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A qualitative exploration of the experiences of undocumented African immigrant women in the health care delivery system
Oluwatoyin Olukotun, PhD, RN*, Peninnah Kako, PhD, RN, FNP-BC, APNP,
Anne Dressel, PhD, CFPH, MLIS, MA, Lucy Mkandawire-Valhmu, PhD, RN
College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI
ARTICLE
INFO
Article history:
Received 18 March 2019
Received in revised form
1 August 2019
Accepted 3 August 2019
Available online September 13,
2019.
Keywords:
African immigrants
Undocumented immigrants
Women’s health
Immigrant’s health
Postcolonial feminism
ABSTRACT
Background: It is widely acknowledged that experiences of poor treatment during
health care encounters can adversely impact how individuals and communities
engage with the health care system. Hence, understanding the health care seeking experiences of diverse patient populations is central to identifying ways to
effectively engage with marginalized patients and provide optimal care for all
patients, particularly those with marginalized identities. Purpose: Drawing on
the narratives of 24 undocumented African immigrant women, this qualitative
study aimed to understand their experiences seeking health care. Methods: Our
study was undergirded by a postcolonial feminist perspective which aims to situate participants’ experiences within their given, broader societal context. Data
were analyzed using the principles of thematic analysis. Findings: Our findings
indicate that women experienced insensitivity during health care encounters and harbored a mistrust of health care staff. Discussion: Findings uncover the need for
health care providers to provide culturally safe care and to identify ways to create
safe spaces for undocumented patients within the health care setting.
Cite this article: Olukotun, O., Kako, P., Dressel, A., & Mkandawire-Valhmu, L. (2020, March/April). A qualitative exploration of the experiences of undocumented African immigrant women in the health care
delivery system. Nurs Outlook, 68(2), 242 251. https://doi.org/10.1016/j.outlook.2019.08.002.
Introduction
The US Department of Health and Human Services defines “undocumented immigrants” as “individuals
who entered as temporary residents and overstayed their visas, or are engaged in activities forbidden by their visa, or who entered without a visa” (U.S.
Department of Health and Human Services, 2009). For both undocumented and documented African immigrants, migration from the African continent to countries in the Global North has largely been driven by
political, social, and economic strife and instability in migrants’ home countries (Naude, 2010). Recent figures
indicate that there are an estimated 11 million undocumented immigrants in the United States (US), with African immigrants comprising 2% of the population, and
women making up about 50% of the population (Baker, 2018; Capps, McCabe, & Fix, 2012).
While undocumented immigrants encounter serious challenges in their host countries, undocumented women, in particular, experience several sources of vulnerability that heighten their risk of poor health outcomes (Goodman, Vesely, Letiecq, & Cleaveland, 2017;
* Corresponding author: Oluwatoyin Olukotun, Medical College of Wisconsin, 10361 Innovation Drive, Suite 2100, Milwaukee, WI 53226.
E-mail address: olukotun@uwm.edu (O. Olukotun).
0029-6554/$ -see front matter Ó 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.outlook.2019.08.002
Nurs Outlook 68 (2020) 242 251
Marshall, Urrutia-Rojas, Mas, & Coggin, 2005; Moynihan, Gaboury, & Onken, 2008). This is in part due to the gendered nature of US immigration policies that have
historically aimed to facilitate the entrance of maledominated skilled labor into the country (Johnson,
2009; Pannel & Altman, 2009) hence, skilled immigration policies that offer migrants permanent residency and naturalization disadvantage women who are less
likely to be employed in such areas (Ruhs, 2013). Consequently, a woman’s immigration status is often dependent on a male member of their family system, heightening her vulnerability to exploitation (Ammar,
Orloff, Dutton, & Aguilar-Hass, 2005; Harzig, 2003). Further, undocumented women’s vulnerability is compounded by policies that restrict access to social resources and pose barriers to accessing health care
(Marshall et al., 2005; U.S. Department of Health and Human Services, 2009).
Beyond the heightened vulnerability that undocumented women experience, it is well established that nativity (country of birth) and immigrant status are determinants of health outcomes (Castaneda et al.,
2015; John, Castro, Martin, Duran, & Takeuchi, 2012).
There are a variety of factors that have been identified as drivers of the relationship between immigrant status and health outcomes. In immigrant populations,
immigration status (whether an immigrant is undocumented, a refugee, a permanent resident or a citizen), socioeconomic status, and discrimination are all integral factors in the immigrant experience that have
been linked to health outcomes, either through direct or indirect pathways (John et al., 2012; Sullivan &
Rehm, 2005). One mechanism through which immigrant and immigration status impacts health outcomes is through perceived quality of care and care seeking experiences. Studies show that health care
experiences can impact future care seeking decisions, future engagement with the health care system, adherence to recommended guidelines and ultimately
the patient’s outcomes (Dang et al., 2013; Fortuna,
Nagel, Rocco, Legette-Sobers, & Quigley, 2017). Specifically, findings from prior work indicate that immigrants’ experiences with the health care system
impact their perception of the health care system and their decision on whether to seek health care (Wafula
& Snipes, 2014; Williams et al., 2007).
Given the relationship between patient experience seeking care and health outcomes (Blanchard & Lurie,
2004), the health care seeking experiences of diverse patient populations is a growing concern for health
professionals in the United States. Though the health care seeking experiences of immigrant populations
has been the focus of some studies, little is known about undocumented African immigrants’ experiences
in the health care system. However, evidence on health care experiences of undocumented immigrants reveal that they report negative experiences such as
discrimination, poor quality of care, being treated with hostility, cultural insensitivity, and an overall poor perception of the health care system (Cleaveland &
243
Ihara, 2012; Rodriguez, Bustamante, & Ang, 2009).
Additionally, evidence on the experiences of African immigrants indicates that fear of discrimination is an impactful barrier to seeking health care (Wafula &
Snipes, 2014). Further, the health care experiences of undocumented, African immigrants’ in the United
States is a legitimate concern given the continuous marginalization of ethnic and racial minority patients within the U.S. health care system (Bristow et al, 2013;
Haywood, Tanabe, Naik, Beach, & Lanzkron, 2013).
The findings from prior work revealing poor health care experiences for immigrant populations indicate
the need for culturally safe health care delivery that fosters provider reflexivity to avoid further marginalization and alienation of immigrant patients (Richardson & Williams, 2007). In evaluating the health care
experiences of marginalized populations, cultural safety has been a useful framework due to its emphasis on acknowledging the experiences of patients within and outside of the health care encounter, delivering equitable and quality care to patients from
diverse backgrounds, and its consideration of how health and health care experiences are impacted by factors that are exogenous to the health care setting
(Williams, 1999). Hence, to support the delivery of culturally safe care to undocumented immigrants, it is
important that we understand how undocumentednpatients experience their current environment and how health care professionals can foster the creation
of a safe space for them within the health care setting.
Thus, this paper reports focused findings from a qualitative study conducted with 24 undocumented African immigrants to understand their care-seeking experiences and how these experiences are impacted by
social, historical, and political context.
Theoretical Framework
This study was informed by a postcolonial feminist framework which situates women’s experiences within the context of historical and sociopolitical processes that marginalize women of color (Mohanty,
1988). Postcolonial feminism contests the purposefulbhomogenization of women of color that has historically characterized hegemonic feminist scholarship
and resulted in “a composite,” singular ’’third world woman’’ who is “uneducated” and “tradition-bound,” and a passive victim of their culture and of patriarchy
who need to be spoken for (Mohanty, 1988). It asserts that the intentional obscurity of the heterogeneity of women is informed by false assumptions of universality in the experiences of women that overemphasizes
the role of gender while minimizing or ignoring the effects of race, class, colonialism, and other structures that shape the experiences of women of color
(Mohanty, 1988). Within the context of these powerful social, cultural, and political forces, women are not passive, but act as agents of resistance (Anderson,
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2002; Tyagi, 2014) contrary to earlier versions of western feminism that were hegemonic in nature.
Postcolonial feminism also influences the conceptualization of the role of the women participating inbresearch. To support the process of decolonization, a
postcolonial feminist lens promotes engagement with women by speaking with, rather than speaking for them (Spivak, 1988). It challenges the patriarchal
methods of knowledge development that devalue subaltern knowledge developed by women who have historically been silenced and excluded from the knowledge development process (Khan et al., 2007).
Participants in research undergirded by a postcolonial framework are viewed as the experts on the subject of inquiry. This counters traditional frameworks that
view the researcher as the expert. Postcolonial feminist research centers knowledge that is truly descriptive of women’s experiences and fosters the
production of transformative and emancipatory knowledge that leads to social change (Khan et al.,
2007; Racine, 2003).
Considering the complex realities of undocumented
African immigrant women, a framework that considersbthe interacting effects of multiple social categories andbsystems that shape women’s realities is most appropriate. Additionally, when analyzing issues about the health of immigrant women, it is essential that we center the role that racism play in leading to differential
access to resources for undocumented people in the
United States (Castaneda et al., 2015). Postcolonial feminism emphasizes how race is a social construct and a
product of slavery and colonialism, used to rationalize domination and to maintain existing social hierarchies
(Narayan, 1997). Thus, postcolonial feminism is well suited for deconstructing and deepening our understanding of these realities.
Methods
This descriptive, qualitative, cross-sectional study employed purposive sampling to recruit participants
through collaboration with local churches, national immigrants’ rights organizations and community
leaders within identified communities in the Midwest.
Recruitment occurred between 2017 and 2018. Snowball technique was also utilized to recruit women
within participants’ social network. A total of 24 undocumented, African immigrant women were recruited.
To be eligible for the study, the women recruited had
to self-identify as a Black, African immigrant living in
the United States who was not documented. They also had to be 18 years or older and be fluent in either English or French. Semistructured and individual
interviews were conducted with participants by the primary investigator. Guided by a postcolonial feminist framework, interview questions were designed to
elicit women’s stories about the impact of their current sociopolitical context on their experiences within different spaces and institutions. For example,
women were asked “What is it like being an African immigrant in the United States? How does being a Black woman impact your experiences in this country?
How does being undocumented affect your ability to get health care?.” Probes were used to clarify participants’ response or to elicit more information as
needed.
Nineteen interviews were conducted face-to-face
and five were conducted over the phone. Interviews were digitally recorded and lasted an average of 1 hr.
Demographic data were also collected from participants and all participants received a gift card of $30
upon completion of the interview.
Ethical Consideration
Approval to conduct the study was obtained from the University of Wisconsin’s Institutional Review Board.
Prior to commencing the interview, the researcher reviewed a study informational sheet with the participant that included information about the study purpose,
methods, risks, and the participant’s right to terminate the interview at any time. Verbal consent was obtained from the women to decrease the risk of breech in anonymity and privacy. This was essential considering the
sensitive nature of immigration status and the potential implications of women’s identity being disclosed. Additionally, to protect women’s identity and anonymity,
where women mentioned their country of origin in their responses were replaced with “Africa.”
Sample
Twenty-four women were interviewed for the study
(Table 1). Fifteen were from West Africa, 4 from East
Africa, and 5 from Southern Africa. Their ages ranged from 23 to 55 years, with a mean age of 32 years. Length
of stay in the United States ranged from 2 to 22 years.
Twenty-one women lived in the Midwest of the United States. Most of the women (n = 17) interviewed were not married at the time of the interview. A total of 14 women reported having at least 1one child and the average number of children for the sample was 1. The most commonly reported annual household income (n = 9) was $10,000 to $19,999. Women were mostly unemployed or employed part-time (