties in social relationships (Ritzer, 2012). Strong ties can be defined as a social relationship between two people that is repeated over time. Examples of a strong tie are relations between family members or close friends (Calvo-Armengol, Verdier & Zenou, 2007). On the other hand, weak ties are individuals that can be met outside the strong partnerships. Weak ties are transitory and only last for a period (Calvo-Armengol, Verdier & Zenou, 2007).
When talking about ties in health care, strong and weak ties are combined (Holbrook & Kulik, 2001). Social relationships with strong ties influence the opinions and perceptions of people by talking and discussing issues about health care with one another (Holbrook & Kulik, 2001). By doing this, they can form perceptions based on other people’s experiences (Holbrook & Kulik, 2001). Strong ties are not perceived as entirely beneficial, relating to the subject of health care. Since people who have strong ties with each other move in similar social circles, people are multiply influenced by the same type of people (Jack, 2005). This might lead to biased opinions about health care and health care staff (Jack, 2005).
When relating weak ties to health care, these ties often have to do with personal contacts with health care staff; since these contacts usually do not happen on a regular basis, the short encounters matter in the perceptions of people (Jack, 2005). Health care is of key importance in people’s lives, and
therefore the weak ties people form with the health care staff they have to deal with need to be positively rated (Calvo-Armengol, Verdier & Zenou, 2007). In the formation of weak ties, it is noticeable that people have a quick way of forming opinions about the other person and that it is difficult to change them after a first experience (Vervoort, 2011).
When combining the theories of micro and macro levels with the theory of strong and weak ties, it becomes clear that people normally form strong ties with people with whom they are in contact on a micro level (Robb & Greenhalgh, 2006). On the other hand, weak ties are often formed with people who represent the macro level, such as people working in hospitals (Jack, 2005). Coming from this, it is easier to develop high levels of trust in people a person forms strong ties with (Holbrook & Kulik, 2001). These people are normally the people a person has already developed a micro relationship with, which makes it easier to trust this person (Uslaner, 2007). Since people often form weak ties with physicians and other people working in health care, this theory partly explains why it is sometimes difficult to develop trust in physicians; because of the lack of a strong relationship (Uslaner, 2007).
Focusing on migrant groups in the formation of strong and weak ties, it has been proven that social ties with members of the ethnic majority in a country can improve migrants’ proficiency in the language of the new country and help them learn the norms and values of their new country
(Vervoort, 2011). Contact between migrants and the majority population influence the perceptions of migrants about their new country and the services provided in this country (Vervoort, 2011). The formation of strong ties with the majority population influences the formation of weak ties and the perceptions on these weak ties (Vervoort, 2011). However, because there are often difficulties between migrants and the majority population, the formation of strong ties between people of both groups is not easy (Dahhan, 2007). Because of this, migrants often feel more comfortable staying in
their own community; people who migrated from the same country and whom have developed the same norms and values as themselves (Dahhan, 2007). When migrants stay put in their own ethnic community, they tend to form strong ties with people originating from the same country and stay away from the majority population (Vervoort, 2011). This might have a negative influence on the formation of weak ties within the new country (Vervoort, 2011).
The above mentioned negative influence of the formation of strong ties within an immigrant’s own community can have consequences for the immigrant’s use of the Dutch health care system (Dahhan, 2007). If they stay put in their own ethnic community and only form strong ties within that
community, the migrants are likely to hold on to the norms and values of their home country, which causes difficulties when they have to use the public services of The Netherlands (Dahhan, 2007). Therefore, it is important that migrants in The Netherlands get guidance from Dutch instances as soon as they arrive in The Netherlands, in order to make them comfortable with the Dutch society and to make sure that they will form both strong and weak ties within The Netherlands (Dahhan, 2007). In this way, they will be more likely to feel comfortable using the Dutch health system and do not feel held back when visiting physicians (Dahhan, 2007).
In conclusion, the formation of strong and weak ties is relevant in this study, because the formation of these ties is likely to influence the perceptions and experiences of migrants. It has to be kept in mind that the migrants are being influenced by other people; both positively and negatively. When their strong ties, the people they associate with, have a positive image about the health care system, the migrants themselves will be more likely to develop a positive image of the health system
themselves, and the other way around. The formation of weak ties influences the perception of health care in such a way that a positive formation of weak ties will create a more positive image about health care and the health care staff.
Public Sphere
The concept of the public sphere, created by Habermas (in: Hamilton, 2009) involves ‘the assembling of private persons to discuss, unrestrictedly, matters of the public interest, and the transmission of the outcome of their deliberations in a form able to influence the state’. The notion of public sphere is relevant in this study, because of the influence the public sphere has on the opinions and
perceptions of people (Hamilton, 2009). Issues about health care are discussed and people are encouraged to form their own opinions and focus on their own priorities and to debate about these issues with other people (Hamilton, 2009).
In the parts above, I explained the theories about trust and strong and weak ties. These theories are interrelated with the theory about the public sphere. Like mentioned above, people are likely to discuss issues about health care with each other (Hamilton, 2009). People will discuss their issues with people they form strong ties with (Calvo-Armengol, Verdier & Zenou, 2007). The public sphere makes sure that people are able to discuss their issues unrestrictedly, which leads to discussions in public and negotiations about the quality of health care (Hamilton, 2009). These discussions are of influence of the formation of trust people will or will not develop in the health system (Dahhan, 2007).
When focusing more directly on health care and the public sphere, it has been researched that discussions that used to be in a private sphere between physician and patient, have become more public (Hallin, Brandt & Briggs, 2013). These health-related conversations were always interpersonal (Hallin, Brandt & Briggs, 2013). When focusing on health care in The Netherlands, the reason for
these interpersonal relations can be found in the fact that the GP used to be an acquaintance of most people (Dibben & Davies, 2004). A GP used to provide health care for a small group of people, either in a village or in a certain district of a large city (Dahhan, 2007). This lead to strong ties between GP and patient and high levels of trust (Dahhan, 2007). Because of the cut-backs in the Dutch health system, this acquaintance has disappeared on a large scale, and together with this, the strong ties and a certain level of trust (Dahhan, 2007). The interpersonal conversations between physician and patient have become more public, due to several reasons (Hallin, Brandt & Briggs, 2013).
One of the main reasons for this is the increasing influence of multimedia (Hallin, Brandt & Briggs, 2013). Multimedia has changed the public sphere, since a larger audience is reached than when the public sphere meant discussing issues in the streets (Hallin, Brandt & Briggs, 2013). Nowadays, people are actively seeking information about issues that might affect their health (Hallin, Brandt & Briggs, 2013). Another issue is people judging the actions of health care professionals and spreading these through multimedia. People have a larger network than they used to have, due to social media and multimedia (Hallin, Brandt & Briggs, 2013). This causes them to get in contact with more people than they used to do and the formation of different ties than some decades ago (Ritzer, 2012). Since the formation of large networks online, people can get in contact with people in other countries and on different continents than their own, which has changed people’s worldviews (Hallin, Brandt & Briggs, 2013). These developments have both changed the formation of strong and weak ties and the definition of the public sphere (Hallin, Brandt & Briggs, 2013). Since it is possible to create strong ties with people on another continent, people are likely to think more about the way the world works and the differences between countries (Jack, 2005). This has an influence on their perceptions of health care as well, since people are more likely to share their stories with people they form strong ties with, they might be influenced by stories from other countries and other systems (Hallin, Brandt
& Briggs, 2013). The popularity of social media has also lead to a new form of the public sphere, in which people are able to post their personal experiences online, making these experiences available for the entire world to read and to form their own experiences about these events (Hallin, Brandt & Briggs, 2013).
Another issue is the public need for information (Tenbensel, 2002). Physicians have to choose between direct and mediated information and constantly have to measure which of both methods will be most effective in particular cases (Tenbensel, 2002). Due to the public’s constant need for
information, physicians have to make sure their information will be well-interpreted and used for the right purposes (Tenbensel, 2002). When there is a high level of trust between physician and patient, it is easier for the physician to provide the patient with direct information, and to be straight to the point (Tenbensel, 2002). In the case of a low level of trust, it is important that the physician is careful with the information he provides, since in that case there is a lack of ties that provides the patient with the level of trust that is needed to believe the physicians’ advice (Dahhan, 2007). When wrongly
understood information is shared in the public sphere, it might cause misunderstandings and difficulties in the health system (Hallin, Brandt & Briggs, 2013).
When focusing on migrants in a new society, it becomes clear that the migrants have their own prejudices about their new country and involved in that, the health care system (Scott & West, 2000). Like mentioned before, the formation of migrants’ prejudices will strongly depend on the group they will settle into (Vervoort, 2011). When the migrants stay put in their own group, their contribution to the public sphere about the health system is likely to be negative (Scott & West, 2000). On the other hand, if the migrants integrate into their new society, they might be influenced by their new ties and be positive about the health system; which will automatically lead to a positive contribution to the public sphere (Vervoort, 2011; Scott & West, 2000). By sharing their opinions into the public sphere,
it will influence the opinions of other people about the Dutch health system as well.
Overall, it can be found that the public sphere has an influence on people’s opinions. Especially in the time of multimedia and sharing important information online, it is difficult not to be influenced by other people’s opinions. This has to do with different formations of ties as well. People are more globally influenced, where it used to be local. When focusing on health care, shared experiences and discussions that happen in the public sphere influence the opinions of people. Because of this, the perceptions of the health care system might have been formed before it is used.
Methodology
system. To be able to find respondents for this study and let me interview them, I had to go through different stages. I started off with determining eligibility, in which I defined the sample criteria generally. Following from that, I negotiated entry and identified my sample. Then I was able to define my sample, I researched their characteristics and created my own conditions in order to create a small, but ‘representative’ sample. Following from that, I started my interviews and analyzed the data. I described these stages below.
Determining eligibility
Determining eligibility has to do with the definition of the sample that participates in the study (Maxwell, 2013). In this research, that means that the term ‘immigrant’ has to be defined.
The term ‘immigrant’ can be divided into several explanations. Generally, a migrant is a person who moves from its own country to a new one (Teste et al., 2012). There are several reasons for this migration. First of all, we can identify the group of refugees, who have fled their own country for reasons of war, or political or economic reasons (Teste et al., 2012). In this paper, the group of refugees will be left out of the study. In my study, I focused on a group of migrants who moved to The Netherlands for personal reasons, either a job offer or love (Teste et al., 2012).
Negotiating entry
When I started my study, I planned on interviewing people who were working at the South African embassy in The Netherlands. However, this plan was not manageable, due to time issues of the people working at the embassy. Following from this, I had to change my tactics to find respondents. I posted messages on Facebook and e-mailed South African organizations in The Netherlands, asking them to help me find respondents. When I had collected my first group of interviewees, I started using the snowball method, asking my respondents whether they knew people who were willing to be
interviewed by me. This method helped me in collecting the necessary amount of respondents.
Besides the interviews with the South African immigrants, I performed three interviews with health care experts. I knew one of them personally and he helped me finding my other two respondents for the expert interviews.
Sample
Before I started collecting my interviewees, I set up including and excluding criteria for myself, in order to get a representative sample, with people who had experienced the Dutch health care system. The participants had to meet the following including criteria: they had to be born and raised in South Africa and they had to have a legal status in the Netherlands. Besides, they had to have been staying in The Netherlands for at least two years at the moment of the interview and they had to be over eighteen years old. Excluding criteria were: being under aged, not having a legal status in The Netherlands and having been in The Netherlands for less than two years.
My sample of immigrants existed of twelve respondents, between 21 and 65 years old. They have been living in The Netherlands between 2 and 21 years. They moved here because they had found a Dutch partner, except for two respondents, who originally came to The Netherlands to study and decided to stay. I interviewed people from different racial backgrounds; six of them were white middle class, three were black and three were coloured. They originated from different parts of South Africa: three from Cape Town, two from Stellenbosch, three from Pretoria, two from small villages in the Eastern Cape, one from Nelspruit and one from Paarl. I purposely tried to find respondents from different backgrounds, in order to cover the differences among the South African population as well as possible.
The Hague and Utrecht. There was only one exception on this; one of my respondents lives nearby Zwolle, in the north of The Netherlands.
The three professionals I used for the expert interviews were all from Rotterdam. They were between 26 and 55 years old. Two of them are physiotherapists and one of them is a nurse in a hospital. Two of them had Dutch ancestors; one of them had parents originating from Suriname.
Interviews
I performed my interviews in and around the residential areas of my respondents, which means that I interviewed my respondents around Amsterdam, Rotterdam, The Hague and Utrecht. My first interview took place on March 26th 2014 and my final interview happened on May 16th. 60% of the interviews took place in public spaces, which were cafes and coffee places. I performed the other 40% of my interviews in the houses of the respondents. During my interviews, I used the
semi-structured interview method, in order to be flexible in my questions (Maxwell, 2013). I adapted my original questionnaire after the second interview, because I found out I included some closed questions and a few other questions were suggestive (Maxwell, 2013). I planned on interviewing my respondents 45 minutes each. In 60% of my interviews, I interviewed between 40 and 50 minutes. 2 of my respondents talked for over an hour; it took one of them 70 minutes to share her ideas and thoughts and the other one close to 90 minutes. I recorded all of my interviews with a voice recorder, after asking my respondents whether they agreed on that and handing them a letter in which I
promised confidentiality of all the information they shared with me. None of my interviewees disagreed.
In the interviews with the experts I used a different strategy. According to Harvey (2011) and Bozoki (n.d.), experts in all work fields are elite members of society, and therefore, need to be treated
differently when they are being interviewed. Expert interviews help in receiving individual insights, firsthand accounts and a rich depth to a story, in this case, the story about perceptions in health care (Bozoki, n.d.). The experts are able to provide other insights to a story, because they look at the subject from a different perspective than the people who use the services (Harvey, 2011). In this case, interviewing the experts provided information about the Dutch health system from an insiders’ perspective.
I performed my expert interviews in the final phase of my interviews, between the 1st and 10th of May. I visited the experts in their working space; two of them in their own practice in Rotterdam and the other one in the hospital she works in. I used the semi-structured interview method as well (Maxwell, 2013). The expert interviews all took about 30 minutes.
Data Analysis
While performing my interviews, I started collecting and analyzing the data as well. I started off with the collection of data sources such as books, published articles, online documents and reports. By doing this, I was able to find out more about my topic of research and it helped me to use my collected data in the right ways. Because I was able to find overarching topics from the beginning, I could focus on finding literature that supported these topics and that provided the information I needed.
During my interviews I wrote fieldnotes and memos (Maxwell, 2013). Fieldnotes are used to describe experiences and observations of the researcher (Maxwell, 2013). I wrote these to remember issues around my interviews and the setting in which I interviewed the respondents. Besides, I wrote memos about my respondents and the way they reacted towards me and the place we were in. I wrote down striking statements to make sure I would remember them when writing my final thesis.
When I was performing the interviews, I made sure that I transcribed my interviews at the same day that I performed them, to be able to incorporate the recorded interview with the fieldnotes and memos I wrote. After I finished my interviews and transcribed them, I used Atlas TI to analyze my interviews and find recurrent themes in my interviews. Using these themes I was able to write my findings, which can be found below.
I used triangulation in order to test all my information on validity and to find overarching themes throughout the interviews and the literature (Maxwell, 2013). Triangulation is used to compare obtained information with different sources, using different visions (Maxwell, 2013). It is important to reach agreement from different sources and perceptions (Maxwell, 2013). I used different sources to obtain my information and compared these sources with one another in order to be able to set clear conclusions.
Findings
When I finished performing my interviews and the analyzing of the interviews, I found themes that were omnipresent among my interviews. In this part, I dig deeper into these themes. First, I shortly introduced my interviewees, using a table to shortly explain where they are from, what their
background is and how long they have been in The Netherlands. I used pseudonyms to maintain their anonymity. I discussed the use of these pseudonyms during my interviews and although all my
interviewees mentioned that they did not mind if I would use their own name, they appreciated the effort I took in providing them pseudonyms. Following from this, I described the themes I withdrew from the interviews below. After these descriptions, I described the perceptions and opinions of the experts I interviewed to find out more about their opinions. Finally, I described some main issues about the South African health care system in order to tell more about the context in which my interviewees made their statements. The questionnaire I used to interview my respondents can be found in Appendix B.
Table 1
Name Age Originating from Living in The
Netherlands for …
Cultural/Reli gious
Background
Anne 21 Pretoria 2 years Atheistic
kaans
Nell 24 Stellenbosch 2 years Protestant
Maria 49 Paarl 4 years Christian
George 65 Stellenbosch 21 years Christian
Marise 25 Nelspruit 2 years Afrikaans
Monique 30 Pretoria 8 years Christian
Rita 28 Cape Town 5 years Christian
Ina 30 Cape Town 2 years Atheist
Renee 31 Eastern Cape 2 years Muslim/Christ
ian
Veronica 41 Eastern Cape 17 years Methodist
Susan 32 Cape Town 3 years Christian
South African health care
The first major theme I found during my analysis of the interviews was the South African health system. My respondents mention that there are differences between private and public health care.
Health care in South Africa is, according to my respondents, excellent if you can afford it.
‘The private hospitals are very good, but the state hospitals are not.’
According to Alana from Pretoria, the private hospitals in South Africa have higher-quality health care than the hospitals in The Netherlands. Alana mentions that the private hospitals in South Africa have high-quality facilities and that she always felt comfortable when she had to visit a physician in South Africa. The physicians gave their full attention to her as a patient and she always felt like they had all the time she needed to share her story and explain her health problems.
All my respondents mentioned that it is necessary to have both a lot of money and a health insurance in South Africa. In these cases, it is possible to use private health care. The health insurances in South Africa cover everything, so when you have one, you will never get confronted with complementary costs. Doctors in private hospitals will do everything to help you and take care of you, because you are seen as an opportunity to make more money. Like Susan from Cape Town mentioned:
‘There are never any unexpected costs’
When you have a health insurance in South Africa, it is clear for you what happens whenever you need health care; you will get all the care you need and the insurance will take care of the costs. Susan told the benefits of this system; although health insurance is quite expensive, especially looking at it from a South African perspective, with low wages and relatively low living costs, there are never unexpected complementary costs to worry about. People find this comforting, especially since the health system in South Africa, according to Susan, still has to battle corruption.
Health care at the private General Practitioners (GPs) is received positive as well. 80% of my respondents told me that they had known their GPs since they were little children and that they had
build personal bonds with their GPs. They were able to call their GPs 24/7 to ask questions about health issues and to deal with small problems.
Rita from Cape Town gave an example about how she felt around her GP:
‘I have had really good experiences with our local GP (General Practitioner). I had 4 implants (of my teeth) done in South-Africa which was not a very pleasant experience but the treatment I got from start to finish was fantastic. Even the check- ups afterwards were good. It just was all in all really expensive, but well worth it.’
This quote represents the overall feelings about the private GPs; my respondents feel high levels of trust in their GPs, because of the strong ties they built with their GPs over the years. The accessibility of the GPs made that my respondents felt comfortable calling them about small issues, to be
comforted or to ask for a prescription for certain medications.
On the other side of the positive experiences with private health care, are the mixed views on and experiences with public health care. Four of my respondents have personally experienced public health care and they were relatively positive about it. They mentioned that although you often have to wait for long hours and travel far to reach the clinics, the health care is professional and you will be provided with the same medications that people in private health care receive.
Veronica, who grew up in a small village in the Eastern Cape told me that she used to live in the only village in the area that had a hospital. She told that some people walked for days to be able to visit a doctor. The hospital was run by European physicians and before taking the step of coming to this hospital, most people had tried traditional health care, which is still commonly used among black South Africans. These traditional healers, or sangomas, try to cure diseases with basic methods such as the use of herbs and traditional spells. However, according to Veronica, the sangomas were always
willing to cooperate with the Western physicians and they would refer their patients to the Western hospital whenever they felt like they were unable to cure the disease.
Not all respondents were as positive about public health care. George, originating from a township nearby Stellenbosch mentions that the public health care system is not good:
‘Living in a township the health care support is not that great. Most of the people in the townships will tell you that the health care during Apartheid was one of the best.’
Continuing on this quote, George told me that during the Apartheid regime the health system was centrally organized and that everyone had the right on equal health care and the government took care of it, even in the townships. He mentioned that if you go into townships now, the health system is badly organized, people are badly informed about basic health issues and do not know where to go with their issues and questions.
And this is what seven other respondents told as well. Public hospitals are, according to them,
difficult to reach and not as hygienic as a hospital is supposed to be. Although health care is available for everyone in the country, some people have to travel far and do not want that, so they just do not use health care, while they do need it.
Dutch health care
The next theme I found in my research is the Dutch care system. Among my respondents, I found mixed emotions about the Dutch health system. The respondents had both positive and negative experiences in the Dutch health system, which I described below.
Starting off with the positive emotions about the Dutch health system, my respondents all agreed that it is a well-organized system. Doctors work effectively and everyone is being served in the same way,
there are no differences between the treatments of middle- and low-class people. Nell from Stellenbosch states that:
‘Everyone here has access to great medical care because almost everyone is obliged to have some form of medical insurance.’
I noticed that all my respondents made constant comparisons between what they were used to in South Africa and what they receive in The Netherlands. Nell for example, explained that she was used to high-quality health care back in South Africa, but that she was aware of the differences in health care. She mentioned that she was positively surprised that these differences do not exist in The Netherlands.
Besides the equality in health care, my respondents were positive about the fact that health care is never far away in The Netherlands. When you are in need of a GP, you are sent to the GP that is closest to your residential area and you will be served there. 75 % of my respondents did not choose their own GP, but just went to the GP their partner was already visiting, which worked well for them. Another positive fact about the Dutch health system was the distribution of medication; you will get a recipe and go to a pharmacy, where you will be provided with the right medication instantly. Again, this situation was compared to the situation in South Africa, where, according to my respondents, it was possible to visit any random pharmacy and just ask for medication. Although the majority of my respondents appreciated that system, the younger generation agreed that the Dutch health system was better organized in providing medication. They told me that, although they often felt like they needed to receive antibiotics when they did not get them, they did notice that diseases like the flu cure without these antibiotics as well and that there are good alternatives to solve their problems.
and relatives. When they did not have certain experiences with the Dutch health system themselves, they told me about what happened to a person they were close to, to mark their personal opinions. Their opinion depended strongly on the stories they had heard from others in their surroundings and on stories they read or saw in the media. Veronica from the Eastern Cape told me the story of her husband:
‘Three years ago, my husband had a headache and then they did the whole dancing around, only to find out he had meningitis, he nearly died. And that is what is wrong with this system, because if you have a patient, who is complaining about a headache, the best is to look why. Even someone who is coming on and off, with little complaints. My husband studied at a hospital, he knows when
something is seriously wrong. I think they can be really slow; they can take the problems really light.’
Veronica was shocked by this experience and lost her trust in the Dutch health system. She
mentioned that after this experience, she found a new GP and started asking for second opinions. The negative experience of her husband influenced her opinion about the entire Dutch health system.
Besides Veronica’s story, more of my respondents shared negative experiences in the Dutch health system. All my respondents, except for one, had experienced difficulties in using the Dutch health system. They told me that physicians in The Netherlands are impersonal and spend more time with their computers and protocols than with their patients. A major issue for my respondents was the feeling that the physicians do not listen to them and do not take their stories seriously. An example of that is Alana’s story:
‘I had a terrible vaginal infection lasting for 3 months and couldn’t get a referral to a gynecologist. I was just given a cream after the medication didn’t help. I was told you be patient. In the end I
contacted a gynecologist in South Africa. He advised that a sample be taken and investigated by a pathologist. It ended up being bacteria.’
Alana experienced the same as Veronica, whose story I shared above; she had a negative experience and lost her trust in the Dutch health system. Alana mentioned that she had never really trusted the Dutch health system and that she always felt more comfortable going back to South Africa and using health care there. However, when she had to, she used Dutch health care. The above shared story was the final call for her and she decided to never use Dutch health care again, unless it was a matter of life and death.
Another issue that came up was the bureaucracy of the Dutch health system. My respondents mentioned the time it takes to get an appointment and the short time you get once you visit a physician. Because of this, it is important to be prepared and to know what you need from the physician. Maria from Paarl mentioned:
‘When I visit a doctor here, I have to be my own lawyer. Not only to get the medication I need, but for everything. In South Africa, my doctor listens to me and I get what I need, without any issues.’
Again, this quotes states the overall lack of confidence in the Dutch health system. Maria told me that she always felt like she was not taken serious and that she had to be firm about her expectations and what she needed from her physician when she visited. She was convinced that in The Netherlands, there is a constant struggle between the needs of the patient and the needs of physicians; the physicians are mainly busy with their own issues and put the needs of their patients secondly.
Trust
responses. All my respondents do trust the Dutch health care system, up to a certain amount, but they are suspicious.
I was told by all my respondents that they do trust the system, because of its effectiveness and professionalism. However, since my respondents felt that in The Netherlands, doctors do not take or have time to build a personal relationship with their patients, they sometimes have difficulties trusting them entirely. They would prefer for a doctor to spend some more time with his patients, in order to get to know their personal stories and backgrounds. They do believe that doctors will do anything to help you and that they respond quickly when something is seriously wrong.
Although all my respondents mention they trust the Dutch health care system, 50% of them felt restraints when using Dutch health care. This had to do with the fact that doctors in The Netherlands are no proponents of the easy description of medications and that they often tell their patients to wait for the disease to solve itself. Maria told me a story from her personal experiences:
‘I developed edema and I was so scared. The doctors did not want to listen to me, so I tried to figure out what to do myself. The only available doctor was at the GP-post in the hospital and he did not allow me to visit, because the edema did not threaten my life. Although, for me it was life
threatening.’
Like I described above when telling about the experiences with the Dutch health system, it took my respondents only one bad experience to lose their trust in the Dutch health system. Maria described the same issue after sharing her story with me. She told me that before, she felt quite comfortable visiting Dutch physicians, but after this experience, she tried to avoid these visits and to postpone all her medical issues until she went to South Africa for a visit.
these issues among others had to do with the idea that not everything was being told to them. They had the feeling that doctors kept certain issues away from them, although none of my respondents was able to tell me concrete examples of these issues. Anne from Pretoria told me:
‘I always find out more about the medications they prescribe to me, because they do not give me enough information.’
Anne felt like there were secrets being kept from her and that made her loose trust in the entire health system. Anne needed certain medication because she had a skin disease and when she needed to change, because of hormonal issues, her physician refused to provide her with more information about this new medicine. Anne felt quite bad about this and decided to perform her own research. Eventually, nothing was wrong with the new medication, but the feeling that something was kept away from her, made her loose trust.
Coming from this, all my respondents told me that if they would fall ill and would need a specialist treatment, they would rather go back to South Africa and being treated there. This had to do with both the issues of the higher level of trust they feel in the South African health care system and the fact that they felt personally connected to their doctors back in South Africa.
Cultural and language issues
When I asked my respondents about the way they are being treated in Dutch health care, regarding the fact that they originate from another country and speak a different language, they were all positive. None of them ever felt mistreated because of their different background when using Dutch health care.
