Challenges in access to health services and its impact on quality of life: a randomised population-based survey within Turkish speaking immigrants in London

The growing scope of migratory movements all over the world raises specific health questions in both sending and receiving countries. Migrants are particularly vulnerable to health problems [1]. The biomedical and biopsychosocial dimensions of migration will possibly pose new and more difficult challenges to those who move, those they leave behind and those who host them in receiving societies [2]. Migrants often experience other life transitions, such as occupational and socioeconomic changes and social network alterations after physical relocation [3]. Significant number of Turkish speaking immigrants is living in London [4]. Like other vulnerable groups, they face with various obstacles in access to health care services. Studies draw attention to cultural and linguistic barriers and a lack of information or understanding about how the healthcare system works in the United Kingdom (UK) [5–7].

There are a number of studies focusing on special health issues including women's health, mental health, and alcohol and smoking habits among Turkish Speaking Communities (TSCs) [8–12]. On the other hand, little attention has been paid to Quality of Life (QoL) of TSCs with validated scales up-to-date. The World Health Organization (WHO) defines QoL as an individual's perception of their position in life in the context of the culture and value systems in which they live. WHOQOL BREF is a QoL assessment tool and was developed by the WHO. It is a cross-culturally valid assessment within four major domains: physical and psychological well-being, social relationship and satisfaction with environment [13–16].

TSCs have been a quite big language community in the UK since the early 1950s. The communities came originally from Cyprus and Turkey and have different immigration patterns. The Turkish Cypriots were the first to arrive in England and can be traced to the 1920s. Increased numbers arrived in the 1940s and late 1950s. A large wave from Cyprus came in the 1960s after the island became independent. Another large wave came as a result of the Turkey's intervention in 1974. This group's ties to Britain are stronger, as Cyprus was a British colony until 1960. Migration from mainland Turkey to Britain due to various economic and political reasons began in the early 1970s and followed 1980s and 1990s. There are smaller communities scattered around Britain but the majority of them live in and around London. They are working and living in the same areas and involved in similar economic, political, social and cultural activities [4].

The aim of this study was to explore the ongoing challenges when accessing to health services and to assess its impact on the QoL. Sharing the results with public authorities will hopefully improve the well-being of TSCs in terms of reaching and using health care services.

This cross-sectional population-based study was conducted between March and August 2010 with Turkish immigrants (n = 416) living in London; Turkish Immigrants (Group A, n = 308, 74%) and Turkish Cypriots (Group B, n = 108, 26.0%). All healthy or unhealthy adults of 17-65 years of age were enrolled. Inclusion criteria were as follows: Being ≥ 17 years of age, giving written consent, living in the UK at least for one year.

TSCs are heavily concentrated in the London boroughs of Haringey, Enfield, Edmonton, Waltham Forest, Islington and Hackney. There are a large number of Turkish enterprises and Turkish food markets, kebab houses and coffee shops especially in Hackney and Haringey. Many Turkish community centres settled in these regions. They help Turkish speaking immigrants overcome barriers to education, employment, health and other problems. Advice on benefits, housing, immigration and nationality is provided. There is also English for Speakers of Other Languages (ESOL), computer, art, dancing and drama courses. Some of them give educational support for primary and secondary school children. Most of them also run a luncheon club for the elderly.

Migration has always been a characteristic of human society, and one that has probably always been pregnant with health challenges [2]. A significant number of Turkish speaking immigrants are living in London. However, there are only a few studies on their health care needs.

In our study, there were some differences among TSCs; Turkish immigrants were younger and less educated than Turkish Cypriots. The unemployment rate was higher in Turkish immigrants and Turkish Cypriots were more crowded in 'middle management'. The mean duration of stay in the UK was longer for Turkish Cypriots and all of them had permanent residence. Turkish Cypriots had come earlier and were more settled than immigrants from mainland Turkey. They have a colonial connection with Britain so their ties to Britain are stronger [16].

Although most of the participants registered with a GP, nearly one fifth reported that they were not using GP services. Language barriers made it difficult to access health care services for minority ethnic groups. Migrants often used family members and children as interpreters. Cinar had investigated primary health care needs of TSCs (n = 129) in London; more than half of the respondents stated that they were experiencing communication problems and needed interpretation when using health care services (n = 72, 55.8%) [5]. In our study, Turkish immigrants needed interpretation more often when using health care services than Turkish Cypriots and they mostly used official interpreters, health advocates and their spouse for interpretation. The need for interpreter was lower in Turkish Cypriots than that of Turkish immigrants (36.5% vs. 15%).

QoL scores of Turkish immigrants and Turkish Cypriots were higher than those obtained from the Turkish population living in Turkey [18]. These results might be attributed to the higher educational status of the respondents of this study compared to the educational status of the population in Turkey. On the other hand, Turkish Cypriots were more likely to have higher scores in overall perceived QoL, perceived health, physical well-being and social relationship dimension scores than Turkish immigrants. However, none of the dimensions were sensitive to the country of origin in the logistic regression analyses.

It was found in literature that older age, female gender, having any chronic disease, having a low educational and socioeconomic status worsen QoL scores. Older age showed a special effect of physical well-being which would be logical since older age is the age of chronic diseases. Bayram et al reported that those who immigrated at younger ages had a better QoL in Turkish immigrants in Sweden. [19] A number of international normative QoL data [20–22] including Turkish normative data [18, 23] also indicated the negative effect of age on QoL.

Turkish immigrant studies from Sweden and the Netherlands also reported that there was a gender difference in QoL in favour of males [19, 24]. In our study, we found that there was a significant relationship between gender and psychological well-being and self-rated health and women had lower scores. However, other studies found lower scores almost in all domains of WHOQOL for women [19–22]. It was reported that men had significantly higher physical well-being scores than women, whereas some of the sub-domains of psychological well-being were not distinctive among men and women [23].

Only the environmental well-being was affected from low educational status, perceived income and home ownership. It is known this domain is much more sensitive to socioeconomic variables than other factors and also could not discriminate ill and well persons [15, 17]. Our results showed that low income was significantly related to psychological and environmental well-being, social relationships, and overall QoL. No significant association was found between marital status and all four domains. Our results were consistent with some other previous studies [25, 26].

The results showed that not owning a home affected physical, social and environmental well-being negatively. Owning a property is an important economic and social indicator. Having a lower socioeconomic status and physical and psychological well-being, social relationships, self-rated health and being unhealthy were significantly related. Low socioeconomic class was significantly related to self-rated health [27–29].

Migrants appear to be more exposed to physical or mental health problems than the rest of the population due to their vulnerable situation and to cultural obstacles in host countries. These health risks increase when compounded by limited access to health care services [1–3]. Poor access to health care services was affected only by the physical well-being negatively. Leavey et al underlined the different nature and importance of the stigma of mental illness in the TSCs [10]. Turkish patients could not easily reveal their mental illness and dislike having someone to translate deeply personal and intimate thoughts and experiences. They are likely to reject or avoid if possible, contact with non Turkish doctors for their mental health problems. May be they could not express themselves fairly based on these cultural aspects and health beliefs.

Antonovsky pointed out the importance of the psychological, social, and cultural resources that people can use and the role of "sense of coherence" to stay healthy [30]. It is also an important factor in a migrant's capacity to cope with stress and improve QoL during the early adaptation. Many organizations and programs in Europe supported research projects and policy works to help ensure that migration and integration can be managed in a socially just and equitable manner [31, 32]. In our study, community integration was found to be associated with the economic power. It was the only variable showing significant relationship with the perceived overall QoL. We found that obesity was significantly related to the psychological well-being. There are some studies focusing on the negative effect of overweight on mental well-being [33–35].

On the other hand, ability to speak English was significantly related to all dimensions in the univariate analysis whereas it was not related to any of the dimensions in the multivariate analysis. These contradicting results suggest that ability to speak English was represented by any other variables such as education, income etc. that were already included in the regression models.

This study has some limitations. First, our results cannot be generalized to the Turkish community living in London due to lack of records of Turkish immigrants living in London. We had to design a mixed sampling method cluster sampling and snowball sampling which cannot be regarded as a probability sampling approach. A second limitation was the measurement of the accessibility of the health care services which was not based on pre-validated measures. A number of recently validated instruments and methods are available for the measurement of the performance of the health care services and health promotion [36–41]. We did not use any of them as they are very long and our respondents will have time constraints. Instead, we followed the main concepts and domains of these instruments while developing our semi-structured questionnaire for the assessment of accessibility of health care. However, our questionnaire needs to be validated.

The results of this study not only demonstrated how the health and well-being of members of the Turkish speaking community living in London were affected by social aspects of their lives but also point to the need for urgent action by local statutory services to address the social issues raised, such as language barriers and integration. Nevertheless, QoL of the Turkish community living in London has a moderate level of health related QoL. The good thing is the indifference of the physical and social well-being scores of the Turkey originated and Cyprus originated Turkish community.

Providing culturally competent care and interpretation services and advocacy may improve the accessibility of the health care services. We anticipate that sharing the results of this study with the public authorities will contribute to the policy making process.

This study was supported by the Social Action for Health, London (SAfH) and funded by the Scientific and Technological Research Council of Turkey (TUBITAK).