Eritrean Refugees’ and Asylum-Seekers’ Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting
2.2. Sampling Procedures
2.3. Data Collection Instrument and Procedures
2.4. Data Analysis
2.5. Ethical Consideration
3. Results
3.1. Perception of Oral Health Care
“I believe Berbere protects you from bad mouth odour! As for me, I am getting Berbere from home [Eritrea] solely prepared by my mother, and I am consuming it every day. You know what […]? as Berbere is my routine food, I do not have any terribly smelling mouth like others do” (IDI-13).
3.2. Understanding of oral Health Determinants
“Life in Europe is somehow different from our country. Most of us here [in Germany] we tend to change our lifestyle. We start to eat differently, like sweet and packaged food that are not common in our country; starting from me, smoking isn’t also uncommon. I believe that those things are the reason for my poor oral health” (IDI-4).
3.3. Dental Care Behaviour
3.4. Approachability and Ability to Perceive
“Back in our country [Eritrea], if we experience any kind of illness, we don’t simply go to the clinic […]. Our parents and community healers used to give us any traditional herbs, potions, and spells. Then we wait for God to heal us. Likewise, here [in Germany] even though I am not using the herbs and potions […], I simply don’t go to the clinic, I just pray at home and wait for God to heal me from my misery” (FGD-1).
“Sometimes though, the dentists work on a tooth that you have not complained about and we might not be comfortable with it too. As far as I am concerned, I don’t like it” (IDI-13).
“For some of us, it is like we don’t even trust some of the dentists in Germany. I think that when they [dentists] are taking out our teeth, they want to do so in their own interest, and to replace ours with artificial teeth, which is not in our interest” (FGD-1).
“I don’t trust the dentists too. I have a trust issue! I mean […], the bureaucracy is very tedious […], they tell you to sign here, and there […], I don’t know what we are sometimes saying. Who knows, later they [dentists] might ask us to pay all (laughter)?” (FGD-1).
3.5. Acceptability and Ability to Seek
“The dentists should try to understand our difficulties in learning the new culture here [Germany]. In our country [Eritrea], we have a different background and practice for tooth care. We don’t know much about the new way of dental care in Germany […], but we used to treat dental pain with herbs. Thus, the doctors should show some kindness and teach us calmly the correct way […]. My dentist expects me to comply to whatever he said, and he is very rigid and strict […]. I really didn’t understand his instructions and he once yelled at me too (sigh)” (FGD-1).
“As far as I am concerned, the reason behind my hesitation in visiting a dental clinic, despite experiencing marked dental problems, is that I had been through a very bad experience on my way to Europe. I saw and witnessed a lot of awful distress and health problems along my way in Sahara, Libya or at sea [Mediterranean]. Comparing to those, I consider my teeth problem as a simple discomfort and I just resist the pain until it resolves itself” (FGD-1).
“I chose not to go back after six months because I hate the machines that trim the teeth. Do you know how annoying are the rotating machines and the other sharp instruments that they [dentists] use? For example, one day, I had experienced a severe headache because of the instruments that they had stuck into my teeth; honestly, I hated it. Now that I am treated, thanks God it’s over […]. It has been three years since I have experienced any kind of dental problem, and I never been in a dental surgery after that too” (IDI-15).
3.6. Availability and Accommodation and Ability to Reach
“Most of the appointments that you get are on weekdays […], where most of us are busy at work or school […]. They [dentists] won’t see you at weekends. So, if we need further visits, we couldn’t miss work or classes so often […]. Thus, we often miss follow-up appointments” (FGD-1).
“I can say that there is some problem, especially for those who reside in villages, where train transport is unpredictable […]. Pregnant mothers have some access problems. My friend’s wife was once caught up in such a difficulty” (FGD-1).
3.7. Affordability and Ability to Pay
“In my opinion, comparing with the other services, dental care is expensive, and it always requires several consecutive appointments so that you need to skip work, pay for trains, and dental products like tooth brush, paste or mouthwash” (IDI-1).
“I haven’t had enough money to get the treatment [orthodontic treatment], because I have no work or income” (IDI-4).
3.8. Appropriateness and Ability to Engage
“My dentist once informed me that my tooth was decayed and suggested to extract it, and I simply agreed. Then when he [the dentist] attempted the extraction, it took him six hours. Since the tooth was decayed only on the upper part not at root, I should have asked him to restore it. It was my mistake. I was looking for a temporary solution but it cost me a lot and my left cheek was really numb for the following six months” (IDI-3).
4. Discussion
4.1. Study Strengths and Limitations
4.2. Practical Implications
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
No. | |
---|---|
1. | What is the first thing that comes to your mind when you hear about oral health? |
2. | What is good oral health to you? What about oral healthcare? |
3. | How concerned are you about your oral health? |
4. | What is your opinion on the relationship of poor oral health and general health? |
5. | Thinking as ERNRAS, how would you describe your overall oral health status? |
6. | What do you think the risk factors for the poor oral health among ERNRAS? |
7. | Can you talk about the oral hygiene tools you are using? How often are you using? |
8. | what is your opinion on ‘when a dentist should be visited?’ |
10. | Can you tell me what are the main factors hindering ERNRAS from demanding oral healthcare services in Germany? |
11. | what is your opinion on how oral health issues of refugees should be managed at the individual, community, governmental or policy levels? |
Appendix B
Themes and Sub-themes | Pertinent Findings According to Participants (ERNRAS) | Quotes |
---|---|---|
Perception of Oral Healthcare | ||
Perceived definition of oral health |
| “we shouldn’t have a dental cavity, oral ulcers, bad mouth odour or no broken or crooked tooth” (FGD-1). |
Social acceptance and Self-esteem |
| “If we don’t have good teeth, we don’t have a girlfriend (laughter)” (FGD-1). “After I knew from my friends about the smell of my mouth […], it wasn’t good news […], I soon lost my confidence and couldn’t stand talking to people.” (IDI-14). “Then, I wouldn’t stop eating Berbere so that I could stay free of bad breath” (IDI-8). |
Understanding of Oral Health Determinants | ||
Awareness of oral health as holistic health |
| “Tooth has to be cleaned and kept healthy so that we can eat nutritious foods and we live longer” (IDI-11). |
Perceived risks of poor oral health |
| “Here [Germany], we, Eritreans, are consuming a lot of sweet, soft, and packed food, unlike the food we used to eat in our country, which was hard to chew and less sweet. I believe this is the reason for this poor oral health” (IDI-5). |
Dental Care Behaviour | ||
Personal dental care |
| “I always clean my teeth in the morning, right after I eat my breakfast, and sometimes in the evening—before I went to bed” (IDI-3). “I don’t have any idea about this thread, and I have never used one in my life” (FGD-2). “Not always and only, but I sometimes use Mewets if I can find a good tree” (IDI-15). |
Professional dental care |
| “I only go to a dentist for an essential treatment; for example, I once went to a dental clinic for a severe dental pain” (IDI-3). “I check my tooth every six months; it doesn’t matter whether I have a problem or not.” (IDI- 2) |
Misperception of oral healthcare practice |
| “From my understanding […], and from what I heard, the chemical in the toothpaste is destructive to our teeth.” (FGD-1). “I guess it might damage our teeth or gum. So, I don’t have any plans to use it” (IDI-14) |
Approachability and Ability to Perceive | ||
Information about availability and navigation of the oral healthcare system |
| “I don’t know where and how to find it [dental clinic” (IDI-6). “I don’t know even whether a regular visiting is free. I am just hearing now that I could go to a dentist on a twice a year basis”(IDI-12). |
Oral health literacy and beliefs |
| “In our case [Eritreans], […] we were neither screened nor taught to take care of our teeth when we were in our country. Then we grew up known nothing, and it is costing us a lot to learn to take good care of our teeth. We are simply detached of the reality” (FGD-2). |
The level of trust and Expectations from a dentist |
| “When they [dentists] are taking out our tooth, they want to use it [tooth] for their interest and replace ours with artificial tooth”(FGD-1). |
Acceptability and Ability to Seek | ||
Interculturally competent professionals |
| “I can say my first dentist could have done more […]. Not only he doesn’t want to hear my opinion, but also wanted me to follow his instructions only. That’s why the treatment he provided that time couldn’t satisfy me” (IDI-3). |
Lack of communication and professional value |
| “There is one staff, she doesn’t really hear you what you want to say, I don’t know why, she is either racist or arrogant” (IDI-4). |
Autonomy and capacity to seek oral healthcare |
| “Sometimes, even though we are in a great misery and needed treatment, we don’t go to the dentist due to lack of confidence the language barrier puts us into” (FGD-1). |
Disregard or negligence |
| “Dental care never been my priority […], unless I have a serious pain, I don’t care to visit a dentist for a minor discomfort” (IDI-6). |
Fear, anxiety and past dental experience |
| “Dental appointment is good, [..] but I would never go to my dentist for a regular check-up unless I have pain; I am scared of the machines”(FGD-2). |
Availability and Accommodation and ability to reach | ||
Language issues and Availability of translator |
| “It is the language problem I have; I can’t tell a dentist what is really happening to me, and that is why I didn’t go to the dentist” (IDI-6). |
Existence of dental services, hours of opening and appointment |
| “Sometimes the long waiting time and all […], we [refugees] don’t visit unless we have serious problem or pain” (IDI-11). |
Living environment and mobility |
| “Well, earlier my dental clinic wasn’t that far, now that I have changed my residence area to small village, it’s a bit far from my dental clinic. I am not going to the dental clinic, maybe because of this” (IDI-5). |
Affordability and Ability to pay | ||
Direct and Indirect cost |
| “And, the other day that I didn’t visit my dentist might have been due to the instinct I developed to avoid paying money to the dentist as it is crazy expensive”(IDI-3). |
Entitlement based on age, refugee and employment status |
| “I wanted to check and clean my teeth. However, I couldn’t get the treatment, both cleaning and filling my teeth, [..] because I wasn’t entitled to that treatment as I was an asylum seeker” (FGD-2). “Dental treatment is so expensive that I can’t really afford it since a I am not working right now” (IDI-3). |
Appropriateness and ability to engage | ||
Adequacy and quality of the dental care providers |
| “I always think that, at my first visit, the dentist could have given me more information. He [dentist] should have checked my teeth very well and he should have filled it instead of removing” (IDI-3). |
Provider-patient relationships |
| “Some of the nurses in the reception shows you bad attitude and are not friendly” (IDI-2). |
Adherence and involvement of ERNRAS in dental treatments |
| “Most of us [refugees] are not registered with the town’s refugee collaboration community, where we could have participated and seek help when we face difficulty in understanding and accessing the dental services” (IDI-7). |
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n | |||
---|---|---|---|
Age range (Years) | |||
18–25 | 11 | 44% | |
26–35 | 9 | 36% | |
36–45 | 5 | 16% | |
46–55 | 1 | 4% | |
Gender | |||
Male | 19 | 76% | |
Female | 6 | 24% | |
Educational Level (Years attending school) | |||
Primary (1–5) | 2 | 8% | |
Middle (6–8) | 4 | 16% | |
Secondary (9–12) | 14 | 56% | |
Higher (13+) | 5 | 20% | |
Marital Status | |||
Married | 7 | 28% | |
Unmarried | 18 | 72% | |
Employment Status | |||
Employed | 15 | 60% | |
Unemployed | 10 | 40% | |
Stay in Germany (Years) | |||
≤3 | 7 | 28% | |
>3 | 19 | 72% | |
Place of Residence | |||
Heidelberg | 15 | 60% | |
Eppelheim | 3 | 12% | |
Plankstadt | 2 | 8% | |
Dossennheim | 3 | 12% | |
Bammental | 2 | 8% | |
Refugee Status | |||
Refugee | 21 | 84% | |
Asylum seeker | 4 | 16% |
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Kidane, Y.S.; Ziegler, S.; Keck, V.; Benson-Martin, J.; Jahn, A.; Gebresilassie, T.; Beiersmann, C. Eritrean Refugees’ and Asylum-Seekers’ Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study. Int. J. Environ. Res. Public Health 2021, 18, 11559. https://doi.org/10.3390/ijerph182111559
Kidane YS, Ziegler S, Keck V, Benson-Martin J, Jahn A, Gebresilassie T, Beiersmann C. Eritrean Refugees’ and Asylum-Seekers’ Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study. International Journal of Environmental Research and Public Health. 2021; 18(21):11559. https://doi.org/10.3390/ijerph182111559
Chicago/Turabian StyleKidane, Yonas Semere, Sandra Ziegler, Verena Keck, Janine Benson-Martin, Albrecht Jahn, Temesghen Gebresilassie, and Claudia Beiersmann. 2021. "Eritrean Refugees’ and Asylum-Seekers’ Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study" International Journal of Environmental Research and Public Health 18, no. 21: 11559. https://doi.org/10.3390/ijerph182111559