Health promotion focusing on migrant women through a community based participatory research approach | BMC Women’s Health

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Two main health issues, mental health, and long-term pain were reflected upon during the dialogues, and the process of action research, including the phases look, reflect and act, was followed (Table 1). Based on this, two main themes were identified in the process of analysis: Prioritising spare time to promote mental health and Collaboration to address healthcare dissatisfaction related to long-term pain.

Table 1 Themes and sub-themes structured according to the process of the story-dialogue method

Prioritising spare time to promote mental health

The sub-themes within this theme were labelled as follows: Mental health issues were considered to be a trajectory to other health problems, Migration and household work were thought to be associated to mental health issues, and Moving forward through prioritising self and teaching children about gender equality (Table 1).

Mental health issues were considered to be a trajectory to other health problems

In the ‘look’ phase, the women defined mental health issues. Their stories of mental health issues were frequently about stress or depression, phenomena associated with their daily lives and struggles to adapt to a new country and to the unstable situation of migration. Several women found that they had similar experiences and talking about this made them feel sad. The women also associated mental health issues to both weight loss and weight gain which led to other, physical, health issues, such as pain, breathing problems, sleep deprivation and decreased ability to move.

Stress affects the whole body. Mental health affects physical health. It causes pain. (Story dialogue 3)

Migration and household work were thought to be associated to mental health

The main reasons for the women’s mental health issues were identified, thus constituting the phase of reflections. When the women reflected with each other in the group, they considered the reasons for their health issues to be outside of their control.

The first reason the women reflected upon was the situation of migration. Both physical and mental symptoms experienced during the process of transfer from one country to another and after arrival in the new country, were described. The physical symptoms could be breathing problems, tension, pain and headache, but were thought to be related to the depression. The women also reflected on specific issues in the migration situation which they thought influenced their mental health. One woman talked about the change in climate when she had moved from a warmer country to a cold one. Another woman described how the cold made her feel tired and depressed. Furthermore, unstable housing and the change of housing when migrating were highlighted.

We used to live in big houses with a bottom floor [quadrangles], but here we must live in apartments in high-rise buildings. (Story dialogue 3)

The uncertain migration status, that is, not knowing whether they would get permission to stay or not, brought about a stressful situation that led to pain and mental health issues. It was highlighted that the society from where they came was completely different from the Swedish society, and fear of the new culture as well as difficulty to integrate were issues encountered. One woman argued that the relationship with their husbands was one reason for women not being able to integrate in the new society. The men had the power to forbid the woman to meet with other people or go out of the home, and this had an impact on their mental health. But some others in the group argued that not all men were alike and that it takes some time to familiarise yourself with the equality in a new system.

I think that my husband has influenced my life negatively. He wants to live here in Sweden, and he knows it’s a completely different culture, but he doesn’t try to balance between the two cultures. I think it’s normal when you move to another society that you try to adjust to the new society. (Story dialogue 3)

The other reason for mental health issues was associated to the responsibility women have in the household, with little support from the husbands. One woman said that before the marriage the women hope to share responsibility for household duties with their husband. However, husbands sometimes work away from the home many hours per day, with little possibility to accomplish household work. This is necessary due to the family’s economic situation, leaving those husbands that want to help with household duties with no option. Additionally, the women argued that as migrant women they are alone here in the new country with no support from relatives. Therefore, the women must handle the children and the household, as well as completing their own education.

I think that women have a lot of responsibility at home and they need to take care of their children. /… / And a lot of women actually suffered depression after giving birth. (Story dialogue 1)

The role of a woman was described as being a leader of the family and hence they felt that they needed to be strong, so as not to rock the boat. The many commitments led to an untenable position, and not completing the household work perfectly was associated with guilt. With the responsibility for the household resting solely on them, the women had little energy remaining for themselves and did not prioritise themselves.

In most cases women think mostly of their children, to take care of them in a correct way. It takes a lot of energy from the woman and then sometimes she forgets herself to give them [the children] a lot of time. (Story dialogue 1)

Moving forward through prioritising self and teaching children about gender equality

After the reflections, a phase with thoughts of actions followed. A successful change described by one woman was given credit by other women and inspired them. One of the women described how she had changed her situation of ill health. She had found motivation in considering the risk of secondary health issues, and in previous experiences of health issues in the family.

When I hear her story, I want to do the same because I also have family and children. I also have [over]weight. Therefore, when I listen to her, I think a lot about myself because I want to get better for myself too. (Story dialogue 1)

They reasoned that to take care of their children they first had to help themselves to health. To bring about change, accountability to oneself and a change of mindset were necessary. Additionally, to maintain changes, the support of a belief, for example, in God, was important.

The women reflected on actions aimed at teaching their children about gender equality to accomplish change for the next generation. They wanted both to make their daughters strong and to equip their sons for the future to take care of their own home. Therefore, it was important not to make a difference between sons and daughters when assigning household duties.

Must teach them about gender equality. /…/ Must treat the two of them equally at home. (Story dialogue 1)

However, this could be difficult, since some sons refused to help in the household, thinking it was the women’s duties, the women argued. To adapt to a behaviour of shared responsibility, maybe smaller children could be asked to help, but older children needed male role models, they said. But one woman had told her sons that the division of duties was an old thinking. Furthermore, it was mentioned that it was important to find a balance between work away from home and household work.

To benefit themselves, the women decided to try to find time for themselves to cope with their stressful situation, time that could be used to engage in physical activities.

I want to have special time for myself. For example, one hour a day or two hours a day to start gymnastics, to do something. (Story dialogue 1)

A women’s group was suggested by the researchers and adopted by the women. To make time for such a group, the women reasoned, they had a responsibility to themselves to let go, for example, by allowing the fathers to take responsibility. Some were eager to try this idea, while others did not have any chance to do so.

Additionally, the women wanted to meet with a psychologist to advise them on how to act. It was also mentioned that maybe the men need a supporting group when arriving in a new country, such groups being normally for women.

Collaboration to address health care dissatisfaction related to long-term pain

The sub-themes within this theme were labelled as follows: Challenges of long-term pain entails other health issues, Household work as the root to pain and dissatisfaction with the healthcare, and Working together in order to make a change, if not for oneself then for someone else (Table 1).

Challenges of long-term pain entails other health issues

Within the ‘look’ phase, long-term pain was identified as a health problem the women encountered in daily life. Many participants could relate to the situation since they had experienced similar pain or had close relatives who had. Long-term pain often led to other problems, such as sleep deprivation and decreased ability to move, as well as being psychologically challenging and sometimes leading to depression. The pain did not just affect the women but also their families, though pain was concealed in front of the children to calm them.

I don’t want to show my children that I’m sick, or weak. I don’t want to show them because they are sensitive. Therefore, I always say to them that I’m very well. Because that makes them a bit calmer as well. (Story dialogue 2)

Household work as the root to pain and dissatisfaction with the healthcare

In this phase, the women reflected on reasons for pain, and reflections on the healthcare were shared. The women talked about the effect household work had on the pain they perceived. Many Arabic women have pain and the reason for this, they said, was that Arabic women are responsible for the household. One woman reflected that women do not work outside the home, only in the household with cleaning and cooking. They do not engage in any physical activity and have not done so while they were young, and now with age this shows.

I know her (referred to the storyteller), pain. All Arabic women [suffer from] pain. Why? Not working, no gym, only working in the home. (Story dialogue 2)

One participant had heard from a physiotherapist that she was weak because she did not exercise. The importance of physical activity and food was highlighted by the women in relation to pain and decreased ability to move. Memories of relatives’ situations had made them realise how important physical activity is.

Self-determination was thought by the women to help them out of the situations they were in. One woman explained that she had done everything she could to prevent herself from ending up in a wheelchair and to avoid operation. Another woman said that it was important for her to continue to teach to prevent depression. She could not work as before, due to her long-term pain, but instead worked on a voluntary basis, and in this way, she helped herself. It was said that one must help oneself and not wait for the doctor to help.

Okay, I like to continue to work as an Arabic teacher. That’s what I want, and I feel happy and proud to work. /…/ I continue to work on a voluntary basis. To feel good and not get depressed because of not being able to handle my life and my job. I need to think how I will help myself. (Story dialogue 3)

Thus, they described how they followed recommendations from the healthcare to help themselves. Weight loss, new shoes, physiotherapy, water aerobics and pain relief treatment were some of the recommendations they had followed, and some had helped. One of the women said she got good help from the doctor she had met and wanted to continue with a follow-up since she was not fully recovered, but, disappointingly, the doctor refused.

Moreover, the women reflected upon difficulties they had encountered within the healthcare in relation to the pain they perceived. Many had the same problem and thought that they had not got proper help from the healthcare. This, one of the women explained, led to a feeling of hopelessness. Another woman said that it brought a feeling of being imprisoned and others went on to say that it brought about mental health issues and physical consequences. They identified some of the difficulties they had encountered. Some of the women highlighted diagnostic difficulties, which were said to lead to a poor medical treatment of their issues. Long waiting times, together with ambiguity regarding the responsibility for one’s care, led to a dissatisfied and uncertain perception of the healthcare. The ambiguity regarding responsibility was thought to be due to both high staff turnover and the fact that physicians did not take into account decisions made by another physician. Too few and inexperienced physicians, especially specialised physicians, were seen as reasons for the difficulties within the healthcare. The women also reasoned that the system was to blame for the difficulties, not the single physicians, as they were required to follow the rules and think economically according to their organisation. Access to Arabic-speaking physicians had shown that the language barrier could not entirely explain the difficulties the women perceived within the healthcare. Instead, the bureaucracy made the women feel that the physicians did not care genuinely about them as patients.

I’ve had enough, they don’t work from the heart, they work to get paid. A physician doesn’t work because he’s a physician and wants to help. (Story dialogue 2)

The difficulties the women encountered within the healthcare, in association with their long-term pain, made them compare the Swedish healthcare to the healthcare in their home countries. This caused them to question and wonder at the long waiting times in emergency care or for results of a simple blood test. However, they also said that in their home countries only those with money were entitled to healthcare; the rest died.

Working together in order to make a change, if not for oneself then for someone else

In the ‘act’ phase, the dialogues stressed the importance of acting within the healthcare system. Many suggestions about what should be done were put forward: the doctors need more experience, access to specialists should be easier, healthcare centres need to be more serious about helping their patients, the government needs to invest more in healthcare centres, and more time is needed to meet with doctors. In relation to this, the women arrived at the conclusion that they themselves needed to understand the system better. It was mentioned that politicians should be addressed, but it was also said that members of the community could help each other.

The women wanted to protest about the healthcare but did not have the resources to do so. To accomplish change, they decided to write something together. Different opinions about this were shared, involving a feeling of hopelessness and a lack of trust that it would lead to a change, but also a feeling that maybe things can get better for someone else.

If one thinks that if one had complained, it might get better for other people. Sometimes one must think like that, why not complain to make them improve. So that what happened to me will not happen to someone else. (Story dialogue 2)

They decided to accept an initiative from the researchers regarding a health circle, to continue to work with the ideas that had been brought up during the dialogues. The attitudes of the participants differed, in that some of them wondered if the health circle would be helpful, while others welcomed the idea.



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