Maternal health care challenges within African ...

May. 2010, Volume 7, No.5 (Serial No.55)

Journal of US-China Public Administration, ISSN 1548-6591, USA

Maternal health care challenges within African immigrant communities Josephine B. Etowa1, Swarna Weerasinghe2, Felicia Eghan3 (1. Faculty of Health Sciences, University of Ottawa, Ottawa ON K1H 8M5, Canada; 2. Faculty of Medicine, Dalhousie University, Halifax NS B3H 1V7, Canada; 3. Department of Family Studies & Gerontology, Mount Saint Vincent University, Halifax NS B3M 2J6, Canada)

Abstract: Historically, immigration has had a significant impact on the changing demographic of the Canadian society. Each year more newcomers enter the country. There are more than 45 ethno-cultural associations and more than 100 different ethno-cultural groups residing in Nova Scotia. In the recent past, social science researchers are becoming increasingly involved in identifying ways of effectively addressing the social and health needs of this culturally diverse Canadian population. There is very limited literature on the Nova Scotian experiences of immigrant women especially those of African descent. For the government to develop public policy that ensures the inclusion of vulnerable and high-risk populations in our society such as recent immigrants and black people, their perspectives should be considered. Some steps are being taken by individual researchers to illuminate these perspectives. The paper will discuss the findings of a project that examined the health care experiences of immigrant women in a Canadian province with a goal of illuminating health care needs of recent immigrant women and facilitating community capacity building to create positive change for more accessible health care. The data collection method was primarily focused group meetings and workshops held with the individual immigrant communities. Although the project was conducted with immigrants from five regions of the world, this paper will focus on the experiences of first generation immigrant women of African descent with emphasis on their perspectives on the process mothering in a multicultural society. The paper will discuss their childrearing needs and their attempt to address these needs within the spaces of multiculturalism, the two predominant ones being the Canadian culture and that of their countries of origin. The paper will conclude with some suggestions for change at both the practitioner and policy level in order to effectively address the social and welfare needs of this population. Key words: maternal health; immigrant women; health care access

1. Introduction Although African Canadian immigrants comprise one of the largest visible minorities in the country, they remain socially, economically, and politically disadvantaged and are underrepresented in health care delivery, health research, and the design and application of health policy. Consequently, there is a critical gap in research-based knowledge on the health issues of this population. Over 250,000 new immigrants and refugees arrive in Canada each year (Stats Canada, 2006). There were 662,210 black people living in Canada (Stats Josephine B. Etowa, Ph.D., associate professor, School of Nursing, Faculty of Health Sciences, University of Ottawa; research fields: inequity in health and health care. Swarna Weerasinghe, Ph.D., associate professor, Department of Epidemiology, Faculty of Medicine, Dalhousie University; research fields: social and physical environments of health, the interactions of social environment and physical environment. Felicia Eghan, Ph.D., associate professor, Department of Family Studies & Gerontology, Mount Saint Vincent University; research fields: immigrants’ retirement, health and well-being. 30

Maternal health care challenges within African immigrant communities

Canada); just over half of this population is composed of immigrants (Mensah, 2005). In most cities across Canada, black immigrants outnumber indigenous black people with the exception of Halifax where indigenous blacks have a larger population (Mensah). More than 2,500 immigrants and refugees arrive in Nova Scotia each year and over 100 different ethno-cultural groups reside in the province of Nova Scotia (Enang, Wojnar & Harper, 2002). According to Census data, Asians (of West, South, East and South East origin), black people (of African and Caribbean origins) and Arabic people are the three largest visible minority groups in Nova Scotia (Stats Canada). Understanding the health status of immigrants is critical in creating effective health policies within a framework that anticipates future health needs of immigrants. However, very little is known about immigrants’ health status and/or health care needs. Institutional policies often grounded in a tradition of Eurocentric ideology that does not account for racial, ethnic and cultural differences of populations often perpetuate and reinforce health inequities (Dominelli, 2002; Racine, 2003; Singh, 2002; Tomlinson, et al., 2002). Unfortunately, without reliable and consistent evidence to support and explain the unique health needs of immigrants and refugees, as well as the requirements for specific services, there is a danger that these communities will continue to face marginalization from the mainstream society. At the policy and institutional level, recognizing cultural themes and understanding immigrants’ perceptions of health and illness are essential to providing better quality health care (Wong & Wong, 2003). A dialogue on these issues is beneficial in providing opportunities for knowledge exchange between the providers and recipients of health care. In this paper, we discuss the findings of a qualitative study that explored the health care experiences of immigrants with a goal of explicating their health care needs and building their capacity to advocate for policy and systemic changes in health care. The primary mode of data collection was focus group meetings and data analysis was facilitated through the grounded theory process of constant comparative analysis. While the immigrant women involved in the study came from various regions of the world, this paper will focus on data from the focus groups of recent immigrant women of African descent. Several themes emerged from the data including the meaning of health, issues influencing health care access such as racism, how they cope with these issues, and issues influencing their mothering experiences. This paper will focus on those issues influencing their health and mothering experiences. These include lack of access to health care, racism and cultural factors. The paper also presents the study participants’ suggestions on how the health care system can be more responsive and efficient in meeting the health needs of all Canadians.

2. Results 2.1 Lack of access to health care Barriers to accessing health care experienced and narrated by the women in this study included issues such as lack of professional knowledge about health issues that disproportionately affect people of African descent, under-representation of minorities in the health professions and language barriers. Lack of professional knowledge refers to lack of adequate education about the issues affecting minority populations including appropriate assessment of dark skin people. This lack of knowledge is explicit in this excerpt from the focus group: I went to the hospital for surgery and they asked me to watch for redness and that means that there is some infection and I should call the doctor. Meanwhile we didn’t see any redness. Then I got an infection and there was no redness. So I stayed there until I saw some liquid oozing out. Finally, I got it that I had to call the doctor. So I went to my family

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Maternal health care challenges within African immigrant communities doctor … he gave me antibiotics …. I was looking for redness. There was no redness coming so I thought I was okay.

Similarly, a second participant elaborated on the point: … that problem started from medical school … they have to be told that there are different types of skin. Where you have lighter skin, look for redness then you are sure that there is an infection … why can’t they learn about (other skin types)? … take the time to teach them what it (infection) will look like on a black skin ….

One of the women recalled the impact that the inadequate professional knowledge had on the quality of health care her friend’s family received. She noted: I had a friend who had a baby and the baby got rashes … she went to the hospital and the doctor looked at her and said he does not know what rashes mean on a black baby. How do you assess that? There is a mother who is desperate and they didn’t know what was happening to her child. All the doctor could say is that “I don’t know how to diagnose rashes on a black baby”. So where do we go for help?

Some of the women identified under-representation of minorities in the health professions as well as the limited number of health professionals trained in the area of tropical medicine: Who can at least affirm that “we belong here” and are conversant with the needs of the visible minority communities, as further barriers to access. One woman felt it beneficial for training institutions to teach about: “symptoms with a particular view of immigrants and people of color … if the disease we get is a symptom like the white people, does it show different treatment? They don’t know malaria but some immigrants (have had it) …”. Along these lines, another woman related: I think that there is only one Dr … who deals with that (Malaria). When you are traveling, one of the things that they write on the pamphlet is that when you come back and you are sick, tell the doctor where you traveled to a country that there was an outbreak of Malaria. It is interesting that there is no one to tell here in case you have this. I think that there should be specific doctors that can take care of tropical diseases.

One woman narrated a conversation she had in the past, discussing health issues of individuals from tropical areas: They say he is the only one that can identify some of the diseases that have just come from tropical countries … I wanted to know the depth of his knowledge in tropical diseases. He told me that at the moment, he was the only one and sometimes he does not feel confident that he knows enough. He has worked in tropical areas and because of that he is now a specialist here. I think that multicultural kind of sharing is needed so that they can bring doctors from there who could teach tropical medicine. Doctors from tropical areas not doctors who were sent to work there and then come back ….

She felt that it should become a requirement for medical students to take at least one course on tropical medicine. Another woman validates this lack of knowledge in relaying her experience: “they didn’t have the medical facts …”. She goes on to explain why research plays a major role in ensuring equitable access to health care for all Canadians: “they need to know more about diseases because Canada is multicultural …”. In the absence of a trusting relationship with health care professionals, some immigrant women often rely on relatives and friends with professional backgrounds to help them navigate the complex health and social service system. The friends are consulted because they are a useful source of information (Neufeld, et al., 2002). They interpret both the details of the specific process about which information is requested, along with cultural differences; thereby allaying fears based on either experience or expectations. However, the limitations of this

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informal network ensuring confidentiality of health information may serve as an additional barrier to accessing both health care and relevant medical information (Neufeld, et al., 2002). Language as a barrier often impedes the health visit due to cultural differences in what is considered appropriate behavior. As one woman said, accent can also become a barrier. She recalled: “… your accent becomes an impediment … when I go to the doctor he will keep saying, ‘pardon me, pardon me’ … you understand what I am saying?” It is important that the provider and recipient of health care have a common understanding of the health problem, and they also need to acknowledge and respect each other’s explanation of the health problem (Harmsen, et al., 2003). 2.2 Racism Racism is a determinant of health through its direct effects on individual, family, and community health and well being. Racism can be experienced at the systemic or institutional, and at the individual level (Jones, 2000). Racism and discrimination are also expressed in both subtle and overt ways including health professionals’ lack of cultural competence. Black women in this study experienced the interlocking expressions of racism in health care policy, programming, and professional practice as well as in research. They shared several experiences they had in accessing health care, which they perceived as racist and discriminatory. For example, one woman explained: You don’t have different shades of brown …. I had my baby here. It was time to dress the wound. I wondered why you only have one shade of plaster. I noticed that for all white people, they try so hard to get a color down to suit their skin where I just had one shade of brown …. These are the things I am talking about. Nobody knows me …. You can’t? Just because I have black skin? Why not respect us?

Other women expressed their feelings more succinctly, stating: Racism says that you don’t have knowledge. You are not even human. It (racism) really hurts you on all level. You’re denied access, a social outcast. It affects you in many ways. … when you come here from Africa and you mention the world they don’t mention Africa. It is like we are not on the globe.

One woman described the effects of under representation in the media in conjunction with insufficient health status information, saying that due to the lack of representation in the media, people often speak of having “a white people disease…”. When they are advertising medicine and other things on TV with all those different health conditions, they never put a black person on the screen to show that black people can also have these things. So a lot of people don’t think that if white people have it we can have it too....

Other system manifestations of racism and discrimination include non-representation of black people in the health professions and limited research on the various disease conditions that disproportionately affect marginalized populations such as people of African descent. This lack of knowledge about black people’s health reinforces their location on the margins and the feeling of being an outsider, which experienced not only by women of African descent but in some cases other visible minority communities. Many of the women in the study expressed frustration over the lack of validation of their international professional and academic experience: “I think that I wasted nine years of my life in medical school … in Canada I have not been able to practice my profession. That is what causes me the most stress … that lack of respect is so hard … ”. Racism at the individual level takes the form of attitudes, beliefs, values and behaviors such as prejudice, bigotry, belittling and stereotyping. The women in the study also related instances in which they experienced

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cultural insensitivity and lack of understanding by health professionals. One woman described the detrimental mental health effects of continuous instances of discrimination: “When you are in a country where they discriminate so much against you. Maybe it was because I was black …” She goes on to describe the internal struggle that accompanies her numerous encounters of prejudice and discrimination: I remember I went to the hospital to be admitted and they gave me tattered clothes. Maybe it was not intentional but everybody else has nice clothes and matching shoes. Here I was the only black and I was wearing this dress, which is torn, and everybody else beside me is wearing a dress that even matches with the shoes. I asked why I am the only one wearing this?

Another woman expressed concern over the quality of care: “I have a friend who has a family doctor, who would not touch him because he is black. The lady won’t touch. They never touch him”. 2.3 Cultural factors The immigrant women in this study perceived health care professionals as being insensitive to their cultural values and beliefs. Some felt like outsiders whose experiences were marked by disrespectful encounters, offensive language and behavior from the health care providers. Body language was perceived by the women as quite different in Canada in comparison to their countries of origin. The women felt that touching, talking and “asking questions” made a “lot of difference” in helping them to “relax and gain some confidence” within the clinical setting. One woman recalled: A doctor in Africa, … the first one minute he doesn’t ask what you came for, it is just social. How is your family and stuff and then tell me. By that time you have relaxed … sometimes here you are sitting in the chair ten minutes … You can see you are being hurried to leave.

Different cultures have specific customs and beliefs that dictate their actions and behaviors towards health. The women in this study also expressed the differences in expectations between the health care provider and recipient about the health visit: When you go to the doctor here, I find that sometimes I just want to talk. I am just mildly depressed. I go in and say I am just not sleeping well. You start talking and they start writing your prescription. I don’t think this is quality care ... I don’t want them to give me a drug, maybe all I need is some psychoanalysis ....

Cultural differences in relation to lifestyle, e.g., exercise and diet, was also discussed: In (country of origin), when you walk when you go home we never really think of it as exercise. We don’t think of it as keeping ourselves healthy, it is a natural thing for us. When you come here (to Canada), we drive everywhere, we eat fatty foods … Over here we start working and exercise going out of the window for African women. A lot of African women would not think of aerobics and going to the gym. We just don’t do it ….

One woman expressed her preference to walk for exercise because of the cost associated with the gym: “Of course I want to walk; I don’t have to go for an aerobic exercise which is expensive ... I can get exercise without paying much …”. The cost of maintaining good health on a fixed income also came up in relation to diet and food choice. Discussions occurred around food, healthy diets and the cost associated with trying to provide balanced and nutritious meals for the family: There is a difference in the food … where we come from we eat healthy and natural food. Here when you are new you still have that taste … when you go to that green section … I am buying only a kilo of green vegetables, but it costs as much as the meat. I don’t eat the greens by themselves. You have to buy the meat and it becomes expensive …

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The women expressed concern about changes to their diet as it might affect their health: “… eventually you grow out of the taste for healthy natural food and you have to go to spaghetti and ground beef”. Increasing healthy behaviors and limiting behavior that is detrimental to health is a major challenge facing these women. This is clearly illustrated by one woman’s concern regarding observed differences in acculturation between the first generation immigrants and their children with regards to diet and food choices: “the immigrant … not their offspring, the immigrant themselves tend to stick to the traditional food, the natural foods that are very healthy … we stick to it but we spend more money on food …”. Finally, and perhaps most significant of all for immigrant women is the difficulty in effectively straddling multiple cultural realities in navigating the health care system and in performing their roles as mothers. This ability to integrate multiple cultural perspectives requires an individual to change personal attitudes around health, health promotion and disease prevention activities. 2.4 Negotiating cultural boundaries as a mother The women in this study faced a number of challenges as they sought to help their children to navigate the Canadian society. In Canada, children’s independence and high achievements are encouraged; in most African cultures, the emphasis is on interdependence, cooperation and contribution to the collective for the benefit of the community as a whole (Enang, 2001). While social dialogue between a mother and a child is encouraged in Canadian culture, some other cultures, do not consider children to be conversational partners with their parents (Enang). As one woman said, Our cultural values … are so different—and there’re clashes between cultural values. Parents are having problems because they cannot discipline the kids the right way … we need to know the culture here yet we are also brought up with certain cultural values to them, but they want to do everything that is here. I don’t blame them because they want to fit into society too ….

For the African immigrant woman, mothering in the western world requires special knowledge and skills to successfully navigate within the spaces of these multicultural and seemingly divergent values. One woman described the tensions and conflict that occur in the process of this kind of mothering on the margins in this narrative: I had a big problem with my daughter. She was born there and she came over here. She came up here when she was about four years old and she was a very stubborn one … she wouldn’t do anything … I tried to get her counseling and try to get me some counseling too, because I want to understand how to deal with her. The counseling really didn’t work … When she got older I put her in different things like music … but she got worse, she was rebellious and she would always talk back ….

The woman went on to describe the problems with disciplining her child and the conflicts that arise when she must put aside what she knows and act in ways permitted in Canada: One day she called Social Services because I hit her … when Social Services came they tell me right in front of the child that “you cannot hit her”. So if you are going to raise your daughter or your son and the government is going to say you are not going to do this in front of the child before even listening to my story on what I did … I think that is why a lot of kids come here and they are having a lot of problems. The parents are having problems because they cannot discipline the kids the right way ….

Another woman concurred with the difficulty of reconciling different cultural ideas around discipline “for a child to be shouting at you all the time is very bad …”. She went on to describe the additional friction this caused 35


within the home: “my older son would never do that. He would never talk down to me and he was very very upset ... he would say you should never talk to mommy like that”. For African immigrant families, the effects of oppression further complicate the mother-child relationship. These create a sense of powerlessness, low self-esteem and/or poor mental and emotional health. One woman described her frustration at not being able to discipline her children in her own cultural way thus: The kids have been controlling the household. The kids can take a temper tantrum. You know, swear at the parents. You cannot do anything. That really affects you as a parent because you are not used to that kind of treatment. When you were brought up you were not brought up like that, so it is very hard to take it from your kids.

Another woman explains her fear that the differences in discipline do not prepare the children for life in a society that does not readily accept people of color: “we don’t really feel safe raising our kids here because of our cultural differences. You are always worried that someone is going to arrest them”. Other women discussed the possibility of sending their children to a cultural school that helped them to understand themselves as Africans as well as Canadians. Such programs are useful in providing opportunities for children to express their thoughts and feelings without parental influence. Some of the women provided examples of how to successfully negotiate the process of mothering within the spaces of multicultural boundaries. One woman noted: I think we all need communication so that we meet sometimes and talk about this and see where we are going wrong … it is kind of difficult, talking about the issues and making new rules as the children grow helps … but it is not easy.

Another woman added, “talking it over as a family is always helpful, talking about problems over family dinner or leaving small notes saying ‘I don’t like the way you did this …’ also helps”. Yet another participant suggested “apologizing” and explaining ones actions especially when they are based on external stressors such as those from the workplaces or study environments. 2.5 Coping strategies Overall, these women identified a number of issues that affect their health and mothering experience. In addition, they also highlighted several strategies they employed in dealing with these health and mothering challenges. These strategies include: social support networks, spirituality and being resilience. The women were able to work through some of the emotional and psychological effects of their experiences with assistance from social support networks of family and friends “you get what you give … our caring nature naturally wins us friends. When we do things without thinking and we just do it, it wins a lot of friends for us and when we are in trouble they just come (to our aid)”. Some women described the importance of maintaining social support networks as: If you don’t get along with people, you are not happy … mental, physical, emotional and psychological all combine to give you that body mind and spirit stuff that you need. … when I was back home I was a very warm person … over the years I have found myself becoming individualistic …. I had to stop and really evaluate who I am as a person. I had two brain surgeries last year and after those surgeries, the help was like raining down …. Some people I had forgotten just came to my aid. I am Canadian and all my Canadian friends were rallying behind me 100% and my African friends—there were many friends and colleagues there ….

Some of the women rely on their spirituality to maintain their mental health and cope with the issues they

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face in accessing health care in the province: “I have been through a lot and I don’t take drugs and never drink alcohol. I just pray. This is my belief. Anytime someone tries to hurt me, I just leave it to God. I don’t try to fight them back. I get stronger… I prayed a lot when people hurt me. I pray for God to help and forgive them … forgiveness is one of the things for health, that you need to be healthy. You need to forgive”.

The women also noted the importance of being “strong” and resilient, especially in dealing with instances of racism: If you are not “strong” street quality then you’ll break down. That is why a lot of blacks have strong street quality, because that is the only thing that they helps them to handle it when there are going against it ….

In dealing with incidents of racism, some women have learnt to be “strong” and to speak out from an early age, while others only started to challenge stereotypes and bigotry in their adulthood especially in situations where discrimination involved their children. Some women indicated that they felt empowered by speaking out against racism. However, being a pillar of strength eventually takes a toll on black women’s health—physically, emotionally and spiritually. Many women do not become aware of their accumulated stress and fatigue until they are diagnosed with diseases such as high blood pressure, hypertension, cancer, and other health problems. Finding a balance in everyday activities was acknowledged as one way of dealing with life challenges. In order to remain healthy, they have to eat well, exercise regularly, and get some rest: … you need to find the balance … try to eat right, try to exercise, try to do things that will relax your mind, to feed your soul, to breathe, to do positive things for yourself and for the people around you … it brings good aura and helps you to promote better health for you.

Some of the women sought out alternative therapy or herbal remedies when they were not satisfied with traditional health care measures: … I have anemia and for the longest time they would give me iron and they just kept increasing the dose and increasing the dose but I wasn’t really getting any better. Finally I got tired of taking the conventional medicine… I know my body and this medicine is not working for me … I went back and sought natural treatment ….

One woman felt that providers of alternative remedies were more holistic in their approach to health care and a similar view of health to hers. She noted: “sometimes I go and see a homeopath … I want to be well and I feel that they look at all three aspects of health…”.

3. Implications The African immigrant women in this study expressed various manifestations of inequities in health care access including inadequate professional knowledge about black people’s health, under-representation of minorities in health professions, language barrier and conflicting cultural values around mothering. Although these issues may not be exclusive to immigrants from a particular region of the world, it is obvious that the degree to which various sub-populations encounter these barriers varies among ethno cultural groups. Discriminatory policies and practices in health care institutions, lack of culturally competent care, lack of data and standardized data collection methods for disease conditions prevalent in specific groups and inadequate inclusion in health care research are all factors that contribute inequities in health and healthcare (Jones, 2000; Kennedy, et al., 1997; 37


Krieger, 2000) Access to healthcare for African immigrant women is further compounded by family and work responsibilities as well as socio-cultural expectations (Dyck, 1995; Newbold & Danforth, 2003). The pressure to meet these expectations often results in limited health service utilization by immigrant women who are reluctant to navigate a foreign system, perceived as un-responsive to their needs. The daily struggle of mothering children in a society that undervalues culturally diverse child-rearing practices; the constant battle to understand racism, classism and sexism and the strength as well as the energy required to deal with these challenges amount to “triple jeopardy” for the black immigrant woman (Enang, 2001). In addition to dealing with the loss of social status and support network of both family and friends in one’s country of origin (Ng & Wilkins, et al., 2005), immigrant families face the challenges of acculturation especially in terms of raising children who have balanced views of their multiple cultural realities. Similarly, other studies suggest that while there may be little variation in the health status of immigrant and non-immigrant children, the formal and informal support accessed by their parents varies considerably thereby affecting the status of the family as a unit (Kobayashi & Moore, et al., 1998; Laroche, 2001). These additional challenges may foster more stress within the homes of immigrants and refugees in comparison to the mainstream population. Overall, although the issues identified in this study by these recent immigrant women of African descent maybe similar to those that have been identified in other jurisdictions (Globerman, 1998; Health Canada, 2001, 1999; LI, 1998; Murty, 1998; Sent, et al., 1998; Stephenson, 1995; Young, et al., 1999), unique and local initiatives, which involves African Canadian women in the planning and implementation process maybe more effective in addressing these barriers to health care and effective mothering. It will be useful to examine what is working in other jurisdictions and develop local policies, and tailor local initiatives to suit local immigrant needs. Strategies to facilitate change in this area should include: (1) conducting culturally competent health education and promotion campaigns with due consideration of the diversity in diet, health seeking behavior and perceptions of illness among immigrants; (2) incorporating issues of racism and multiculturalism in existing curriculum of educational institutions; and (3) creating networking opportunities within the immigrant community to promote dialogue between community representatives and policy makers, academic researchers, and health care professionals. These strategies are imperative for the social inclusion of African immigrants and the development of culturally relevant health care for this community. In conclusion, poverty, unemployment, poor health, inadequate access to appropriate health care and educational disadvantages create barriers that are all too common among marginalized groups such as immigrants of African descent. It is necessary to create a collaborative environment in which immigrant women, policy makers and health professionals can work together to develop culturally appropriate, evidence-based and socially inclusive health policy and programs. For many immigrants, the process of immigration is often stressful and disruptive involving the loss of social status and support networks of both family and friends in the country of origin. Although racism has been a long-standing preoccupation of people in political and social science discourse, health researchers have only recently begun to investigate its effects on the well-being of individuals and their families (Etowa, et al., 2007). Disadvantaged class background, inadequate income, and unemployment—all consequences of systemic racism—are also determinants of health that have significant impact on the lives of black women. The consequences of gender oppression cannot be disassociated from racism or from economic disadvantage; nevertheless, it exists in systemic, institutional, and individual practices that have significant impact on health and well being (Lynch & Kaplan, et al., 1998; MCEWH, 2001; Singh, 2002).

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