Determinants and Inequities in Sexual and Reproductive Health (SRH) Care Access Among Im/Migrant Women in Canada: Findings of a Comprehensive Review (2008–2018)

Given growing concerns of im/migrant women’s access to sexual and reproductive health (SRH) services, we aimed to (1) describe inequities and determinants of their engagement with SRH services in Canada; and (2) understand their lived experiences of barriers and facilitators to healthcare. Using a comprehensive review methodology, we searched the quantitative and qualitative peer-reviewed literature of im/migrant women’s access to SRH care in Canada from 2008 to 2018. Of 782 studies, 38 met inclusion criteria. Ontario (n?=?18), British Columbia (n?=?6), and Alberta (n?=?6) were primary settings represented. Studies focused primarily on maternity care (n?=?20) and sexual health screenings (n?=?12). Determinants included health system navigation and service information; experiences with health personnel; culturally safe and language-specific care; social isolation and support; immigration-specific factors; discrimination and racialization; and gender and power relations. There is a need for research that compares experiences across diverse groups of racialized im/migrants and a broader range of SRH services to inform responsive, equity-focused programs and policies.

     

Cultural Background and Socioeconomic Influence of Immigrant and Refugee Women Coping with Postpartum Depression

Postpartum depression is a serious condition that can have long lasting traumatic effects on women and their families. Until recently postpartum depression research has focused more on the population as a whole rather than refugee and immigrant women. Informed by Kleinman’s explanatory model and the postcolonial feminist perspective, 30 immigrant and refugee women were interviewed to find out what factors influenced them in seeking postpartum care and what strategies would be helpful in prevention and treatment of postpartum depression. We found that the immigrant and refugee women in our sample: (a) were influenced by both cultural background and socioeconomic factors in seeking support and treatment; (b) were influenced by cultural differences and social stigma when making decisions about health care practices; and (c) employed numerous coping strategies to deal with postpartum depression. Recommendations are provided for more culturally appropriate and equitable mental health care services for immigrant and refugee women living in Canada.     

An investigation of culturally competent terminology in healthcare policy finds ambiguity and lack of definition

Objective : This research explored how the concept of cultural competence was represented and expressed through health policies that were intended to improve the quality and efficacy of healthcare provided to families from culturally marginalised communities, particularly women and children with refugee backgrounds. Method : A critical document analysis was conducted of policies that inform healthcare for families from culturally marginalised communities in two local government areas in South Australia. Results : The analysis identified two major themes: lack of, or inconsistent, definitions of ‘culture’ and ‘cultural competency’ and related terms; and the paradoxical use of language to determine care. Conclusions : Cultural competence within health services has been identified as an important factor that can improve the health outcomes for families from marginalised communities. However, inconsistency in definitions, understanding and implementation of cultural competence in health practice makes it difficult to implement care using these frameworks. Implications : Clearly defined pathways are necessary from health policy to inform culturally competent service delivery. The capacity for policy directives to effectively circumvent the potential deleterious outcomes of culturally incompetent services is only possible when that policy provides clear definitions and instructions. Consultation and partnership are necessary to develop effective definitions and processes relating to cultural competence.     

Responding to the health needs of women from migrant and refugee backgrounds—Models of maternity and postpartum care in high‐income countries: A systematic scoping review

Pregnant women from migrant and refugee backgrounds living in high‐income countries (HIC) are at increased risk of adverse perinatal outcomes compared with women born in the host country. Women from migrant and refugee background have perinatal healthcare needs that are recognised internationally as a public health priority. The aim of this study was to identify, appraise and synthesise available evidence on the effectiveness of models of care in pregnancy or first 12 months postpartum for women from migrant and refugee backgrounds living in HIC. Care models were mapped in terms of (a) effectiveness at improving service access, (b) effectiveness at improving maternal and infant health outcomes, (c) acceptability and appropriateness from the perspective of women and (d) acceptability and appropriateness from the perspective of service providers. Using systematic scoping review methodology, qualitative, quantitative, and mixed methods research published in English 2008–2019 were included. The databases MEDLINE, Embase, Emcare, PubMed, Scopus, CINAHL, PsycINFO, Web of Science, Google Scholar, Cochrane Database of Systematic Reviews and Joanna Briggs Institute were searched between 27 February 2019 and updated 27 December 2019. Qualitative and quantitative data were analysed narratively. Seventeen studies, involving 1,499 women and 203 service providers, were included. A diverse range of interventions were identified, including bilingual/bicultural workers, group antenatal care and specialised clinics. All identified interventions were acceptable to women, and improved access, however, few provided evidence of improved perinatal outcomes. Gaps identified for future research include the use of qualitative and quantitative approaches to ascertain the experiences of women, their families, service providers and impact on perinatal outcomes. Synthesis of the included studies indicates the key elements of acceptable and accessible models, which were as follows: culturally responsive care, continuity of care, effective communication, psychosocial and practical support, support to navigate systems, flexible and accessible services.     

Building Social Capital Through a Peer-Led Community Health Workshop: A Pilot with the Bhutanese Refugee Community

Despite the high health and mental health care needs, resettled refugees often face cultural and linguistic challenges that hinder the access to appropriate and timely interventions and services. Additionally, such concepts as preventive health or mental health treatment are foreign to this population, which creates additional burdens to the refugee community that already have difficulty navigating a complex health care system in the U.S. To address multiple and complex gaps in health and mental health support for the refugee community, requested is an innovative approach that can convey culturally responsive and effective interventions for health promotion, such as peer-based health education. Few studies have been conducted on the effectiveness of peer-led community health interventions with refugee populations in the U.S. resettlement context. However, peer-led interventions have been shown to be effective when working with cultural minorities and interventions in an international context. Adopting a social capital framework, the current study conducted qualitative evaluation on the impact of a pilot peer-led community health workshop (CHW) in the Bhutanese refugee community. A hybrid thematic analysis of focus group discussion data revealed the improvement in health promotion outcomes and health practice, as well as perceived emotional health. The results also showed that the peer-led CHW provided a platform of community building and participation, while increasing a sense of community, sense of belonging and unity. The findings posit that a peer-led intervention model provides culturally responsive and effective tools for building social capital and promoting community health in the refugee community.     

The Family-School-Primary Care Triangle and the Access to Mental Health Care Among Migrant and Ethnic Minorities

Understanding the concepts of mental health and help seeking behaviours of migrant and ethnic minority families constitutes an important step toward improving the intercultural competence of health and education professionals. This paper addresses these goals among ethnic and migrant minorities in Portugal. For this a multi-informant approach was selected. The study involved nine focus groups (N = 39) conducted with different samples: young immigrants (12-17 years), immigrant parents, teachers and health professionals. The results showed similarities and differences in concepts of mental health, as well as help seeking processes. Stigma continued to be recognized as a barrier in the access to mental health care. The paper argues that providing adequate training on mental health on cultural diversity competencies to health and education professionals can contribute to a better inter-communication and -relation system in the family-school-primary care triangle and thus facilitate access to mental health care for youth.     

Discursos profesionales sobre la violencia del compañero íntimo: implicación en la atención de las mujeres inmigrantes en España

Objective1) to examine the discourses of professionals involved in the care of female victims of intimate partner violence (IPV), with emphasis on how they describe the immigrant women, the perpetrators and their own responsibility of care; and 2) to compare these discourses with the other professions involved in caring for these women (social services, associations and police and justice).MethodsQualitative study based on semi-structured interviews with 43 professionals from social services, associations and the police and judicial systems. A discourse analysis was carried out to identify interpretive repertoires about IPV, immigrant women and their aggressors, their culture and professional practices.ResultsFour interpretive repertoires emerged from professional discourses: “Cultural prototypes of women affected by IPV”, “Perpetrators are similar regardless of their culture of origin”, “Are victims credible and the perpetrators responsible?” and “Lack of cultural sensitivity of professionals in helping immigrant women in abusive situations”. These repertoires correspond to preconceptions that professionals construct about affected women and their perpetrators, the credibility and responsibility they attribute to them and the interpretation of their professional roles.ConclusionsThe employment of IPV-trained cultural mediators in the services responsible for caring for the female victims, together with cultural training for the professionals, will facilitate the provision of culturally sensitive care to immigrant female victims of intimate partner violence.     

Perspectives on Preventive Health Care and Barriers to Breast Cancer Screening Among Iraqi Women Refugees

Since the Iraq war began in 2003, over 4 million Iraqis have been displaced. Little is known about preventive cancer care in this population, but stark disparities have been documented. The purpose of this study was to assess the perspectives of Iraqi women refugees on preventive care and perceived barriers to breast cancer screening. Interviews were conducted in Arabic with twenty Iraqi refugee women by a bilingual (English/Arabic) medical student, transcribed, translated and coded according to established qualitative content and thematic analysis procedures. Psychosocial barriers, culturally mediated beliefs, and health consequences of war were identified as major themes, ultimately showing what factors, alone and collectively, have impeded Iraqi refugee women's ability and motivation to obtain breast cancer screening. To improve cancer prevention and decrease disparities in care in this most vulnerable population, culturally appropriate health education and outreach programs, as well as further community-level targeted studies, are needed.     

A Cross-Generational Study of Contraception and Reproductive Health Among Sudanese and Eritrean Women in Brisbane,Australia

This study conducted in Brisbane, Australia, was undertaken with a cross-section of Sudanese and Eritrean mothers and daughters. We explored and documented the women's intergenerational experiences and knowledge of reproductive health and contraception. Underpinned by a qualitative approach, focus group discussions were undertaken along with key informant interviews with health and multicultural sector professionals. Through examination of knowledge shared, the analysis distilled key aspects of intergenerational fears, cultural safety, and health. Participants proposed recommendations on how refugee and migrant women in Australia and resettled countries globally can more effectively and holistically exercise their sexual and reproductive health rights.     

Practitioner and Client Explanations for Disparities in Health Care Use Between Migrant and Non-migrant Groups in Sweden: A Qualitative Study

To investigate variations in explanations given for disparities in health care use between migrant and non-migrant groups, by clients and care providers in Sweden. Qualitative evidence collected during in-depth interviews with five ‘migrant’ health service clients and five physicians. The interview data generated three categories which were perceived by respondents to produce ethnic differences in health service use: “Communication issues”, “Cultural differences in approaches to medical consultations” and “Effects of perceptions of inequalities in care quality and discrimination”. Explanations for disparities in health care use in Sweden can be categorized into those reflecting social/structural conditions and the presence/absence of power and those using cultural/behavioural explanations. The negative perceptions of ‘migrant’ clients held by some Swedish physicians place the onus for addressing their poor health with the clients themselves and risks perpetuating their health disadvantage. The power disparity between doctors and ‘migrant’ patients encourages a sense of powerlessness and mistreatment among patients.     

Health issues of migrant and seasonal farmworkers

This paper describes the socioeconomic conditions under which the 3 to 5 million migrant and seasonal farmworkers in the United States live. Health consequences resulting from occupational hazards and from poverty, substandard living conditions, migrancy, language and cultural barriers, and impaired access to health care are described. Specific problems include infectious diseases, chemical- and pesticide-related illnesses, dermatitis, heat stress, respiratory conditions, musculoskeletal disorders and traumatic injuries, reproductive health problems, dental diseases, cancer, poor child health, inadequate preventive care, and social and mental health problems. By increasing awareness among health care professionals of the plight of migrant and seasonal farmworkers, the authors hope to encourage development of a stronger public health infrastructure and to improve the health status of these individuals.     

Understanding wellness and barriers to care among Iraqi refugee women in the United States

Iraqi refugees in the US experience a high prevalence of non‐communicable diseases. In this article, we explore how cultural and structural realities intersect to influence utilisation of preventative healthcare and cancer screening with the aim of understanding health disparities in this population. We conducted three focus group discussions with a total of 14 Iraqi refugee women living in a northeastern US city in 2016 and analysed the qualitative data using a thematic analysis. Eight themes emerged from our data: (a) ‘prevention is better than cure:' Iraqi refugee women maintain wellness; (b) physical and mental health are interrelated in causing and curing ill‐health; (c) Iraqi refugee women embrace both biomedical and other healing practices; (d) God contributes to healing; (e) cancer is caused by dangerous environments. Three of the eight themes related to barriers to care; (f) multi‐level problems within hospitals and clinics prevent the delivery of care; (g) financial barriers prevent access to care and good health; (h) competing priorities are a barrier to good health. We argue that understanding refugee health requires critical analysis of both culturally informed understandings of health and illness as well as the structural aspects of health disparities that result in limited access to life opportunities, racism and inequality for refugees and their communities.     

Access to Health Care for Undocumented Migrant Children and Pregnant Women: The Paradox Between Values and Attitudes of Health Care Professionals

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children’s rights are needed to promote equitable practices and advocacy against regulations limiting services.     

Health,Cultural and Socioeconomic Factors Related to Self-Rated Health of Long-Term Jewish Residents,Immigrants, and Arab Women in Midlife in Israel

Self-rated health (SRH) has been found to predict future health, yet its importance is unique in the information it captures, beyond more objective measures. This information can include psychosocial and cultural factors that can be important in understanding women’s health. Our goal was to test whether long-term Jewish residents (LTJR), immigrant, and Arab women differed in their SRH, whether these differences were maintained after controlling for indicators of health status, and, if so, whether the differences among the three groups reflected psychosocial or socioeconomic factors. A nationally representative sample of 814 women in Israel aged 45–64 years was interviewed (between June 2004 and March 2006) regarding socio-demographics, physical health, health behaviors, and psychosocial aspects. Both immigrant and Arab women reported poorer SRH, physical and mental health, and socioeconomic status. Differences between Arab women and LTJR were mostly explained by differences in health measures (e.g., medications and symptoms) and psychosocial measures (e.g., caregiving load and depressive symptoms) and were eliminated when socioeconomic measures were added to the multiple regression models. Differences in SRH between immigrants and LTJR remained after multiple adjustments, suggesting that they reflected unmeasured cultural factors. Even with universal healthcare coverage in a small country (i.e., with minimal financial and geographical barriers to healthcare) minority groups’ health suffers in relation to their socioeconomic and life circumstances.     

Health issues among Afghan women in California

Afghan refugee women are part of the largest refugee population in the world. In the United States, they deal with loss of family members, property, and status and cultural, familial, religious, role, and generational conflict in making the transition from a traditional patriarchal society to a more egalitarian postindustrial society. Findings from a San Francisco Bay Area Afghan community health assessment conducted from 1992 to 1993 are presented. The assessment included 38 telephone interviews, seven community meetings, and a survey of 196 Afghan families. Six years of ethnographic study with more than 200 Afghans and their health providers provide contextual data. We describe cultural characteristics that influence women's access to health care, women's approach toward preventive care, control of information regarding sexuality, and spouse abuse.     

A model program for providing health services for migrant farmworker mothers and children

A bilingual, multidisciplinary team of health professionals collaborated with a migrant health center in North Carolina to develop a model program to deliver primary health care services to migrant farmworker women and children. The program included case finding and outreach, coordination of maternal and child health services locally as well as interstate, and innovative health education programming. Data were collected on the health status of 359 pregnant migrant farmworker women and 560 children, ages birth to 5 years, the majority of Mexican descent, who received primary care services at the center. The mean age of the women was 23.1 years and their mean gravidity was 2.9. Dietary assessments showed that the protein intakes of most met or exceeded the U.S. Recommended Dietary Allowances, but their consumption of foods in the milk-dairy group and the fruit-vegetable group was below recommended standards. Low hematocrit was a common problem among the women (43 percent) and, to a lesser extent, among the children (26 percent). Among the infants and children, 18 percent were obese. Black American women had the highest proportion of low birth weight infants. The project emphasized coordinated services for migrant farmworker mothers and children, such as transportation services, language translation, followup, and advocacy. An outreach strategy involved case finding, home visits, and services by lay health advisors. By the third year of the project, there were increases in the average number of prenatal visits, the proportion of women entering prenatal care in their first trimester, and in the use of well-child services. The project demonstrated effective methods for delivering culturally appropriate health care services to migrant farmworkermothers and children using bilingual public health professionals.     

Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study

Ethnic minorities across the globe encounter disparities in healthcare. While a great deal of research has been conducted on the experiences of these patients, studies focusing on the perspectives of healthcare professionals are limited, particularly in the context of Asia. This study explores the perceptions of and challenges faced by Hong Kong healthcare professionals in the provision of culturally appropriate care to South Asian ethnic minority patients. Taking a qualitative approach, interviews were conducted with 22 healthcare professionals. Two main themes were identified: ‘lack of support’ at the healthcare system level and ‘dysfunctional relationship with South Asian ethnic minority patients’ at the interpersonal level. Challenges at the healthcare system level include information outreach, cultural competency, utilisation of available resources and time and workload, whereas challenges at the interpersonal level include patient–provider interaction, patient–provider perceptions of illness and care and patient–provider sociocultural discordance. Intercultural care was found to be influenced by both the healthcare system and interpersonal characteristics. The study highlights the need for healthcare professional education and training in cultural competency, in order to improve the provision of intercultural care. Identifying the challenges faced by healthcare professionals and the implications of these challenges for the provision of healthcare to South Asian ethnic minority patients will help practitioners, policy makers and care provider agencies to improve quality of care and health outcomes for culturally diverse patients.     

Improving health care provision to Somali refugee women

A growing number of Somali refugees are calling Minnesota home. Health care providers need to understand how best to serve these newcomers, many of whom are accustomed to a very different health care system and have a variety of expectations when it comes to the care they receive and the way it's delivered. This study sought to gain insight into the health practices and health care preferences of Somali refugee women living in the United States, as well as their experiences with the U.S. health care system. In focus group discussions, participants expressed their preference for seeing women physicians, distrust of interpreters, and willingness to follow their physician's advice. They also shared stories about incidents during which they felt they had been the victims of stereotyping. Increasing the number of qualified translators and providing cultural competency training for clinic staff are recommended first steps for improving the provision of care to Somali refugee women.     

The clinical gaze in the practice of migrant health: Mexican migrants in the United States

This paper utilizes eighteen months of ethnographic and interview research undertaken in 2003 and 2004 as well as follow-up fieldwork from 2005 to 2007 to explore the sociocultural factors affecting the interactions and barriers between U.S. biomedical professionals and their unauthorized Mexican migrant patients. The participants include unauthorized indigenous Triqui migrants along a transnational circuit from the mountains of Oaxaca, Mexico, to central California, to northwest Washington State and the physicians and nurses staffing the clinics serving Triqui people in these locations. The data show that social and economic structures in health care and subtle cultural factors in biomedicine keep medical professionals from seeing the social determinants of suffering of their unauthorized migrant patients. These barriers lead clinicians inadvertently to blame their patients--specifically their biology or behavior--for their suffering. This paper challenges the focus of mainstream cultural competency training by showing that it is not the culture of the patient, but rather the structure and culture of biomedicine that form the primary barriers to effective multicultural health care.