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Keeping healthy and accessing primary and preventive health services in Glasgow: the experiences of refugees and asylum seekers from Sub Saharan Africa Anna Isaacs* Dr. Nicola Burns Dr. Sara Macdonald Prof. Catherine O’Donnell *Postdoctoral Fellow, City, University of London I’m Anna Isaacs, I’m currently a postdoctoral fellow at the Centre for Food Policy, City, University of London. But my presentation today is about the research I did for my PhD, which was in General Practice and Primary Care at the University of Glasgow. My PhD focused on the health and healthcare related experiences of refugees and asylum seekers from Sub Saharan Africa in Glasgow, but in particular I was looking at how intersecting structural determinants shaped both perceptions of health, and the process of accessing care. I’m really pleased that there’s already been a lot of interesting work at the conference looking at the impact of various types of discrimination and structural inequalities on migrant health, and I think that there’s a lot of scope for shared learning across borders. @anna_isaacs
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My research was based in Glasgow, which is a city that has been rapidly increasing in diversity in the past years. As regards refugees and asylum seekers, Glasgow was the first city outside of London to offer to home refugees and asylum seekers, when in 1999 the UK government started its policy of dispersal. It now has one of the largest asylum seeker populations outside of London. Glasgow is an interesting place to study refugee and asylum seeker health. UK immigration policy applies in Scotland, which means that asylum seekers are subject to the dehumanising and often drawn out process of the UK asylum application process, denied from work, kept in limbo and generally treated with distrust. However, being in Scotland also brings some protective factors that mean that the impact of the ‘hostile environment’ is perhaps less felt than in the rest of the UK. In particular Scottish integration policy, unlike in England starts the moment someone arrives in the country regardless of whether their asylum application has been decided on. Similarly healthcare charges for refused asylum seekers has not been introduced in Scotland as it has in England. The narrative in Scotland is different to that in England. Photo by P&P/CCBY
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As I mentioned I wanted to understand how the context in which refugees and asylum seekers lived in Glasgow, shaped both their understandings of what being healthy meant, as well as the process to accessing care. This was against the backdrop of thinking about how you best design health services and programmes that meet the needs of individuals in increasingly diverse societies. I did this by conducting a focused ethnography over the course of This was an intense, fairly short period of ethnography, that involved using a variety of methods to engage with refugees and people seeking asylum from Sub Saharan Africa. I spent a lot of time at community groups, and out of that I ran participatory focus groups using the mind-mapping tool KETSO which considered the question “is Glasgow good for my health?”. I also spent time talking to participants in their homes, and I went on walks with participants around their neighbourhoods. The countries that the participants came from were Ghana, South Africa, Zimbabwe, Malawi, Eritrea, The Sudan and Somalia, so quite a diversity in terms of backgrounds. What they did all share though, was the experience of seeking asylum in the UK, and engaging with the healthcare service in Glasgow.
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Interview topics Can you be healthy in Glasgow?
What’s it like living in Glasgow as an asylum seeker/refugee? What does it mean to be healthy? What are your experiences of using health services? What do you do if you are feeling ill? Do doctors understand your needs? Have you changed the way you think about your health? Is it possible to prevent diabetes/ heart disease? How can you prevent diabetes/heart disease? How are migrants talked about in the media?
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I utilised Dixon-Woods et al’s model of candidacy to frame my understanding of refugee’s experience of access to care but extended it to thinking access to health practices (such as a healthy diet) as well – candidacy charts a non-linear pathway (though it looks it in the diagram) which goes from identifying oneself as a candidate for a specific service or prevention up to the point where that service is accessed or engaged with. Dixon-Woods et al’s candidacy model as illustrated in Mackenzie et al 2013
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Audrey’s story “I was so depressed and then I got for depression tablets because of the living, the cost of living, it was very hard to me. I was a destitute for a long time, I think for three months. Three to four months, I was just two days I am sleeping on another place. I said “I just want you for two days”, another one for one week, another one for... it was so stressing me.” “Yeah, I was just eating. I was just eating, you know? It was the time I was just cooking and I liked the fat and the fat I needed and I just, so the time I was diagnosed diabetes, oh my heart, they were saying it’s full of, what do you call it? The fat is too much in me.” I have lots of stories that illustrate these points, but I want just briefly to take the stories of two participants to show how some of those factors impacted on the candidacy process. In this first case to inhibit access to the means of a healthy life, and to put Audrey at risk of chronic illness. Audrey who was from Zimbabwe was in her 70s with 3 now adult children at home, she had not seen for many years. During her time in the UK she had gone through various different immigration statuses, had been destitute for a long time, and was now back in the process of seeking asylum. Audrey was diagnosed with type II diabetes, at a time she was destitute. Because it wasn’t something that was accessible to her, either in terms of relevance, or in terms of affordability, it was not something she identified as being necessary for her.
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Elizabeth’s story “It’s very embarrassing to be honest. Me, if I go to see the doctor and then the doctors says ‘do you work? Do you go to work?’ I say ‘no’. I feel very, very embarrassed. From there, that person doesn’t have respect with you. They will do whatever they want to do.” “Because some of the doctors and the nurses, they get like ‘these people, they are foreigners – they don’t know their rights.’ That’s the problem, again. We know our rights, but what can you do?” “No. Even if I’ve got like, now, a very painful like (…) I’m not going to call an ambulance, I’m not going to do nothing.”
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What impacts the candidacy journey
Asylum process Access to financial resources Refugee experiences What impacts the candidacy journey Access to social resources Language Experiences of racism/ perceived racism and the way that might limit willingness to engage or reingage with services Environment in many senses of the world: whether people feel comfortable using the amenities in their local area. Many did not as they felt either generally unsafe, or conspicuously foreign (for some this might be a protective factor, since refugees and asylum seekers tend to be housed in some of the most deprived areas of Glasgow which suffer from significant health inequalities, but it also means that very localised place-based interventions may not be appropriate or relevant). Language: for those who don’t speak English – another set of barriers, puts them further down a hierarchy they’re already pretty close to the bottom of. Access to resources: poverty is perhaps one of the most significant factors in putting people at risk, since they are physically unable to do the things that might be required to keep healthy, but there are other resources too – social, cultural etc. The experience of being a refugee and all that that entails – pre, during and post migration And also, important is looking at some of the norms around health and wellbeing, so many participants talked about the difference between keeping healthy as something they didn’t think about/ was just a natural part of life to being in the UK where it has to be an active decision for everyone, but particularly in an environment where everything is set up to make it harder to be ‘healthy’ And at the top, interacting with all these other things, is the UK asylum process itself which I would argue is one of the most significant risk factors in placing individuals at risk of poor health, poor access and chronic disease. Said this is a tiny bit of PhD, but to give context I’m using critical theories from anthro and concept of structural violence has been instrumental in thinking through how structures influence people’s access to health. ‘Cultural’ norms about meanings of health The environment Experiences of racism
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Some Conclusions… Refugees are put in situations where they are made vulnerable Multiple and intersecting structural inequalities impact on capacity to access care and engage with health practices. Extend right to healthcare to right to the means to live a healthy life. Public health must be at the forefront of changing the narrative!
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Prof. Catherine O’Donnell
Thank you! Anna Isaacs* Dr. Nicola Burns Dr. Sara Macdonald Prof. Catherine O’Donnell *Postdoctoral Fellow, Centre for Food Policy, City, University of London @anna_isaacs
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