This document discusses a master's thesis that examines dental care seeking behavior among ethnic minorities in the Netherlands. The thesis conducted ethnographic interviews with Turkish and Moroccan ethnic minorities to understand their perceptions and habits related to dental health care. The research found that most respondents were aware of the importance of visiting a dentist twice a year, but many still considered the cost of dental treatment a significant burden. Communication barriers and lack of cultural sensitivity among healthcare providers also prevented some ethnic minorities from accessing proper dental care. The goal of the research was to gain insights that could help improve the dental health of ethnic minority groups in the Netherlands.

1. Dental care seeking behavior
among ethnic minorities in
The Netherlands
Master Thesis
Ajeng Wulandari
ID: I6056491
Master of Global Health
1st
Supervisor: Anja Krumeich
2nd
Supervisor: Agnes Meershoek
FHML
Maastricht University

2.
Table of Contents
1 Introduction 1
1.1 Literature Review 3
1.2 Relevance 6
2 Methods 7
2.1 Participants 8
2.2 Data Collection 8
2.3 Procedure 9
2.4 Data Analysis 10
3 Results 12
3.1 The perspectives among ethnic minorities in the Netherlands, in particular
Turkish and Moroccan ethnics on dental care, and their dental healthcare
seeking behavior and the environmental factors preventing them from
seeking and receiving the right care
13
3.2 The attitude and knowledge regarding dental health care 14
3.3 The communication factors not impede access to dental health care among
Turkish and Moroccans ethnic minorities in the Netherlands
16
3.4 The lack of access be explained by structural issues 17
4 Discussion 19
4.1 Understanding the findings in relation to the research question 19
4.2 Conclusion 20
5 References 22
6 Appendix 25

3. Abstract
The study discusses difficulties in seeking behavior related to dental care.
Ethnographic interviews with ethnic minorities have been conducted to obtain a
comprehensive insight in perceptions and habits of migrants in the Netherlands
underlying seeking dental health care. In the end, this knowledge is can result in
improving the dental health status of ethnic minorities in The Netherlands.
The research outcomes revealed that dental care seeking behavior among ethnic
minorities in The Netherlands is clearly a principal matter. The majority of the
sampled correspondents were well aware of the importance to visit a dentist at
least twice a year, although most of them still consider the cost of dental
treatments a sizeable burden.
Keywords: (Dental) Health Seeking behavior, ethnic minority, and dental care,
The Netherlands.

4. 1
1.Introduction
Throughout the last few decades the Netherlands has become host to a large
number of different ethnic groups, which can be mostly attributed to the
extensive colonization programs, exercised during the imperialist era from the
17th century up to the early 20th century. (Penninx et al., 1993). As in other
countries, ethnic minority patients are dealing with difficulties when using health
care services including dental health care compared with the local people (Van
Wersch et al., 1997; Uniken Vernema et al., 1995; Uitenbroek and Verhoeff,
2002; Razum and Twardella, 2002). The need for culturally adequate health care
professionals was identified which is addressed by increased involvement of
ethnic health care workers and the introduction of additional training to improve
cultural sensitivity among health workers (Van Wersch et al., 1997; Uniken
Vernema et al., 1995; Uitenbroek and Verhoeff, 2002; Razum and Twardella,
2002).
Figure 1 Demographic Trend
Source: CBS (2003a, 2003b)
According to CBS forecasts, “in 2020 there will be almost 300,000 ethnic
minorities from African countries in the Netherlands, 550,000 of Asiatic origin and
more than 100,000 from Latin American countries. In 1990 people from these
countries accounted for only a fifth of the total number of non-Western migrants,
in 2003 roughly a third and in 2020 around an estimated 40%. This means that
almost a million residents of the Netherlands will originate from one of the other

5. 2
non-Western countries”. (cbs 2003a). Mean while the ‘traditional groups’ (Turks,
Moroccans, Surinamese and Antilleans) will form a numerical majority in 2020 as
these groups are still growing speedily in size. The total of Moroccans will
moreover beat the number of Surinamese in the coming years. Turks and
Moroccans will be the largest ethnic groups in the Netherlands in 2020 (Gijsbert,
2004).
In general, most European countries claim to offer full equality of treatment to
migrants who have permanent residency status. However, there are many
reasons why migrants still experience unequal access to healthcare. According to
Mladovsky (2007a, 2007b), there are three main factors that contribute to
inequality in healthcare access for migrants:
1) Requirements for obtaining permanent status can be very stringent;
2) Literacy, language and cultural differences;
3) Administrative and bureaucratic factors, lack of knowledge of the system
and mistrust of health providers (particularly for undocumented migrants
fearing detection).
The barriers to healthcare access that are created by the above mentioned
factors have significant impact on migrants’ health, as shown by diverse patterns
of mortality and morbidity affecting migrant populations. This also influences
patterns of services utilization, inducing increased use of emergency services
(Ingleby et al., 2005).
Furthermore, evidence from the Netherlands also suggests that immigrants have
both worse health and worse self assessed health than the native population,
although illness prevalence patterns differ across the four main migrant
populations (Philipa Mladovsky, 2007). Unfortunately there is lack of evidence
produced that relates to dental health care considering that the research was
focused on overall health, however our logical assumption resulting from the
above research is that, if general health is proven to be deteriorated among
migrants then the possibility of decline in dental health is certainly becoming an
area of concern. The growing number of citizens of foreign origin with different
cultural perceptions of health and medicine constitutes an additional factor that
will increase the need for anthropological research in Dutch society.
Anthropologists are drawing attention to the "culturalization" of health problems
among migrant citizens (Van Dijk 1998) and to policies of exclusion in health

6. 3
care. A large number of initiatives (both research and training courses) have been
taken to address the interculturalisation of health and health care (Vulpiani et al.
2000). These immigrants end up in a minority position, handicapped by various
kinds of social disadvantages. As in other regions, also with respect to health,
ethnic minorities are frequently disadvantaged, and their health status is often
poorer than that of the indigenous population (Van Wersch et al., 1997; Uniken
Vernema et al., 1995; Uitenbroek and Verhoeff, 2002; Razum and Twardella,
2002).
1.1 Literature Review
About 35 to 40 million foreign-born people in Europe continue to face difficulties
in becoming a full part of the economic, cultural, social, and political lives of their
adopted societies. First of all this situation is undesirable in the light of European
integration. Integration of immigrants is one of the key policy issues currently
facing Europe (Papademetriou, 2006). For migrants, as with all vulnerable
groups, illness exacerbates marginalisation and marginalisation exacerbates
illness, creating a downward spiral (Ingleby et al., 2005). Access to healthcare
should be seen as no less important than housing and education for the well-
being, and thus the integration, of migrants (Ingleby et al., 2005). However, the
European Commission has found that “While Member States identify immigrants
among those particularly at risk of poverty and social exclusion, many countries
still fail to provide in-depth analysis of the factors leading to this situation. Little
attention is given to promoting access to resources, rights, goods and services, in
particular to appropriate healthcare” (CEC, 2004).
Barriers to access may result in delaying care, resulting in health inequalities but
also the increased consumption of more expensive emergency treatments, as
demonstrated by studies in Madrid (Sanz et al., 2000) and thus such barriers
may also result in self-medication, again potentially causing inequalities and
increased costs to the health system. Barriers to health care may also result in
worse health outcomes, as is suggested by the relatively higher rate of avoidable
mortality among immigrants than among native Dutch (Stirbu et al., 2006a). In
Sweden, on the other hand, the national census reveals few indications of
inequity reflected in the mortality outcome of medical care between immigrants
and native Swedes (Westerling and Rosen, 2002). Certainly, migrants are likely
to face different barriers/inequalities in different European countries. For
example, in a Danish study, there was no overall effect of ethnicity on duration of

7. 4
hospital stay and consequently the utilization patterns of inpatient care seem to
reflect equal care for equal needs (Krasnik et al., 2002). In a Spanish hospital, on
the other hand, the mean cost of discharge of immigrants from low-income
countries was 30% lower than that for the remaining discharges (Cots et al.,
2002). After adjusting for age, case mix and severity, length of stay among the
immigrant population was still significantly shorter, suggesting unequal treatment
for equal need. Looking at the literature different kinds of barriers to proper
access to health care can be identified.
Communication
Unable to communicate in the language of the host country is all too common and
one of the many hurdles immigrants must face from the beginning. Migrants may
have to rely on members of their family or friends that are bilingual, although this
raises issues of privacy (Ingleby et al 2005). This consensus is also in agreement
and supported by the evidence produced by this research, where one of the main
factors in decision making when choosing a dentist was the opinion and advice of
family members and relatives. An interesting solution extrinsic to the health
system is to tailor the content of language lessons to immigrants’ likely health
needs (Taylor et al., 2005). In addition to language, miscommunication and
dissatisfaction stemming from cultural differences and expectations can also
contribute to suboptimal care (Sheridan, 2006, Rhodes et al., 2003, Baarnhielm
and Ekblad, 2000, Webster, 1997) (Eshiett and Parry, 2003). All of the
participants were non-English speaking natives; due to this they would
sometimes use certain words in Dutch during the interview but a difficulty in
communication is not the only problem. According to LM Slack-Smith, CR Mills,
MK Bulsara, and MJ O’Grady (2007), Access to health services, including those for
oral health, also depends upon socioeconomic, environmental and individual
factors. Furthermore, cultural and lifestyle differences also influence the degree
to which services are sought and accessed.
Environmental risk factors
Another issue raised in the literature is linked to social economic factors. In the
Netherlands, ethnic minorities account for 23.4% of the total number of
minimum-income households, with females being at particular risk of poverty
(European Commission, 2007).

8. 5
Not all health care is covered by a single and standardized health care package
but it is divided into the basic layer which is compulsory and the supplementary
layer, which is optional and covers secondary health care benefits such as dental
care, alternative medicine and others. The supplementary insurance is very
flexible and easily applied to specific wishes or needs, however it quickly increase
the monthly cost of your health insurance, which is why it is expected that the
vast majority of the population opts in for only with the basic insurance and thus
often chooses to neglect health related concerns that would be only covered by
the supplementary insurance tier in order to avoid increased monthly payments
and rather risk higher one-off cost due to unprecedented or emergency
treatments that are otherwise not covered by the standard insurance. It has been
also shown that low socioeconomic status could increase the risk of adopting
health risk behaviors (Viner RM, Haines MM, Head JA, Bhui K, Taylor S, Stansfeld
SA et al, 2006).
Large parts of the older generation of Turks and Moroccans, in particular, have
been on the sidelines for so long that they can be regarded as written off as
reformulate their participation in the labor market and also largely as reformulate
their participation in society, given their poor command of the Dutch language.
This pattern has become the reality for many Turkish and Moroccan migrants by
marriage that have little or no education and have no command of the Dutch
language (Gijsbert M, 2004). The issue of language and culture barrier has
prompted a set of programs promoting cultural awareness in medical practices
and also increased the demand for health workers that command one or more
languages native to the larger minority groups. Dental practices employing staff
with training in cultural sensitivity and staff of ethnic origin have suddenly
become accessibly for the relevant minority groups.
Considering the fact that our research has focused on the younger generation as
stated in the sample population one of the criteria requirement for the
respondents was to fit in the age category of 18 to 25 years old due to this
requirement the language and cultural barrier was almost completely eliminated.
Respondents were able to comfortably respond either in Dutch and most of them
were able to complete the interview in English most likely due to the fact that
they have received prior education in the Dutch schooling system. Since the
language barrier is non-existent for the younger generation of ethnic Moroccans
and Turks some residual cultural differences might be still present even after
completing their education in the Dutch schooling system, however there was

9. 6
also very little evidence of concerns that might be caused due to their cultural
diversity inherited from their ethnicity since all have shown adequate knowledge
of the general health and insurance system.
Individual Factors
The age group of adolescents has drawn the attention of the World Health
Organization, since adolescence is a period marked by considerable physical,
sexual, cognitive and emotional changes (World Health Organization). It is a
period when habits and behavior change, remaining in the future and influencing
both their general and oral health. This is why adolescence represents an
essential time for health promotion (Slack-Smith LM, Mills CR, Bulsara MK,
O’Grady MJ, 2007). Furthermore, unhealthy lifestyles such as smoking, eating
sweets and physical inactivity are linked with fewer visits to dentists and greater
curative needs (Freddo SL, Aerts DRGC, Abegg C, Davoglio RS, Vieira PC,
Monteiro L, 2000). Freeman mentions that oral health behaviors are also
influenced by adolescents’ social contacts, tending to adopt behavior similar to
their peers (Freeman R, 1999). Since the health insurance in The Netherlands is
free for consumers that are not older than 18, it is important that good practices
and relationships are established during this period when they are not subject to
cost. These practices could render dental care to be considered as a necessity
rather than an additional cost that one would rather try to avoid.
1.2 Relevance
Studies of the same nature have been already conducted in Sweden, China and
Brazil where the focal point was to identify dental health seeking behavior, but in
The Netherlands, there have been no studies so far focusing on secondary health
care such as dental health.
The major driver behind the studies already conducted in other countries was the
need to describe access to dental treatment in relation to the socio-economic
situation, dental health and equity in access to dental treatment for ethnic
minorities. To this point no studies have been conducted in The Netherlands that
would connect dental health seeking behavior to ethnic minorities, while it has a
sizeable minority population of non-indigenous people due to immigration.
However, research in other EU countries such as Sweden did show inequality in

10. 7
access to dental care. Assumedly similar processes will also play a role in the
Dutch dental care system.
In Summary, this research focuses on all these possible difficulties in seeking
behavior involving dental care. In depth interviews with ethnic minorities have
been conducted to get a complete picture of the perspectives and the current
utilization of minorities in the Netherlands the current and future state of the
dental health care. This knowledge is essential in improving the dental health
status of ethnic minorities in The Netherlands.
2. Methods
The aim of this study is to identify dental care seeking behavior among ethnic
minorities in The Netherlands. For the purpose of this study, a qualitative
research was chosen in order to gain in depth insights from the target group. The
qualitative data of the study were collected from literature reviews and
ethnographic interviews with 10 Turkish and 10 Moroccans in the province of
Utrecht in the Netherlands.
Although the Netherlands was the first countries to introduce policies to tackle
the problem of minorities’ access to (dental) health are, many problems still
remain. The main purpose of this research is to get a complete view about dental
care-seeking behavior of the ethnic minority in The Netherlands, the service
system, and the perception on dental health care and dental health including the
role of perception in their culture regarding dental health. Furthermore, the role
of the government and policy making in promoting dental health and to ensure
that a good service delivery system will be included as well.
The main research question is:
1) What are perspectives among ethnic minorities in the Netherlands, in
particular Turkish and Moroccan ethnics on dental care?
2) How do they seek dental health care and what individual and what
environmental factors prevent them from seeking and receiving the right
care?

11. 8
Sub questions:
1. Do communication factors impede access to dental health care among Turkish
and Moroccans ethnics minorities in the Netherlands, and if so, how?
2. How and to what extend do cultural notions regarding the need for dental care
prevent them from accessing appropriate care?
3. What are their attitude and knowledge regarding dental health care?
4. To what extend and how can lack of access be explained by structural issues
(problems within) the health care system?
Special attention will be paid to the costs people have to pay for the services and
other barriers to seeking dental health care will be covered as well. With
expectations, the question whether dental health care is easily accessible will be
answered in the end.
2.1 Participants
The target group was young adults between 18-25 years old, Dutch citizens with
either Turkish or Moroccan ethnicity in Utrecht. A total of 20 interviews was
conducted, 10 Turkish and 10 Moroccan ethnics were sampled. The majority of
the participants were female (17 of a total of 20). All of the participants were
non-English speaking natives; due to this they would sometimes use certain
words in Dutch during the interview to further the point they were making.
Translation of these Dutch words to English was done on the spot and during the
transcription of the interviews.
All participants agreed to participate in the interview while also ensuring their
confidentiality and anonymity throughout the process. No information that would
allow identification and indemnification was collected or recorded.
2.2 Data Collection
Data collection took place in June 2015 just after the end of Ramadan, in Utrecht,
The Netherlands. A two-part questionnaire was used to collect the data. The type
of interview chosen for this research is ethnographic interviews, containing
questions aimed to collect demographic data to identify target group and open
ended question to inquire insight on the topic of the research. This type of
method was chosen in order to identify dental care seeking behavior among
ethnic minorities in The Netherlands. Interviews illustrate the interviewee’s

12. 9
perspective of dental health care. "Ethnography" is an ambiguous term, but it is
essentially a form of social research that includes some or all of the following
characteristics: the exploration of a social phenomena; "unstructured" data; small
number of cases; analysis that involves and interpretation of meanings of human
action (Atkinson & Hammersley, 1994). However, ethnicity is allow for study, the
link between environment, individual, communication issues, and cultural barriers
can be defined as a set of guidelines, which individuals inherit as members of a
particular society, which "tells them how to view the world, how to experience it
emotionally, and how to behave in relation to other people to supernatural forces
or gods, and to the natural environment" (Helman, 1994 pp.2-3). There are
noticeable cultural differences even among the younger generation but these
cultural differences are either inherited by heritage or by religion and this can
impose an impression in inter community behavior but also to the external
observer. However almost no impact was noticeable in regards to dental health
patient not decline treatment due to gender differences, ratio or cultural barriers.
The special focus of ethnography is "the work of describing a culture, and to
understand another way of life from the other person's point of view" (Spradley,
1980). The interviews were covered different aspects, such as their perceptions
of the causes of dental health, they valuation of the need for dental care, their
perspective about available treatment methods, their awareness about available
services, the impact of health insurance functions and how much patients need to
pay, what factors may restrict people in seeking dental health care services and
their opinion about the government can do to improve the service delivery
system.
2.3 Procedure
The interview began with a collection of demographic questions including age,
nationality, ethnicity, and occupation. The subsequent questions were in regards
to the topic of the research, the perception and dental health behavior of Dutch
citizens with Moroccan or Turkish ethnicity, there were 9 such questions with an
open-ended answer. The initial question with an open ended answer began with
an inquiry of insurance type, since there are 3 tiers of available health insurance
in the Netherlands, beginning with the basic health insurance which is also
obligatory, progressing into the second tier which usually contains broader dental
insurance a package related to family and lastly a 3rd tier which can be either
quite specialized or complimentary to the packages found in the lower tiers. The

13. 10
interview progressed and prompted answers from the participants on the dental
hygiene, the frequency of visits required from their dentists and how they reflect
upon such visits, importance of the visits to the dental clinic, in this section they
were provided with adequate space to recollect their personal experience with
dental healthcare professionals.
Subsequently, the next questions were about the importance of visiting the
dentist twice a year; how often have they visited the dentist and when was the
last time they visited the dentist. This type of interview allowed us to see and
provided us with a view from their perspective and their behavior in regards to
dental health based on the imposed theoretical frameworks. The second half,
more specifically the last five questions similarly inquired about treatment
methods and thus indirectly probed the knowledge of our respondents in regards
to the dental hygiene and healthcare. We tested whether the respondents were
keeping to the obligatory “twice a year” check-up by asking when was the last
time they have had visited a dental clinic, according to which we could deduct
whether this occurred in the past six months; and if they have visited their
dentist they were asked to provide the reason for the visit, e.g. regular check-up,
medical or cosmetic treatment. The mechanics behind how patients choose their
dentist were also a point of interest and such the respondents were asked to
provide their process of decision making when choosing their dental healthcare
professional. Since equitably everyone is requested to visit a dental clinic twice a
year we were curious to see as to what opinions our respondents have on the
current state of the dental health industry and what can be done in their opinion
and own view to improve it. Lastly we wanted to know the satisfaction level of the
patients and overall feeling towards the dentist, insurance and policies governing
the dental healthcare industry.
After all the points that were established in the presented questionnaire further
conversation with the participants was enabled and encouraged to see if there
was any additional information or insight they were ready to share.
2.4 Data Analysis
Research among ethnic minority groups creates additional problems compared to
the general population, which require special attention (Alberts, 1998). Snowball
sampling is the most appropriate way to do this research because the method is a
study sample through referrals made among people who share or know of others

14. 11
who possess some characteristics that are of research interest. This method is
well suited for a number of research purposes and is particularly applicable when
the focus of study is on a sensitive issue, possibly concerning a relatively private
matter, and thus requires the knowledge of insiders to locate people for study
(Biernacki & Waldrof, 1982).
Subsequently all the interviews were transcribed and the data was coded. The
coding purposes no statistical program was used; instead, the coding was done
directly in Google sheets. First of all, the transcribed material was read once, so
the author could become familiar with the data. Then the material was read a few
more time in search of patterns or repetitive sentences to identify a theme. This
analysis based on theoretical framework and research questions. The actual
coding process started after the transcripts were read for the second time. The
analysis consisted of the following:
First step was to identify statements in the transcript relating to type oh health
insurance. Statements relating to their behavior and perspective, how they
prevent from seeking and receiving the right care.
The second step was about their statements relating to the attitude and
knowledge regarding dental health care and statements lack of access by
structural issues concerning the health care system. In order to recognize the
main message of the interviewee’s answers, the codes were created. These codes
were then the base for the classification of the material gathered from the
interviewees. Every statement related to behavior, perspective, knowledge, and
things to improve the health care system was categorized.
2.5 Limitations and Strength
Admittedly the sample size was limited to 20 interviews, which might not provide
a detailed and in-depth insight however it did prove to be enough to portrait a
general picture in regards to our research question. In order to gain more insight
and to get more clear results about the topic, a larger sample should be applied.
A limitation in conducting this research is that direct interviewees about this topic
might have felt slight discrimination due to questioning their ethnicity, which has
proven to be quite sensitive for some. In some cases it was necessary to explain
the meaning of “ethnicity” or to provide some examples and in some cases
respondents have stated to be of Dutch origin (noted Dutch/”Nederland” under

15. 12
ethnicity) while this clearly was not the case. It became apparent that the
respondents might have felt afraid of being judged or targeted specifically by this
question. It felt that, at times, that the answers on the questions were not
completely honest and in result a complete mockery was made of the whole
process, this particular behavior was specific and limited only to the male
respondents. Thus, this ‘socially desirable responding’ was a limitation for this
study.
Subsequently, the sample is also strength of this study, as it provides us with
direct explanation and understanding of issue and possible problem themes
among ethnic minorities, which inherently involves dealing with sensitivity.
Additionally the sample ought to provide a good impression on how individuals
are thinking towards dental health care and their point of view as the minorities
about the dental insurance system. Arguably when drastically increasing the
sample size, conducting the research becomes inconvenient and resource and
time consuming and thus might influence the depth of the collected data.
3. Results
Based on the research, the majority of the correspondents are very well
acquainted with the dental health care system. Table 1 displays the result, which
interpret that nearly all of the participants are also insured for dental care in
addition to the basic and obligatory health care.
Table 1
The Type of Insurance
Basic Insurance only Basic Insurance
including additional
Insurance
Participants 6 14

16. 13
3.1 The perspectives among ethnic minorities in the Netherlands, in
particular Turkish and Moroccan ethnics on dental care, and their dental
healthcare seeking behavior and the environmental factors preventing
them from seeking and receiving the right care
When prompted to share personal perspectives on dental health, topics of
interest such as visiting the dentist twice a year were identified. Two contrasting
opinions become apparent. A sizeable portion pointed out that it is necessary to
visit a dental health care professional at least twice a year. However, others
stated that preventive measures render such procedures unnecessary.
“Yes, for ensuring the health of gums and teeth and avoid developing cavities
when I get older” –Turkish, 24 years old
“No, because I don’t eat sweets/candies. I always brush my teeth twice a day “ –
Turkish, 25 years old,
“ I think it is a waste of money when you can keep your teeth clean and healthy
yourself.” – Turkish, 21 years old.
As Table 2 shows, the correspondents are also well aware of preventive measures
such as brushing teeth at least twice a day, use of mouthwash or dental floss, not
smoking, and avoiding foods and beverages with high sugar content, however the
vast majority of participants would find visiting a dentist twice a year for regular
check-ups necessary.
Table 2
The Need to visit the dentist twice a year
Not Necessary Necessary
Participants
Sample Quotes
Sample Quotes
4
“ No, because I don’t eat
sweets/candies. I always
brush my teeth twice a
day “ –Turkish, 25 years
old
16
“Yes, for ensuring the
health of gums and teeth
and avoid developing
cavities when I get older”
–Turkish, 24

17. 14
“ I think it is a waste of
money when you can
keep your teeth clean and
healthy yourself.” –
Turkish, 21 years old.
“Yes, because in 6
months you may get
some issues with your
teeth” –Moroccan, 20
years old
Table 3 shows that the majority agreed on the importance of visiting the dentist
for a check up at least twice a year, the portion that was in disagreement argued
their position that preventive measures such as good hygiene and healthy habits
would make visiting a dentist twice a year unnecessary.
Table 3
Frequently to visit dentist twice a year
Infrequently Twice a Year
Participants 5 15
3.2 The attitude and knowledge regarding dental health care
The vast majority of the participants in this research indicated that they do not
possess broader knowledge in regards to dental health care. Half of the
participants admitted lack of knowledge of any treatment methods that are
available at a dental health care facility, however the other 50% of participants
indicated that they have experience in regards to various dental health care
treatments due to having undergone such services personally or by having heard
from acquaintances, direct family and other relatives.
“ Wortelkanaal behandeling, I do not know how to say it in English ” – Moroccan,
25
“ Filling two holes of my teeth ” -Turkish, 25
“ I know you can whitening your teeth but I have never done it before ” –
Moroccan, 25

18. 15
“ I know about cleaning treatments “ – Turkish, 24
Moreover, table 4 presents the current awareness of available treatments that are
known to the correspondents. About half of the participants have shown no
recollection of any type of dental treatments while the other half was split
between cosmetic (bleaching/whitening) and corrective (root canal, cavity,
filling).
Table 4
Available treatment method
Participants Sample quotes
Do not know about it 10 “I have no Idea”
Root Canal treatments
Filling a hole
2
3
“Wortelkanaal
behandeling, I do not
know how to say it in
English” – Moroccan, 25
“Filling two holes of my
teeth” -Turkish, 25
Bleaching 2 “ I know you can
whitening your teeth but
I have never done it
before” – Moroccan, 25
Scaling/Cleaning 3 “ I know about cleaning
treatments “ – Turkish,
24

19. 16
3.3 Communication factors do not impede access to dental health care
among Turkish and Moroccans ethnic minorities in the Netherlands.
The following section describes how participants proceeded when they were
prompted to select a dental clinic or a dental health care professional for
treatments or regular check-ups.
There were two ways in which participants made their choice. Firstly participants
claimed that their choice was established on advice received from family
members and relatives.
“Opinion from the family, the dentist knows me since I was a child” –Turkish 23
years old
Other stated however, that their choice was based on the proximity of their home
address to the dental clinic.
“My dentist is located very close to my home and this was the criteria to chose it”
– Turkish, 24 years old.
While the majority’s choice is based on opinion or feedback from their family
members and the proximity of the clinic, 7 out of 20 participants are strictly
service oriented and prefer to receive the best possible service for the best
possible price while proximity and opinion of relatives might turn into a lesser
factor.
“ Available 24/7 and price might be added value” – Turkish, 25
Furthermore, table 5 provides evidence that when choosing a dental health
professional, the opinion of family members matters the most while price/service
ratio being mentioned nearly as often as family advice. Based on the interviews
the third most commonly cited denominator was the proximity of the dentist’s
practice. This would suggest that a dentist practice would most commonly
welcome patients from the direct neighborhood, considering the facts that
relatives would not endorse a practice with unreasonable prices or bad service
and the fact that a practice would do anything in their power to satisfy every
patient or customer.

20. 17
Table 5
The criteria to chose the dentist
Participants Sample Quotes
Based on advise from
family members
8 “Opinion from the family,
the dentist knows me
since I was a child” –
Turkish 23 years old.
Based on proximity to
their home
5 “My dentist is located
very close to my home
and this was the criteria
to chose it” – Turkish, 24
years old.
Based on price/service
ratio
7 “ Available 24/7 and
price might be added
value” – Turkish, 25
3.4 The lack of access due to structural issues
Arguably one of the most important things in terms of health is a service delivery
system. In this part all participants stated their opinion on how things could be
improved in the system. Unfortunately, the majority of the participants either
showed no interest or no opinion in regards to this matter, which would either
suggest that they are absolutely satisfied with the status quo or are indifferent.
Nevertheless, 7 out of 20 participants wished for more affordable dental health
care and would prefer for it to be included in the basic insurance.
“Make it cheaper!” – Moroccan, 25 years old
Additionally the rest of participants consider that reminders are sent too close to
the appointment causing scheduling issues and possible penalties for missing an
appointment.

21. 18
“ The reminder email with the time and date of the appointment sent
automatically by the dentist practice office to the patient should be done at least
3 days in advance, in order to give the chance to cancel the appointment if I am
not available. In this way avoiding any penalty for not going to the dental
appointments.”– Turkish, 25 years old.
Finally, table 6 shows our respondents found that dental health care should be
more affordable and preferably included together with basic health insurance.
Another issue pointed out were the automated reminders for appointments, some
found that these are sent too close to the date of the appointment and therefore
can lead to scheduling issues and possibly to penalties for missing such an
appointment. This doesn't come as a surprise considering that these
appointments are agreed on 6 months in advance and might easily slip one’s
mind.
Table 6
Things to improve the service delivery system
Participants Sample Quotes
No Opinion 11
Asked for more
affordable dental
health care and to be
included in the basic
insurance
7 “Make it cheaper!” –
Moroccan, 25 years old
Found that reminders
are sent too close to
the appointment
causing scheduling
issues and possible
penalties for missing
an appointment
2 “ The reminder email with
the time and date of the
appointment sent
automatically by the
dentist practice office to
the patient should be
done at least 3 days in
advance, in order to give
the chance to cancel the
appointment if I am not

22. 19
available. In this way
avoiding any penalty for
not going to the dental
appointments.”– Turkish,
25 years old.
Overall the purpose of this chapter was to highlight the findings based on the
interviews that were carried out. It is clear that dental care seeking behavior
among ethnic minorities in The Netherlands is a principal matter. The majority of
them were aware of the importance to visit dentist at least twice a year. Although
most of them still consider the cost of the dentist a sizeable burden, ethnic
minorities in The Netherlands, in our case the vast majority of the interviewed
Moroccans and Turks already possess at least basic dental health care plan
coverage.
4. Discussion
The main objectives of this study were to observe the behavior among ethnic
minorities in the Netherlands in this case Turkish and Moroccans with regard to
seeking dental health care. The study focused on what individual and
environmental factors might prevent them from seeking and receiving the right
care. This chapter will offer a summary and a reflection of the findings and the
overall outcome; it will explain why the findings are relevant for dental health
care in the Netherlands. The outcomes of this study are based on the
interpretation and analysis of data obtained through the process of ethnographic
interviews of 20 participants who at the time of the interview lived in Utrecht.
4.1 Understanding the findings in relation to the research questions
While literature on access to health care in general in the Netherlands, and
studies in other countries on access to dental health care suggest that there
might be problems with access to dental care in the Netherlands as well, due to
individual, environmental or structural factors, to our surprise this was not
confirmed by our qualitative study. Although some respondents believed good
maintenance would make regular visits to the dentist unnecessary the majority of
the migrants involved in the study turned out to be aware of the importance to

23. 20
visit dentist at least twice a year. Other than we expected they considered dental
care an important matter and most of participants possessed at least basic dental
health care plan coverage. The costs of the dentist or a dental care insurance
was, however, considered to be a sizeable burden. As the findings of this study
highlight, the dental seeking behavior among ethnic minorities in Netherlands is a
principal matter. The attitude and the knowledge concerning different dental
health treatments was less satisfactory, as half of the participants have shown no
recollection of any type of dental treatments. This, however did not seems to
have any impact on their going for regular check-ups.
4.2 Conclusion
The purpose of this study was to identify factors that might prevent two ethnic
minorities in the Netherlands from seeking dental care. A qualitative research
was chosen in order to gain in depth insights from the target group. This study
focused on young adult men and women between 18-25 years old and looked at
their attitude, knowledge, and perspective regarding dental care. It also took
environmental factors preventing them from seeking and receiving the right care
into consideration.
The research questions were examined through a qualitative approach in the form
of ethnographic interviews. The use of ethnographic interviews, allowed for in-
depth insight into the personal experiences and practices of ethnic minorities with
regard to dental health care. A review of the literature was conducted to identify
potential barriers to access that could result in delaying care, resulting in health
inequalities. These factors were used to structure the ethnographic interviews.
We believe that the research has successfully managed to answer the research
question and provided a rather positive picture on the health seeking behavior of
young Dutch natives with either Moroccan or Turkish heritage. It is pleasing to
know that neither or the groups are being discriminated against or have lesser
access to care or face any difficulties in obtaining care in dental health.
In conclusion further research on this topic can be conducted to gain more in
depth in-sight in order to examine dental health insurance in the Netherlands. In
order to obtain further understanding on the status of the dental health care in
the Netherlands it is worthwhile to conduct additional studies making use of
comparative research and findings, to test dental health association between

24. 21
Dutch natives and ethnic minorities residing in the Netherlands where the results
of the research would provide supporting evidence on health seeking behavior
and consciousness in regards to dental health care, do ethnic minorities perform
worse in this aspect compared to the natives?

25. 22
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Appendix 1
Ethnographic interview for Ethnic Minorities 18 – 25 Years old

29. 26
Appendix 1a

30. 27