Characteristics of respondents
The characteristics of the participants are described in Table 1. Fourteen respondents were invited to participate in the study. Two of them declined because of the unfamiliarity and the lack of knowledge regarding research methods. Five males and nine females participated. They were between 30 and 46 years old. Most participants finished secondary school whereas four of them finished higher education. Before coming to the Netherlands, the participants were employed in various professions.
Table 1. Respondent characteristics.
Respondent
|
Gender
|
Age
|
Level of education
|
Former profession in Syria
|
Interview duration (min.)
|
|
|
|
|
|
|
R1
|
Male
|
40
|
Secondary
|
Truck driver
|
35
|
R2
|
Male
|
46
|
Secondary
|
Pharmacist assistant
|
40
|
R3
|
Female
|
31
|
Secondary
|
Housewife
|
47
|
R4
|
Female
|
32
|
Higher
|
English teacher
|
40
|
R5
|
Female
|
30
|
Secondary
|
Nurse
|
45
|
R6
|
Male
|
42
|
Higher
|
Marketer
|
35
|
R7
|
Male
|
35
|
Higher
|
Pharmacist
|
37
|
R8
|
Male
|
40
|
Higher
|
Psychologist
|
45
|
R9
|
Female
|
35
|
Secondary
|
Agriculture engineer assistant
|
35
|
R10
|
Female
|
31
|
Secondary
|
Housewife
|
44
|
R11
|
Female
|
42
|
Higher
|
English teacher
|
37
|
R12
|
Female
|
37
|
Higher
|
Arabic teacher
|
45
|
Three main themes were derived from data analysis. Each theme consists of additional subthemes. The main themes were:
1. Different practices in use and prescription of antibiotics in Syria and the Netherlands
In Syria most respondents were used to getting antibiotics prescribed in case of minor illnesses, also for young children. However, some respondents explained that one does not always consult the doctor for a minor illness. It mainly takes place when the minor illness occurs in combination with additional symptoms which makes it difficult to diagnose oneself and to self-prescribe an antibiotic. When a person has the same symptoms, he or she tries to repeat the same medication using the previous prescription without re-consulting the doctor.
‘Now I will explain how I acted in Syria. When the condition was more than usual, I consulted a doctor and when I had the same symptoms again, I went to the pharmacist to take the same antibiotic which the doctor prescribed the first time. For instance, when I had the flu, I went to the pharmacist to take antibiotics. But when I had additional symptoms such as vomiting, coughing or diarrhea I went to the doctor.’ (female, 30 years old, nurse)
All respondents mentioned that Syrians usually seek the advice of the pharmacist. They also are allowed to self-prescribe and buy antibiotics without an official prescription or consultation from the pharmacist. When a patient can pay more money, they often buy the most expensive antibiotic, which is perceived of as the best quality medication.
Some respondents reported not completing treatment courses. They stopped taking antibiotics once they felt better. Other respondents adhered to the instructions of completing antibiotic course.
When arriving to the Netherlands, Syrian refugees suddenly were confronted with a Dutch GP who declined to prescribe antibiotics for minor illnesses. Instead, the GP advised to drink warm tea or buy Paracetamol.
Since the dispensing of antibiotics without prescription is restricted in the Netherlands, half of the respondents accepted the advice of the GP and tried to use natural alternatives such as drinking (green) tea with lemon. A few respondents reported the adaptation to the new health care system, adhering to the GP’s instructions regarding antibiotic use, completing the treatment course and not giving antibiotics to children without an official prescription.
However, the frustration with the GP service led one third of the patients to bring antibiotics in from outside the Netherlands or through a migrant network. The patients saved these antibiotics for emergencies and intended to self-medicate in case the GP refused to prescribe antibiotics to them.
‘I have experienced a long time of tiredness and sickness until I contacted my family in Germany to send me antibiotics. From the first capsule, my health condition became much better.’ (female, 31 years old, housewife)
2. Health beliefs about the curative power of antibiotics
The positive experiences with antibiotic use in Syria evoked belief in the curative power of antibiotics. Some participants had personal experience with the healing power of antibiotics and the necessity of antibiotics to recover.
Taking antibiotics was used by one respondent as prevention. He believed that one capsule of antibiotics daily can decrease the likelihood of being susceptible for an infection.
‘Even if you are not sick, taking antibiotics, every day one pill, can prevent the illness. Therefore, in Syria, I used to take one pill daily or every two days.’ (male, 40 years old, truck driver)
Most respondents considered that taking antibiotics could also be helpful for viral or influenza-like infections. Some of them believed that antibiotics are harmful for the body, so they stopped using antibiotics after feeling better. Others stressed the importance of completing the treatment course to recover completely and decrease the risk of falling ill again. Almost all respondents criticized the random use of antibiotics is Syria.
‘There is chaos and mess regarding antibiotic prescribing in Syria. They prescribe antibiotics for any minor illness. After living here, I realized that it is wrong and inefficient to do so.’ (female, 35 years old, engineer assistant)
After having visited the Dutch GP, some Syrian refugees stated that it takes more time for them to recover when adhering to the suggested natural alternatives. For that reason, they rejected the natural alternatives and preferred antibiotics to have a shorter period of suffering from the illness.
‘I had flu one time after coming to the Netherlands and I did not take antibiotics. The duration of my illness was long. By taking antibiotics I feel that I recover quicker.’ (male, 40 years old, psychologist).
Most respondents did not hear about the “antibiotic resistance” concept before. However, they became aware of it after coming in touch with the Dutch health care system. Some of them conceptualized antibiotic resistance as not being able to recover without taking antibiotics.
It was also evident that their health behavior was strongly influenced by their previous ways of dealing with illness. Therefore, they had difficulty in changing their behavior. Syrian refugees perceived having a weak immunity compared to Dutch persons since they started taking antibiotics from childhood on in Syria.
‘I am trying to use antibiotics as they do in the Netherlands. However, our body immunity is different from theirs. For us, it is more difficult to reduce the use of antibiotics because we have been used to taking antibiotics from childhood on. Therefore, our bodies are not able to combat the illness without the aid of antibiotics.’ (female, 31 years old, housewife)
Syrian refugees who believed that they had a vulnerable body immunity, which could not combat the illness, tried to find ways to self-medicate with antibiotics. Others started to reinforce their body immunity by not taking antibiotics, since they changed their perspective of using antibiotics after coming to the Netherlands. They also became more aware of the negative effects of antibiotics consumption. Some of them acknowledged resorting to self-medicating with antibiotics when feeling tired in order to alleviate the symptoms and to try to recover quicker.
On the other hand, mothers with young children adapted rapidly to the restricted regime in prescribing antibiotics in the Netherlands, because the children can overcome the obstacles of not prescribing antibiotics much easier than the adults.
‘My children adapted to the Dutch health care system more easily than me because they are still children and their body immunity is still strong. For me, it is difficult to recover without antibiotics because I have been used to take it from childhood on.’ (female, 37 years old, Arabic teacher)
Consequently, antibiotics were not given to the children without a prescription. Also the mothers perceived their children being less frequently sick and more able to recover from a minor illness without the aid of antibiotics.
3. Perspectives on two different health care systems
The Syrian respondents showed a general sense of dissatisfaction with the Dutch health care system. The main issue was the difficult access to medication they desired. For example, antibiotics were not prescribed after an operation and instead a mild dose of Paracetamol was administered. This way of treatment made them feel that their ailments were not taken seriously. Another major complaint concerned the lack of professional knowledge they experienced in Dutch health care providers.
‘In the Netherlands, the doctor does not have the courage to diagnose your illness without the help of an apparatus. The GP has insufficient knowledge to treat you.’ (female, 32 years old, English teacher)
The third point of criticism of the Dutch health care system concerned the difficulty of getting an immediate appointment with the GP. Therefore, respondents described how they exaggerated their symptoms and even lied about their symptoms in order to get an appointment with the GP.
‘They do not give me an appointment if I do not have a fever for more than three days. I am always forced to lie and tell them that I have a fever for more than three days. In this way, I can make an appointment with the GP.’ (female, 31 years old, housewife)
Finally, they also criticized the reluctance of Dutch GPs to refer patients to specialist are, which they cannot access without referral.
The participants emphasized that the GP should be aware of their cultural background and about the healthcare system they were used to. For instance, respondents mentioned the detailed questions doctors would ask them in Syria and the easy access to antibiotics within the Syrian health care system they prefer. The experience of having more freedom to choose the specialist and the instant help within the Syrian health care system appeared to be the main reasons for preferring the Syrian health care system.
‘I prefer the Syrian health care system because they have more professional knowledge than the Dutch doctors. In Syria, they help you instantly and you do not have to sustain that amount of pain to be helped afterwards. The specialists are available all the time.’ (female, 42 years old, English teacher).