An exploration of the factors that influence how asylum seeking or refugee women access preventive healthcare, using cervical screening as a case study

Background Forced migration has become an issue of great political, economic, and humanitarian importance. It is estimated that there are 30.1 million asylum seekers and refugees globally. Since 2000, Glasgow has been a dispersal city for asylum seekers and refugees and hosts one of the largest numbers of asylum seekers of any local authority in the U.K. Asylum seekers and refugees in Scotland are entitled to universal healthcare at all stages of the asylum process. However, there are known inequalities in access, particularly for women. Asylum seeker and refugee women have poorer health outcomes than economic migrant and host country populations. There is a specific gap in the literature with regards to asylum seeker and refugee women’s preventive sexual healthcare needs, out with pregnancy and maternal care. Therefore, this thesis aimed to address this gap. Aim To identify and explore the factors that influence how asylum seeking and refugee women access preventive healthcare, using cervical screening as a case study. This aim was addressed by three research questions: 1) What discourses are constructed in the UK’s print media around asylum seekers, refugees, and health? 2) How do these discourses affect asylum seeking and refugee women’s and health care workers perceptions of this population’s deservingness for preventive healthcare? 3) What are the barriers and facilitators, identified by asylum seeker/refugee women, community workers and primary care healthcare workers, with regards to the identification of candidacy, the assertion of this candidacy and the provision of cervical screening to women who are asylum seekers and refugees? Methods A multiple qualitative approach was taken, with newspaper analysis, focus group and individual interviews. Data collection and analysis were underpinned by the theory of candidacy. Intersectionality was a conceptual lens with which to interpret more fully the data generated. The newspaper analysis covered the years 2008-2013. Newspapers were purposively selected to represent the breadth of the U.K. and Scottish national newspapers, in terms of political alignments and readership demographics. Articles were included if they focussed on asylum seekers or refugees in the U.K. and if >50% of the story focused on health of healthcare. A pro-forma was used to collect data on article tone; migrant group; and themes such as health access and healthcare spending. NVivo 10 software was used to organise the data and it was then analysed using both content and thematic analysis. The second study involved semi-structured individual and focus group interviews. A purposive sampling approach was taken, and interpreter services were used as required. 17 asylum seeking and refugee women, 2 community workers and 7 primary healthcare workers were interviewed. The focus group of asylum seeking and refugee women was recruited through a community group, as were the two community workers. Individual asylum seeker and refugee interviews were recruited through a flyer advertisement placed with the Scottish Refugee Council and through contacts of the focus group. Healthcare workers were recruited by contacting practices who were known to care for asylum seekers and refugees. These interviews were coded using NVivo 10 software and analysis facilitated using the One Sheet of Paper (OSOP) approach. Findings 198 newspaper articles were included. Despite left-wing and local publications being more positive and sympathetic in their construction of deservingness for asylum seekers and refugees to seek healthcare, the volume of articles from right-wing publications which portrayed asylum seekers and refugees as undeserving outweighed these. This created a hostile tone, constructing migrants as a threat to resources, to the health of others and to British culture. The hostile environment created by both newspaper constructions of deservingness and the asylum system was internalised by asylum seekers and refugee women. This affected their presentation at services. Being female and an asylum seeker creates an intersection of vulnerability and acts as a barrier to accessing preventive healthcare. This is worsened by the intersection of other identities such as language, culture, educational level, religious beliefs and socioeconomic status. Healthcare workers shared frustrations that they had little influence over the asylum system as they realised the effect this was having on their patients. They also acknowledged the impact of the hostile environment but took little personal responsibility about how to combat this within their own service. However, a key finding in this thesis was that if the offer for cervical screening was encouraging, informed, supportive, and empowering, it would be more likely accepted. Conclusion This thesis found that asylum seeking, and refugee women operate within a hostile environment and have many intersecting factors which make them particularly vulnerable when accessing healthcare. However, if they are given the correct support both within healthcare and in the community, they are keen to seek preventive sexual healthcare, such as cervical screening. Recommendations from this thesis include widening the availability of clinics, to include drop in, evening and weekend periods; encourage community organisations to signpost for cervical screening; further training for primary healthcare workers in working with this population, recording data, and increase awareness of their role in reducing health inequalities for this population. This thesis critiqued how candidacy, intersectionality, and deservingness work together as theories. Through using these theories together, a more nuanced understanding was achieved, particularly around the impact of structural and system inequalities affecting health access for this group. This thesis offers an advancement of the Mackenzie (2012) figure of candidacy to show the direct relationship of intersecting structural and system factors on individual interactions in healthcare, in addition to the impact of deservingness discourses