How narration could unfold oppression: insights from the experiences of the Kurds in access to Turkish healthcare services

Abstract

Background

Uncovering the nuances of oppression in qualitative research can be challenging, as oppression often manifests in subtle, implicit ways. In such contexts, individuals from oppressed groups may share their experiences in ways that reveal embedded meanings. As such, when interpreting interviews with people from oppressed groups, it is crucial to look beyond what is explicitly stated to uncover their true experiences. This paper examines how the way non-Turkish-speaking Kurds narrate their experiences reveals the effects of language-related oppression and internalized oppression within Turkish healthcare services.

Methods

This paper is a methodological reflection on a prior qualitative study examining how the exclusion of the Kurdish language from Turkish healthcare system impacts access. Through semi-structured interviews conducted in 2018–2019 with 12 non-Turkish-speaking Kurds, the primary study revealed that language barriers extended beyond miscommunication and were deeply rooted in systemic oppression. In this paper, we reanalysed the data using the concepts of the narrated, nonnarrated, and disnarrated, developed by Vindrola-Padros and Johnson, to reveal how narration could unfold oppression.

Results

We found that non-Turkish-speaking Kurds seeking healthcare in Turkey often excluded (nonnarrated) government services due to the lack of services in Kurdish. They indirectly mentioned (disnarrated) the political conflict as the root cause of their negative experiences; and portrayed themselves as the ones who must adjust to the system, rather than the system accommodating their needs which implied internalized oppression (circumnarrated). As a result of this complexity, the individual often disappeared from their own narrative, relying heavily on family involvement (conarrated) as their primary means of access.

Conclusion

Applying the concepts of the narrated, nonnarrated, and disnarrated to the healthcare access experiences of Kurds in Turkey has revealed important insights into the structural and internalized oppression. By extending the original framework to include the concepts of conarration and circumnarration, we have provided a more comprehensive understanding of the complexities of oppression in healthcare access. Additionally, we found that one form of narration often acts as a response, replacement, or justification for another, urging researchers to consider the dynamism and the intricate relationship between different forms of narration.

Introduction

Oppression refers to a system of power dynamics where one group exert control and dominance over another group [1]. This control is often maintained through social, economic, and political structures. Internalized oppression refers to the psychological and emotional effects of oppression, in which oppressed individuals accept and believe in the inferiority or limitations imposed upon them [1]. Internalized oppression remains one of the least studied aspects of oppression [2, 3], partly because of the fear that researching it might unintentionally imply weakness of the oppressed group itself [3]. This assumption has shifted the theoretical dominance in research from oppression to resistance/resilience [3, 4]. Thus, the members of oppressed groups are depicted as active agents rather than passive victims [3, 4]. While it is true that oppressed populations demonstrate strength in certain areas of their lives [5], reluctance to discuss internalized oppression might unintentionally lead to a denial of the underlying problem and a shift of focus from oppressive structures to individual capacities [3].

Recognizing internalized oppression and acknowledging it as an outcome of oppressive structures is, therefore, essential in anti-oppressive research [6]. On the other hand, capturing the nuances of internalized oppression in qualitative interviews can be challenging, because at the individual level, internalized oppression can manifest in various implicit ways. It can manifest as low self-esteem, a feeling of inferiority and unworthiness [3]. Individuals might reject their cultural heritage as a coping mechanism to fit into the dominant society [7]. They might direct their frustrations and negative behaviors toward themselves and their community members [1]. Individuals might accept their marginalized status and systemic inequalities as natural and be self-discouraged to challenge systemic inequities [1]. In this climate, individuals from oppressed populations may tell their stories in a way that may indicate embedded meanings. The way they narrate their experiences may signal the boundaries of their power and abilities of expression [8]. As such, in the interpretation of qualitative interviews with individuals from oppressed groups, it is critical to go beyond what is explicitly said to understand their true experiences.

Background

In healthcare research, the oversight of internalized oppression is particularly evident when examining language-related barriers to accessing services. In healthcare research, language barriers have typically been framed as (mis)communication issues between patients and providers [9, 10]. However, this is a narrow view of language, as language serves as more complex attribute than a simple tool of communication. It can reveal aspects of a person’s social status, ethnic background, and group affiliation [11, 12]. As a result, it may influence how they are treated within the healthcare system. This, consequently, impacts healthcare access for marginalized groups, such as migrants and ethnic minorities [9, 13, 14].

One of the marginalized groups in this sense is the Kurdish population in Turkey. The Kurds are an ethnic group native to a region in the Middle East historically known as Kurdistan, which today spans southeastern Turkey, northern Syria, northern Iraq, and western Iran [15]. Distinct from neighboring populations such as Turks, Arabs, and Persians, Kurds have their own language (Kurdish), unique cultural traditions, and historical identity. Despite their longstanding pursuit of autonomy and recognition, the Kurds—numbering around 30 to 50 million—remain one of the largest ethnic groups in the world without a nation-state [15]. In Turkey, where the highest number of Kurdish population resides, Kurds constitute approximately 20% of Turkey’s 85 million population [16]. In Turkey, Kurds have endured systematic oppression for over a century, and the Kurdish language has been systematically repressed as part of efforts to create a unified Turkish-speaking nation-state [17, 18]. During this time, the Kurdish language has been excluded from all official contexts like healthcare, as well as marginalized, demeaned, and at times even criminalized through strict laws and restrictions [17–19]. Although the Turkish state has recently taken symbolic steps toward linguistic inclusion—such as introducing optional Kurdish language classes in public schools in 2012—these initiatives remain limited in both scope and impact. Their effectiveness is undermined by implementation barriers, including the state’s reluctance to assign teachers, discouraging enrollment policies, and the ongoing fear of stigmatization among Kurdish families [20]. As a result, Kurds rely on their own efforts to preserve their linguistic heritage. Despite strong resistance from below [21], due to systemic obstacles and longstanding assimilation policies, the use of the Kurdish language has declined significantly. Currently, only about 30% of Kurds in Turkey are fully fluent in Kurdish and another 30% speak intermediate level [22].

In the healthcare sector, language barriers remain a significant challenge for non-Turkish-speaking Kurds, as the services are provided exclusively in Turkish. While the exact number of Turkish-speaking Kurds is unclear, using schooling as a proxy for their language proficiency since the Kurds primarily learn Turkish in school, it is estimated that around one-quarter of Kurds have limited comprehension of Turkish [23]. Additionally, due to the longstanding underinvestment in southeastern Turkey, where the majority of the population is Kurdish, the number of Kurdish students admitted to medical schools is considerably lower than in other regions of the country [24]. As a result, the number of Kurdish-speaking healthcare professionals is also limited. Healthcare provision in Kurdish regions largely relies on the compulsory service placements of newly graduated medical doctors, most of whom speak only Turkish.

Since the Kurds’ access to Turkish healthcare services had not been adequately researched, in 2018-19, we conducted a qualitative study to investigate how the exclusion of the Kurdish language from healthcare services impacted access for Kurds who do not speak Turkish [25]. In the initial stages of data analysis, we too, adhered to a conventional approach and treated language mainly as an issue of miscommunication between healthcare providers and Kurdish-speaking patients. However, as the analysis progressed, we began to observe that participants’ narratives indicated underlying themes of oppression, particularly internalized oppression, that went beyond simple communication issues [25]. This observation led us to shift our analytical framework from a narrow focus on miscommunication to a broader exploration of the psycho-social impacts of language-related oppression. In this paper, we provide a methodological reflection on how our examination of the interview data, particularly the way experiences were narrated, let us unfold the nuances of language-related oppression and internalized oppression in access to healthcare.

Methods

In 2018-19 we conducted 12 face-to-face in-depth interviews in Şırnak, Turkey, with 6 women, 6 men, ethnically Kurdish participants, who did not speak Turkish and had preexisting health conditions (for further details please see [25]). The interviews were conducted in Kurdish, using Levesque et al.’s [26] patient-centred framework to examine healthcare access. In this framework, access to healthcare refers to a multi-step process that includes the perception of healthcare needs, the act of seeking care, the ability to physically reach services, the utilization of services, and the consequences following their use [26]. We used a combination of deductive and inductive coding for our primary analysis. Deductively, we adopted most of the components from Levesque’s model as predefined codes or categories. However, the coding process was flexible, allowing for the emergence of new topics beyond Levesque’s model, such as internalized oppression [25].

Initially, we applied a thematic analysis to the interview transcripts. The analysis was done by two researchers, one Public Health resident of Kurdish origin (TB) and one Public Health Professor of Turkish origin (SS, please see the acknowledgements). The principal investigator of the study (TB) was originally from the same province where the study was conducted. TB had been raised in an exclusively Kurdish-speaking family and had firsthand experience navigating healthcare without speaking Turkish, an experience that persisted until primary school when Turkish was learned. TB had also accompanied family members who did not speak Turkish, providing a unique perspective on the challenges faced by non-Turkish-speaking individuals in healthcare settings. Additionally, as a medical doctor and Public Health professional, TB had worked as a care provider in the same province, treating individuals who faced similar language barriers. Growing up in this sociopolitical and cultural context, TB possessed a deep understanding of the local customs, dialect, and community dynamics. In contrast, the second researcher (SS) was a medical doctor and Public Health Professor of Turkish origin. She had grown up mainly in the Western part of Turkey which placed her at a relative distance from the study population, as opposed to TB. SS also had extensive research experience in migrant and minority health, as well as critical health literacy, which was closely related to the study topic.

During the initial thematic analysis, we recognized that the way participants narrate their experiences revealed deeper, more complex issues, particularly the psychological impact of oppression. To better capture these complexities, TB retrospectively applied the theoretical framework of Vindrola-Padros and Johnson [8] as an analytical tool, which is the focus of this paper. This framework offers a way to analyze narratives by considering not only what participants explicitly stated, but also what was left unsaid, avoided, or mentioned indirectly. While we were aware that various other critical methodologies have been used to examine power dynamics and oppression in qualitative research, in our study, we chose to apply Vindrola-Padros and Johnson’s framework [8] because it specifically focused on narration. This decision particularly stemmed from our initial thematic analysis, which revealed that not only there were implicit power dynamics behind individual experiences, but the ‘act of narration’ itself was exposing deeper, more complex issues—particularly related to internalized oppression tied to language in healthcare access. Therefore, we needed an analytical approach that not only critically examined power dynamics and oppression but also focused specifically on the act of storytelling itself. In this sense, Vindrola-Padros and Johnson’s [8] framework provided a practical and focused analytical tool for examining the subtleties of participant narration. This framework has proven insightful in research examining issues similar to what we studied, such as patients’ and providers’ experiences of communication with each other [27, 28], as well as topics of inclusion/exclusion [29] and stigma [30]. However, to our knowledge, no research has yet directly applied this framework as an analytical tool to empirical data in the way we have done in our study.

Vindrola-Padros and Johnson’s [8] framework categorizes narrative forms into three distinct types: the narrated, the nonnarrated and the disnarrated elements. The narrated refers to everything that is explicitly said in the story; the nonnarrated everything that is not said (or avoided); and the disnarrated everything that is said but unrelated to the main storyline. The nonnarrated might portray an element that goes beyond the narrator’s power of expression, because it violates a law or social norm which is imposed upon them. The disnarrated might indicate hidden connections between the element being told and the experience lived. It raises the question, if this event didn’t have a direct relationship with the main narrative, why did the narrator needed to tell this story [8]. The concept of the disnarrated is particularly important in presenting an ‘alternative reality’ imagined by the narrator, contrasting with their current experience [8]. In this paper, we applied this framework to the interview data, categorizing relevant empirical findings into each forms of narration. Namely we explored what is represented, what is not represented and what is represented despite not being directly aligned with the narration. As a result, we aimed to explore how this framework could illuminate the nuances of language-related oppression and internalized oppression in access to healthcare. We identified significant outcomes related to each of these forms of narration, but also discovered additional forms beyond Vindrola-Padros and Johnson’s framework, namely the ‘conarrated’, which refers to narrating multiple elements together, and the ‘circumnarrated’ which refers to a roundabout way of narration. Below, we present each of these categories, supported by relevant empirical evidence from the interviews.

Findings

The nonnarrated: government services

The nonnarrated refers to what or who is left out or not represented in the narration [8]. We found that, the most notable absence in the participants’ narratives was the mention of government services. For instance, when discussing how they obtained health information, participants did not mention any government health awareness programs, as such programs were not available in Kurdish. Instead, they referred to their social circles and sometimes Kurdish TV channels, which sometimes provided health information. Similarly, there was no mention of interpretation services for making appointments or communicating with healthcare providers, as these services were not offered in Kurdish. Particularly striking was the absence of any reference to services that one would typically expect to be mentioned, such as the use of an ambulance in case of an emergency (further discussed below). The only exception for this non-narration of government services was when the healthcare provider was a person who speaks Kurdish.

The narrated: Family

The narrated refers to what or who is represented in the narration [8]. We found that family was a central figure in the participants’ experiences with healthcare services, often dominating the narrative. It was not just narrated—it was almost over-narrated. In nearly every aspect of healthcare access, family was indispensable: providing health knowledge, arranging appointments, facilitating physical access, offering financial resources, providing interpretation, and managing treatment follow-up. We found that this overwhelming presence of family was particularly related to the non-existence of government services in Kurdish. Essentially, the less government services were mentioned (indicating their unavailability), the more family was brought up as a substitute for those services. In instances where participants lacked a family member’s availability, they typically did not bring up alternative options; instead, they would often postpone or cancel their healthcare-seeking efforts. The interdependence of the narrated (family) and nonnarrated (government services) is demonstrated with relevant quotes in Table 1.

Table 1.

Illustration of the narrated experiences, as a response to the nonnarrated government services

Stage of access	The nonnarrated (government services)	The narrated (mainly family), as a response to the nonnarrated
Perception of need and desire for care (Question about health literacy: knowledge about health issues or the needed health services)	Lack of health information/promotion services in Kurdish	• “I ask my daughter.” (68-year-old man) • “Who will I ask? I will ask a sister, what do you do with your knees?” (67-year-old woman) • “For example, I will ask a neighbor, if I trust. I will say I have this issue, what should I do?” (33-year-old woman) • “I ask those who have the same health problem, what they do.” (49-year-old woman) • “Sometimes I watch TV. Sometimes they talk about what is good and what is not [for health]. I watch the Kurdish ones.” (51-year-old woman) • “For example, our [family] doctor is Kurdish, because he explains in Kurdish, everybody goes to him. Everybody goes and asks about whatever they want to learn about. Even those who do not have a health issue go. The one before him was Turkish, no one would go [for asking something].”* (33-year-old woman)
Healthcare seeking (Questions about making an appointment)	Lack of appointment-making services, call centers etc. in Kurdish	• “I give my ID card to my kids and ask them to make an appointment for me. I can’t do it myself.” (59-year-old man) • “I have never done that [making an appointment]. I would ask my son, and he would do it and tell me the [appointment] time.” (51-year-old woman) • “There is no way, I could never do that, I would ask my daughter-in-law, my daughter, son etc.” (67-year-old woman)
Healthcare reaching (Questions about physically reaching and navigating healthcare facilities)	Hesitation to use certain services due to internalized oppression (e.g., ambulances)	• “My son would either take a car and take me to the hospital, or ask someone to drive me. I can’t go [to the hospital] by myself.” (67-year-old woman) • “Once, I had an infection in my kidneys, I was in pain, I asked my son to call his uncle [who is a minibus (dolmuş) driver] and immediately take me to the hospital. I couldn’t stand the pain.”* (51-year-old woman) • “It’s very hard [to navigate the healthcare facility]. If someone is not with me, I can’t help myself. They would tell you go do some tests, go do a tomography etc.… I would just go back and forth.”* (49-year-old woman) • “[When I go to hospital alone] I ask the people around. I say, my son, I don’t speak Turkish, please come translate for me. Some people help, but some say I have work to do. It’s like that.” (66-year-old woman)
Healthcare utilisation (Questions about patient provider relationship)	Lack of healthcare services in Kurdish, as well as Kurdish interpretation services	• “If I don’t have anyone with me, I don’t go. Because I can’t speak. I would tell the person with me I have pain here and there, and they would tell the doctor.” (59-year-old man) • “The doctor talks to the person with me. And I talk with that person too. I say I have a problem here. It is sometimes my husband, sometimes my son, my brother, my uncle… Always a relative.” (51-year-old woman) • “If [the doctor] is Kurdish, I tell him myself. I can let him understand [my health problem] more clearly. But if it is Turkish, I would just stare at him till the morning.” (59-year-old man)
Healthcare consequences (inductively derived from answers to different questions)	Not being able to negotiate treatments with doctors, and do the follow-up after healthcare utilisation	• “If I could help myself, I would go [to doctor] 2–3 times a month. But I can’t. Last year I had that thing [MRI], I didn’t go check my results for 5–6 months. I stayed in that [painful] situation until my granddaughter came [from another city] and said Grandpa I got your test results.”* (68-year-old man) • “I go [to doctor] only for those big issues. I don’t go for a headache or stomach-ache. I don’t want to be a burden. Who is going to take me there and back?” (67-year-old man) • “If my daughter is not with me, I won’t go, even if I die here.”* (68-year-old man)

The quotes marked with an * are also partially cited in the primary paper of this study (please see [25])

The conarrated: Oneself +

An additional concept we introduced in this research is the ‘conarrated.’ The conarrated refers to the mention of one element or actor alongside another in the narration. It refers to the togetherness of more than one element in the narration. We found that, in the cracks left by the absence of government services and the overwhelming presence of family in the narrative, the patients themselves often became invisible. In our interviews, individuals rarely appeared in the story on their own; there was almost always another person in the narrative. We can compare this with taking a selfie with a cellphone but there is always a mysterious second person in the image. That is, the participants did not describe themselves as a ‘solely functional entity’. This was partly because of direct language barriers, as patient-provider communication was done through an interpreter (mostly a lay interpreter from family); but, it went beyond miscommunication. The reason patients refrained from mentioning themselves alone in their narratives laid in the self-portrait they described. The participants described a self-portrait that was disconnected, devalued, disabled and disempowered (Fig. 1). This self-portrait made them hesitant to navigate healthcare on their own or obligated them to have someone accompany them.

Fig. 1.

The self-portrait described by the participants and the way the experiences have been narrated

The disconnection was mostly expressed through the feeling they had when they were not able to talk to a care provider directly in healthcare system. Sometimes they wouldn’t feel as human beings because they couldn’t communicate with their care providers.

“Sometimes, when I wake up in the morning, I have trouble breathing… If I could speak Turkish, I’d go to the doctor three, four times a month. But I don’t. I go there like an animal.”* (68-year-old man).

“It is like playing the shepherd’s pipe for a bull.” (Kurdish idiom - original: wekî bilûra ji gayî re ye – meaning the shepherd’s pipe is used to communicate with goats/sheep, not bulls) (67-year-old woman).

Regarding devaluation, particularly the (non)use of ambulances revealed notable findings. When most participants did not mention calling an ambulance in case of an emergency, we specifically asked why. Their responses often reflected a reluctance to “bother” an ambulance, or a belief that an ambulance wouldn’t come to their aid. This suggests a possible sense of low self-worth regarding their entitlement to certain public services or viewing them more as privileges than rights—and questioning whether they would actually be granted these privileges.

“I don’t have the strength to call an ambulance. Of course, an ambulance would be better [than going to the hospital with a taxi], but I feel like it won’t come for me. How’s it going to come for someone like me, just a poor guy? I don’t have any confidence in that. I’d rather call a taxi, maybe a minibus. Sometimes, we’d even go in the middle of the night.”* (67-year-old man).

“Ambulance? Do I speak Turkish? It wouldn’t even cross my mind. Not even in my dreams.”* (60-year-old man).

“I’ve never called an ambulance. Why would I bother anyone? Ambulance, is it even available or not? But with a taxi, you pay your money and you’re good, at peace.” (62-year-old man)* [19].

As for disempowerment, it was mainly expressed through not being able to negotiate their treatments with their doctors or having difficulties in pursuing their health rights. This sense of disempowerment was further compounded by the lack of self-esteem when interacting with Turkish-speaking healthcare providers. This lack of confidence was clearer when the participants compared it to their experiences with Kurdish-speaking providers, in which they would feel confident and empowered.

“Once my daughter had a car accident. They took her to the hospital, and then they called me for the police report. I took a deep sigh and thought to myself, I wish I could speak Turkish, then you’d see who’s innocent and who’s not [the police blamed his daughter for the accident]. I’d fight for my rights. But now, someone will just tell me this and that, and in the end, they’ll do whatever they want.”* (63-year-old man).

“When it’s your own language, it’s different. We’d go and chat with our family doctor [who is Kurdish]. It’s different when you feel confident. For example, when it’s Turkish, you can’t say ‘do this, do that.’ You can’t argue. But when it’s with someone from here [Kurdish], I’ll say [confidently], ‘Hey doctor, you have to do this.‘“* (68-year-old man) [19].

“Of course, it’s different. When it’s Kurdish, you can say whatever you want, no fear. But when it’s Turkish, you know, you feel a bit hesitant.” (33-year-old woman).

Sometimes the self-perception of patients with Turkish-speaking doctors was also making them feel more disempowered.

“Sometimes I feel like they think they’re above me just because they speak Turkish. They probably feel sorry for me, like, ‘oh, this guy doesn’t even speak Turkish’. And then, I would end up feeling sorry for myself.” (68-year-old man).

“This is something I feel myself, not something the doctor has said to me. Sometimes, I hated myself… because I don’t speak Turkish. The person [the lay interpreter] would just tell the doctor what I said [but I wouldn’t be sure about the translation]. I couldn’t express what I wanted to say about my own body. And then I would just get angry [at myself].” (59-year-old man).

This feeling of disempowerment wasn’t only experienced by patients, but also by Kurdish healthcare providers. Some participants shared that even some Kurdish-speaking doctors wouldn’t speak Kurdish with them. This could be tied to the negative labels associated with the Kurdish language. Some participants felt that doctors might see them as “ignorant” for not speaking Turkish, and some others believed that doctors might think they were somehow superior for speaking Turkish (it should be noted here that these are the labels perceived by the patients, not actually experienced with their care-providers). These labels that have been attached to the Kurdish language might have also been perceived by healthcare providers and consequently led to avoid speaking Kurdish with them.

“How do doctors see me? I don’t really know. But think they must see me as ignorant [for not speaking Turkish]. But it is not my fault.”* (51-year-old woman).

Regarding the feeling of being disabled, one participant described not speaking the official language as a physical impairment when the communication was done through an interpreter [25].

“Of course, it’s different [to communicate directly]. Is it the same if you could eat on your own, or if someone has to feed you with a spoon? Of course, it’s better if you can eat by yourself.”* (59-year-old man).

As a result, the participants depicted a self-portrait marked by devaluation, disablement and disempowerment along with their disconnection with their care providers, which consequently led to a reluctance to be alone.

The circumnarrated: Internalized oppression

Another element that we introduced and went beyond the concepts of narrated, nonnarrated and disnarrated was ‘the circumnarrated’. Circumnarration refers to a narrative strategy that indirectly narrates events or subjects rather than directly reporting them [31]. This approach allows the storyteller to communicate information in a more roundabout manner, often to avoid explicit mention [31]. It involves navigating around a subject or event using tools like substituted narratives and misdirections [31]. Fan et al. [31] describe circumnarration (in a different context), as a process of storytelling where, instead of moving directly from point A to point B (as in traditional narration), the circumnarration follows a curved path to connect the same points. In our research we found that the way or the direction the experiences was narrated was also pointed at significant issues. For instance, when talking about dealing with language barriers in accessing healthcare, the main way of narration was “I wish/if only I could speak Turkish” rather than “I wish/if only the services were provided in my language (Kurdish)” [25]. This way of narration pointed at ‘internalized oppression’, in which the participants found themselves unfit to the system, rather than seeing the system being unfair to them (For further details see [25]). Or else, participants internalized the enduring exclusion of Kurdish from healthcare services and felt little hope for change—prompting them to learn Turkish as a means of ensuring access to care. Thus, the solutions they imagined for reducing language related barriers were self-directed. They tried to find ways to learn Turkish, rather than expecting the services could be provided in their own language, Kurdish.

“We are so miserable, when it comes to language. I’ve been so angry with myself that I once promised to myself I would send all my children to school, no matter how many I have [to learn Turkish]. We’ve suffered too much because of this.” (67-year-old man).

“If there were a school for elderly people like me, where we could learn how to read and write, and how to speak [Turkish], it would be wonderful.” (51-year-old woman).

“Who wouldn’t want to speak Turkish? Who wouldn’t want to help themselves? Isn’t that a huge thing?” (33-year-old woman).

The disnarrated: political conflict

The disnarrated refers to what or who is narrated despite not being directly related with the main storyline [8]. We found that the most disnarrated elements emerged towards the end of the interviews (sometimes, even after the interviews were ended and audio-recording was stopped – the quotes not included due to ethical reasons). The most disnarrated element was regarding the general political context. Several participants made statements pointing at conflict or lack of peace without being specifically asked. When the participants were asked “How do you think healthcare access could be improved for you?”, many participants made statements like the commonly used Kurdish expression “May god pour some water on this fire – Xwedê avekê vî agirî de bike” referring to an end to the armed conflict.

“What can I say? I wish God would put some mercy in the hearts of these governments so they could extinguish this oven [conflict]. I wish a solution could be found, and there would be peace and relief. That’s all I can say. What more can I do with the power I have?” (63-year-old man).

“My dear son, since Şırnak [the city] has been destroyed [because of the conflict], we haven’t seen any good. If only God would grant us some peace, some sun [hope], and take away all the bad [conflict]. We don’t ask for anything more.” (66-year-old woman).

“If this world [referring to the region] could find some peace, if there were no more death or detainment, we would finally feel a sense of relief.” (62-year-old man).

Upon reflecting on why these statements were made, we realized that they in fact highlight the potential underlying causes of the entire experience. In other words, in an alternate reality where the conflict didn’t exist, the healthcare access barriers they discussed would not have been experienced (Fig. 1).

Discussion

In this study, we applied the concepts of ‘narrated’, ‘nonnarrated’, and ‘disnarrated’ developed by Vindrola-Padros and Johnson [8] to examine the healthcare access experiences of Kurdish individuals within the Turkish healthcare system. Our findings suggested that these concepts provide valuable insights into language-related oppression, as well as internalized oppression, in the context of healthcare access. While the concepts of ‘narrated’, ‘nonnarrated’, and ‘disnarrated’ were crucial for understanding the complexities of oppression and internalized oppression in healthcare access, we also identified the need for additional concepts to fully capture the dynamics of these experiences. In particular, we introduced the concepts of ‘conarration’ and ‘circumnarration’, as important additions to Vindrola-Padros and Johnson’s [8] original framework. Furthermore, we found that these concepts are not static but are deeply interconnected and dynamic. These forms of narration were not isolated but rather functioned together. One form of narration often served as a response, replacement or justification for another. Below we will discuss this interdependency of different forms of narration and how they worked together to explain the healthcare access experiences of Kurdish individuals within the Turkish healthcare system.

We begin by the larger picture, namely examining the concept of ‘disnarration’. We found that disnarration offered an important lens for understanding the bigger picture in healthcare access. In ‘the disnarrated’ the participants described an alternative reality in which there is no conflict and consequently no language-related healthcare access barriers. This alternative reality pointed directly to the root causes of the healthcare access issues faced by Kurdish individuals. From this point of departure, we were able to better understand the other forms of narration. In this sense, the disnarrated served as a critical lens to understand what was ‘nonnarrated’ and ‘circumnarrated’. Namely, it was pointing to the structural and individual manifestations of conflict and oppression.

The structural manifestation of conflict or oppression was expressed as the ‘nonnarration’ of government services in the interviews. The government services were not mentioned by participants because they were, in fact, non-existent, or the participants would view them as privileges rather than rights. This was evidenced by the nonnarration of government-provided services in Kurdish, or any services related to Kurdish-language interpretation. On the individual level, conflict or oppression manifested as internalized oppression which was expressed through ‘circumnarration’ in the interviews. That is there was a reluctance or refusal to use certain services that were technically available. For example, participants often reported not using ambulances in emergencies due to feelings of low self-worth or the belief that they couldn’t rely on government services. This way of narration highlighted the deep psychological and emotional consequences of oppression.

As a response to the structural absence of services and the internalized oppression that discouraged them to use available services led participants to relying on alternative sources of support. This led to a new and prominent element in the narratives: the overwhelming narration of family. Family played such a key role at every stage of accessing healthcare that participants nearly answered every question with family. Health knowledge? Family. Appointments? Family. Physical access? Family. Financial resources? Family. Interpretation? Family. Treatment follow-up? Family. This overwhelming presence of family in participants’ narratives did not represent a mere preference but rather a form of dependency and obligation. Family had to step in where healthcare services failed or where participants felt inadequate or alienated by the system.

This dependence on family led to the appearance of ‘conarration’. Within the structural absence of services in Kurdish, the feeling of powerlessness due to internalized oppression, and the overwhelming involvement of family, the individual itself often disappeared from their own narrative. Participants not only directly said they had never been to a doctor on their own, but they also rarely narrated their healthcare experiences in isolation. In fact, the individual itself, in isolation, was even ‘nonnarrated’. The individual by itself mostly did not exist in their narrative. They would come to existence only with the accompaniment of another person, typically a family member.

Lastly, another form of ‘circumnarration’ emerged as a solution to all the access barriers mentioned. When participants described an alternative reality where healthcare access was less obstructed, they often employed a self-directed mode of narration. At first glance, this idea of ‘an alternative reality’ [8] seemed more to align with the concept of ‘disnarrated’. However, there was a key distinction, the direction of change within this imagined alternative reality. The alternative reality participants envisioned didn’t involve a shift in the healthcare system to better accommodate their needs (such as healthcare services in Kurdish). Instead, they adjusted their own identities to fit the existing system. In other words, the alternative (external) reality they imagined was essentially the same as the current one; the only difference was that participants could speak Turkish. The solution, as they saw it, was to become more “Turkified” in order to navigate the healthcare system more effectively. This was evident in statements like, “I wish I could speak Turkish” or “I would send all my kids to school to learn Turkish.” This seems similar to Fan et al.‘s [31] description of circumnarration, where they suggest that if “narration” is like a straight line from point A to point B, then “circumnarration” can be seen as a curved path connecting the same points. The participants in this study not only curved the narrative but completely reversed its direction. More specifically, they expressed that if the healthcare system doesn’t adjust to their needs (A to B), they will adjust to the system’s needs (B to A). Thus, the “circumnarration” revealed how participants’ internalized oppression imagined an alternative reality in which they need to conform to a system that failed to accommodate their realities.

Limitations

This study has several limitations worth noting. The first limitation is that this study was not originally designed to use the framework of Vindrola-Padros and Johnson [8]. As a result, by applying this framework retrospectively, there may be other elements or forms of narration that were not identified. Had the interview guides and analytical methods been specifically designed to capture narrative elements, subtleties, and other narrative aspects from the outset, additional elements might have been identified. Although we unintentionally delved into some narrative elements during the interviews, such as exploring why participants did not mention calling an ambulance in emergency situations, it’s possible that additional insights would have emerged had we been guided by this framework from the start. Applying the framework retrospectively may have led to the disappearance of some narrative elements or theoretical dimensions of narration.

Secondly, this framework was applied to 12 interviews conducted in a single city in Turkey, which might have limited the generalizability of the findings. While generalizability is not typically a primary concern in qualitative studies, the inferences made here may not fully reflect the experiences of Kurds living in other regions. Similarly, the narrative dimensions found in this study might not necessarily capture the diverse experiences of Kurds in different contexts. Expanding the participant pool to include a broader range of individuals from different regions of Turkey would enable the study to encompass a more diverse array of Kurdish groups. This would offer a more comprehensive understanding of the experiences in question and enhance the study’s applicability to other contexts, potentially extending to other forms of oppression, such as gender-based or racial discrimination.

Reflexivity on the researcher’s position

TB, as mentioned earlier, had a close connection to the study population, with being ethnically Kurdish and growing up in a similar context to the participants. This proximity may have introduced certain biases in interpreting the data. It is worth noting that, the participants, in addition to not speaking Turkish, were also uneducated (illiterate) and from low socio-economic backgrounds. This indicates that they may have experienced other forms of exclusion, oppression, or internalized oppression. Therefore, some of the associations made between oppression and access to healthcare might not only relate to language, but could also stem from their uneducated status or low socio-economic position. In this sense, TB may have unintentionally been more inclined to link them with language over other aspects of their marginalized identities. The findings of the study were not verified with the study participants for validation of the inferences. On the other hand, the involvement of SS in the analysis of the primary study likely acted as a counterbalance to these potential biases. Her particular contribution was to highlight other forms of marginalization—such as those stemming from low socio-economic status or limited education—which can lead to outcomes similar to those caused by language-related oppression. SS’s relative distance from the study population, along with her research expertise in migrant and minority health as well as health literacy, provided a balancing mechanism to help mitigate unintended biases. In this regard, the conversations with her guided the overall research toward selecting more concrete evidence directly linking language-related oppression to healthcare access, rather than relying on more ambiguous cases.

Despite these potential biases, the closeness of TB to the community might have enriched the study in ways that might not have been possible for an external researcher. Several indicators suggested that a deep understanding of the socio-political context, local culture, and idiomatic expressions was crucial to fully comprehending participants’ experiences. Such understanding would likely be difficult for a solely external research team to achieve. For example, the consistent nonnarration of calling an ambulance or other government services by various interviewees may not have been as apparent to an outsider researcher. Similarly, making connection between narrative elements, such as between the disnarrated (conflict) and the main storyline would have been challenging without insider knowledge. For example, some participants used the metaphor of “extinguishing fire” to describe the end of political conflict — as quoted: “may God pour some water on this fire [Kurdish: Xwedê avekê vî agirî de bike].” An external researcher might have struggled to understand the cultural and political layers behind this statement. Likewise, the idiomatic expression “It is like playing the shepherd’s pipe for a bull” (Kurdish: wekî bilûra ji gayî re ye), which implies attempting to use something that has no relevance or meaning to the other side (like speaking Turkish to a Kurd), would likely be lost on someone unfamiliar with the political and cultural context. Understanding these nuances required not just knowledge of idiomatic expressions but also a deep immersion in the socio-political environment.

This suggests that the involvement of insider researchers, particularly in data interpretation, is crucial for gaining a thorough understanding of the experiences of marginalized groups. While inclusive research approaches—encompassing anti-oppressive, emancipatory, community-based, participatory research etc.—emphasize doing research with people, rather than on them [32, 33], their involvement often remains limited to the initial phases of research. This typically includes tasks like building trust, using culturally appropriate language and methods, facilitating participation, and refining data collection materials [32, 34, 35]. However, when studying oppression, it is vital for individuals from oppressed populations to be involved in the interpretation of data. While this may introduce potential biases, their perspectives can lead to valuable insights that would be difficult for outsider researchers to access. In this sense, a collaborative approach which is led by the members of the community but includes outsider researchers could help mitigate potential biases, offering a more balanced and comprehensive interpretation of the data [36]. While the insiders can interpret responses more accurately, understanding the subtleties and underlying meanings that might be lost on outsiders; outsiders can provide a broader perspective, comparing and contrasting the studied culture with other cultures they are familiar with [36]. Their lack of deep immersion in the culture can help them see things from a fresh perspective and avoid biases that insiders might have [36]. This can lead to uncovering insights that might be overlooked by those deeply embedded in the culture [36]. This eventually can lead to more comprehensive and comparative analyses and bring a level of objectivity to the research.

Conclusion

Our application of the narrated, nonnarrated, and disnarrated concepts to the healthcare access experiences of Kurds in Turkey has revealed important insights into the structural and internalized forms of oppression that affect their ability to access care. By expanding the original framework to include the concepts of conarration, which refers to narrating multiple elements together, and circumnarration, which refers to a roundabout way of narration, we have provided a more comprehensive understanding of how narration contributes to understanding oppression in healthcare access. Additionally, our findings highlighted the dynamic and interdependent nature of these concepts, urging researchers to consider the relationships between different forms of narration. One of the primary contributions of our analysis lies in showing this intricate interrelation between various forms of narration. In other words, we found that one form of narration often acts as a response, replacement, or justification for another. That is, when applying these concepts in research, it’s important not just to identify narrative elements in isolation, such as “A is represented”, “B is not represented,” but also to uncover their complex interrelationships and find out for example “A is overwhelmingly represented as a response to the underrepresentation of B (essentially replacing B),” or that “X is nearly always co-represented with Y because X alone was inadequate to convey the experience.” Understanding these concepts in relation to one another will offer a deeper understanding of how power structures are embodied in individuals’ personal narratives.

We acknowledge that various other critical methodologies have been used to examine power dynamics and oppression in qualitative research. For instance, Critical Thematic Analysis (CTA), extends traditional thematic analysis by incorporating closed coding to highlight ideologies, power relations, and status-based hierarchies [37]. CTA focuses primarily on identifying themes within data and understanding how these themes reflect power structures (37). Similarly, Critical Discourse Analysis (CDA), as outlined by Fairclough [38] and van Dijk [39], examines how discourse (language use) both constructs and is shaped by power relations and societal norms. CDA explores how language reflects, reinforces, and challenges power structures and embedded ideologies [38, 39]. In a similar vein, feminist methodologies [40], anticolonial approaches [41], and other anti-oppressive research methodologies also investigate how social identities and power dynamics shape individual and community experiences. Each of these methodologies provides valuable insights into how power and marginalization are experienced in society and could have offered a deeper, more critical reflection for this particular research. However, we chose to apply Vindrola-Padros and Johnson’s framework [8] because it specifically emphasizes how power structures are embodied in individuals’ personal narratives. This focus on the individual perspective is crucial for understanding oppression from the ground up—particularly from the viewpoint of those directly experiencing it. We believe this makes their framework especially relevant in healthcare contexts, where individuals, such as Kurds in our study, may hesitate to share their experiences due to fear of political oppression. It is important to note that the aim of this paper was not to explore which methodologies are most relevant for examining language-related oppression and internalized oppression in healthcare access. Rather, it aimed to explore how Vindrola-Padros and Johnson’s framework could serve as a valuable tool for analyzing these issues.

Author contributions

TB led the overall study with primarily writing the research proposal, interviewing the participants, coding, analysing and interpreting the transcribed content, and designing and writing this particular manuscript.

Funding

This research has been funded by the Pears IMPH Alumni Seed-Grant Program to Promote Public Health Research, which is the result of a continuing partnership between the Braun School of Public Health, Hebrew University of Jerusalem-Hadassah and the Pears Foundation.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study has been approved by the ethics committee of Marmara University, School of Medicine, Istanbul, Turkey, on April 6, 2018 with the approval number 09.2018.221 in accordance with the Declaration of Helsinki. Since all the participants of the study were illiterate, the informed consents were obtained verbally and audio-recorded as suggested by the ethics committee.

Competing interests

The authors declare no competing interests.