When Suha (not her real name), 70, was invited to a workshop on healthy living, she arrived full of curiosity. But the conversation with the dietician quickly turned out to be irrelevant. “She explained to us about healing herbs and the damage they do,” Suha said. “She told us to use fruits like bananas, apples and cherries and put them in a blender.” But healing herbs are an essential part of Suha’s culture and that of other women the dietician met. And in the Negev’s unrecognized Bedouin villages there’s no direct electricity supply to run a blender, nor do they necessarily have one, and fruit is not easy to come by.
“Bedouin women are the very fringe of Israeli society – as women, as a minority Arab group and residents of outlying areas,” says Haneen Shibli, a Ben-Gurion University doctoral candidate in public health. Shibli conducted 21 interviews with 14 women and seven men. The interviews revealed the obstacles Bedouin women face when they seek medical care. “There are gender and cultural obstacles that intersect and work full force,” she says. Her research, advised by Dr. Paula Feder Bubis and Prof. Limor Aharonson-Daniel, was published last month in the International Journal for Equity in Health.
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How do these obstacles hurt Bedouin women?
“They might put off or forego health services, which can worsen their health,” she said, citing as an example a woman from an unrecognized village dealing with unbalanced diabetes, whose condition could worsen due to lack of physical access to treatment. Studies show that Bedouin women in the Negev suffer more from diabetes per capita relative to their age than Jewish women in the south.
How common is it for Bedouin women who don’t know Hebrew to have to speak to a doctor who doesn’t know Arabic?
“It’s common. It doesn’t necessarily happen in the community clinics. But it’s enough for a woman to get to the hospital in Be’er Sheva or a primary care facility where a doctor doesn’t know Arabic for a communication obstacle to develop during treatment. But even in the community clinics, substitute doctors can come, or specialists who come once a week, who speak [only] Hebrew,” Shibli says.
How are these problems usually resolved?
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“Help from an Arabic-speaking staff member. That’s not always the ideal solution. In some cases, where translation is required with a doctor, the woman’s privacy is compromised because they have to communicate through someone else. Sometimes a secretary or national civil service volunteer, who don’t necessary know the terminology, has to translate and that could compromise the quality of the consultation. The Health Ministry and the HMOs provide translation services by phone and encourage staff to use them, but in practice it doesn’t happen.”
How does the cultural obstacle play out?
“The opening hours of the clinics don’t suit the norms of Bedouin society. One of the women interviewed talked about clinic hours in the evening for some of the services, although women can’t leave home late in the evening because they’re expected in most cases to do housework and take care of their children and their husband.
“In addition, in cases where the service is not accessible, they have to ask for help. This seems like something natural and trivial, but Bedouin women are embarrassed to ask for help from a stranger, because this is considered culturally unacceptable.”
Shibli said she was recently at the clinic in the Bedouin town of Hura where she saw women, including young women, who were unable to manage with the machine that patients insert their card into to receive their appointment number and room number, unless a clerk notices their difficulty and helps them.
“Healthcare literacy is low among these women, which means it’s a challenge for them to use these machines. They have to be informed about these new things before they come to treatment facilities, in community centers, enrichment programs, health education, etc.,” Shibli says.
What other technological obstacles are there? Why isn’t their healthcare literacy, as you call it, higher?
“Healthcare literacy refers to understanding, processing and applying information associated with health in the context of using health services, disease prevention, etc. There’s also online healthcare literacy having to do with searching, finding and understanding information associated with health, using technology and the internet. This is not taught in school, it’s learned over time, among other ways also by turning to the healthcare services. The moment there are obstacles in health services, and health education is not good enough, the result is low healthcare literacy.”
Shibli cites as examples making appointments for specialists or mammography, which require a phone call or going online. In many cases, Shibli says, women don’t do this on their own but through the secretary in their primary clinic.
Is this a problem mainly among older women?
“An older woman who lacks physical access and doesn’t know how to read and write, and doesn’t know how to act in regard to the healthcare services, will have difficulty getting to a doctor and getting treatment. The situation of younger women is a bit better. But of course there are exceptions. Young Bedouin women don’t necessarily know Hebrew or have a high degree of healthcare literacy. It depends on the exposure they got at home. There are quite a few stories about young Bedouin women who recently finished high school and are not fluent in Hebrew. The same is true for their healthcare literacy.”
What about the gender obstacle?
“One interviewee told me: ‘In some cases I’m embarrassed to go to a male doctor and tell him what I have. It stops me from making an appointment and I don’t feel comfortable discussing my health problems.’ Other young women told me they also face this situation. That’s one of the common reasons Bedouin women delay or forego treatment.”
What do women do to overcome these obstacles?
“They put off treatment until the situation gets worse or they approach the Palestinian Authority.”
There have been reports published about Jewish women also seeking health services in the Palestinian Authority because it’s cheaper. Isn’t that the reason in this case?
“In this case they go to the Palestinian healthcare services for other reasons. Usually it’s because these are treatments they can get in their primary clinic [in Israel], but they want doctors who speak Arabic. And also because the husband can go in with her in certain cases and know what’s going on during the treatment.”
So in some cases, the main reason for going to the PA is because the husband wants to know about the treatment and decide, which he wouldn’t be allowed to do in Israel?
“Yes, that’s one of the reasons. One of the women I interviewed said, ‘I went to see a doctor in the PA because he made me feel better.’ That’s something that’s especially said by interviewees.
Is the Health Ministry, and Clalit HMO, to which almost all the Negev Bedouin belong, promoting programs to overcome the obstacles?
“The Health Ministry as well as the other HMOs. The forum of imams at Soroka Hospital is a wonderful example of [enabling] cultural access to health services. Cooperation between Clalit and the other HMOs with local authorities during the recent vaccination drive is an example of this.”
What is the forum of imams?
“The imams meet with the doctors and hospital personnel and bring up issues that require special attention to suit them to cultural norms and make medical information accessible to the Bedouin.”
Doesn’t the state actually have to fight the cultural norms? After all, to a certain extent the cultural, language and gender obstacles largely stem from the Bedouin way of life. Alongside relying on religious figures as a channel of information, isn’t there also quite a clear danger that in cases where the good or the desire of the female patient clashes with religion, they will favor religion?
“Fight is a very harsh word and I’m not sure it would lead to an improvement of the situation. First of all, the state has a responsibility to see to the population’s health according to the State Health Insurance Law. Thus there is a need to recognize the special characteristics of the community itself. Enforcement is also required, for example, such as with the whole issue of polygamy. There is a clear law but it isn’t enforced enough.”
What solutions do you propose to overcome the obstacles?
“First of all, speak to the population, not over it. Understand that there is an intersection of obstacles. The interviewees suggested solutions like community healthcare clinics in the Bedouin villages that will ease access, provide professional translators or a Bedouin woman in the office willing to help, to have an appointments system in Arabic and, of course, Bedouin doctors who know the culture, the needs and the special sensitivities.”
Do you think there’s something that Bedouin society also needs to do something to improve the ability of these women to receive the best healthcare services?
“Indeed, education and raising awareness of health, health services and life skills among young people and especially among young women.”
To what extent did the fact that you are a Bedouin woman help you conduct the research?
“As a Bedouin woman I was able to talk to the people and not over them. I could understand what remained unspoken, that a stranger to the culture or the gender could have trouble identifying. I didn’t feel a need to explain why I was doing the research. The fact that I, with my knowledge, wanted to help my people was welcomed as a blessing.”