PUSHED TO THE SIDE
Antenatal and Delivery care for Eritrean refugees in Israel
MASTER THESIS
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MASTER THESIS INTERNATIONAL DEVELOPMENT STUDIES
University of Amsterdam
PUSHED TO THE SIDE
Antenatal and Delivery care for Eritrean refugees in
Israel
Nellie van den Bos -June 28, 2016-
Supervisor: Dr. J. Olthoff First reader: Dr. J. Olthoff Second reader: Dr. W. Koster Student number: 10964177 Email: nellievdb@live.nl
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Dedication
To Nekubaya. I’m amazed and will continue to be amazed by your strength and resilience. The despair never defeated you.
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Acknowledgements
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First and foremost, I’m so grateful for all the Eritrean women that were willing to participate in this research. You didn’t gain much, but were nevertheless willing to reflect on your personal circumstances which are actually none of my business. You are stronger than you may think. I respect you endlessly.
Second, a humble thank you to dr. Shiri Tenenboim and prof. Galia Sabar for inviting me to conduct the current study. It was more interesting, fruitful, challenging and wonderful I ever thought it would be. Shiri, thanks for the interesting insights you offered and the innumerable helpful gatekeepers you put me in touch with. Galia, thank you for reflecting so wisely on my preliminary findings and asking the right questions.
My personal supervisor of the UvA, Dr. Jacobijn Olthoff, also deserves a big thank you. Your no-nonsense, direct and comprehensive supervision was of great help!
The translators and gatekeepers that assisted were simply indispensible. Tomy, Samuel, Kebbedom, Tesfu, Tess, Gere and Elza, I could have done none of the interviews or
questionnaires without your help and friendship. I’m grateful that you allowed me to get to know the challenging and beautiful world of the women we interviewed.
Several organizations kindly opened their doors for me. Kuchinate, the Eritrean Women Community Center, the Dekel Tipat Halav, the Yoseftal Hospital, the Terem Clinic, the Isrotel Hotel’s and the Eritrean church: I’m thankful that you allowed me to visit you, use your time and talk to your people.
Numerous individuals helped me along the way. Racheli (I gained so much of your help and I enjoyed to see you at work), Dr. Tzabari (The hospital became a very dear place to me, toda raba), Avital (your interview was essential), dr. Shay (dankjewel, it was nice to get to know you), Rachel (I respect the work you do a lot), Dina (we only talked on the phone, but you were of a great help) and Yonathan & Stephanie (your hospitality and couch calmed me down in the stressful times): THANK YOU.
Dongdiet, you endured my complains, worries and fears on my bad days, as well as my gains and successes on my good days. You will never know how much I need you. Love.
God. I stand in awe of You. The more I study, the less I can grasp Your infinite wisdom and love. I can’t wait for You to redeem us from ourselves and restore the beauty.
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Abstract
Research assessing refugees’ use of host countries’ health services is strong in focusing how the availability, accessibility, acceptability and adaptability of health services may influence refugees use of health services. However, the relative importance of the dimension acceptability is mostly overlooked. Also, the current literature disregards host countries’ mental constructs affect service delivery, which may constrain host countries in offering acceptable and adaptable care. To addresses this conceptual gap, first a theoretical exercise will be performed that unveils host countries’ mental constructs (i.e., health believes and images on refugees) as coming forward from the literature. A case study on antenatal and delivery care for Eritrean refugees in Israel will follow, in which quantitative and qualitative methods are triangulated to assess how Eritrean women’s experiences with the availability, acceptability, accessibility and adaptability of Israeli antenatal and delivery services explain their user rates of these services.
A critical analysis of the current literature on healthcare for refugees, shows that in offering healthcare to refugees, host countries often lean on biomedical principles and tend to picture refugees as medicalized and disempowered. The case study confirms that Israeli providers embrace these mental constructs and shows how these constructs affect Eritrean women’s service use. That is, the biomedical principles that underpin the Israeli healthcare feed Eritrean women’s appreciation of services(i.e., enhances acceptability) and encourages Eritrean women’s active pursuit of these services. However, while user rates of delivery care are high and stable, user rates of antenatal care are low and unstable. The latter are attributed to specific barriers for the dimensions availability and accessibility. That is, antenatal care is often offered in special facilities where the profession and effective flow of the regular system misses, while language, navigation and job-related barriers hinder Eritrean women’s actual access of services. As for the dimension adaptability, Israeli providers’ medicalized and disempowered pictures of refugees thwart their adaptive behaviors, resulting in Eritrean women feeling pushed to the side.
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Table of Contents
1. Introduction ………..8
1.1 Eritrean Refugees in Israel ……….. ..8
1.2 A Focus on Antenatal and Delivery Services ………... 9
1.3 Research Relevance ……… ...10 2. Conceptual Framework……… 12 2.1 Research Questions ………... 12 2.2 Conceptual Scheme ………...12 3. Theoretical Framework………. .14 BUILDING BLOCK 1 3.1 Refugees’ Use of Host Countries’ Healthcare……… 14
3.2 Refugees’ Experiences with Host Countries’ Healthcare………... 15
3.2.1 The ‘4-A Scheme’ Introduced ……… 15
3.2.2 The ‘4-A Scheme’ Applied ………... 16
3.2.3 The ‘4-A Scheme’ Adapted ………. 17
3.3 Heterogeneity Within Refugee Populations ………. 19
BUILDING BLOCK 2 3.4 The Need for Analyzing Host Countries’ Mental Constructs ……… 19
3.5 Host Countries’ Mental Constructs Unveiled ………. 21
3.5.1 Biomedical Health Believes …….……… 21
3.5.2 Images of Refugees: Medicalization and Disempowerment ……… 22
3.6 Mental Constructs and the Proposed Case Study……… 23
4. Methodological Chapter………. 25 4.1 Epistemological Stance……… 25 4.2 Research Location ………. 25 4.3 Sampling Strategy ………. 26 4.4 Sample ………. 28 4.5 Methods ………... 30 4.5.1 Survey ……….. 31 4.5.2 Semi-structured Interviews ………... 32 4.5.3 Unstructured Interviews ………. 33 4.6 Data Analysis ……… 34 4.6.1 Quantitative Data: SPSS ……… 34.
4.6.2 Qualitative Data: Manually ……….. 35
4.7 Ethical Considerations ……… 36
5. The Israeli and Eritrean Context of Antenatal and Delivery Care …….……... 38
5.1 Israeli Context of Antenatal and Delivery Care ………38
5.2 Eritrean Context of Antenatal and Delivery Care ………39
5.3 Clashing Opinions on the Similarity of Contexts ………. 41
5.4 Resolving Clashing Opinions ……….. 42
6. Understanding Numbers……… 45
6.1 Use of Antenatal Care ……….. 45
6.1.1 Type: Where is the Logic? ………45
6.1.2 Frequency: Low and Unstable ………...48
6.1.2 Location: Opposing the Regular System ………..50
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6.3 The Divide between Antenatal and Delivery care ……… .54
7. Reflecting on Experiences……… 56
7.1 Availability Partly Ensured………56
7.2 Acceptability Fundamentally Present ……… 58
7.3 Accessibility Strongly Hindered ……… 59
7.4 Adaptability Thwarted………. 62
7.5 How Experiences Influence Numbers ………... 65
8. Conclusion ……… 68
8.1 Limitations ………. 70
8.2 Recommendations for Future Research……… 70
8.2 Recommendations for Practical Implementation……… 71
9. References ……… 73
10. Appendixes ……… 77
10.1 Appendix I: Sample Characteristics of the Survey ………77
10.2 Appendix II: Sample Characteristics of the Interviews ……… 79
10.3 Appendix III: Operationalization Table ……….. 80
10.4 Appendix IV: Survey and Informed Consent in English and Tygrinia ……….. 82
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1. Introduction
‘They have children at home, they are nervous about not having their visa proper, they don’t have a status, it is hectic and difficult, and they always have to work to get more money to meet all the expenses (…). What I
think basically happens, is that checkups get pushed to the side’.
-Abigail, Israel-
The abovementioned quote of Abigail refers to Eritrean refugee women living in Israel. Abigail is the founder of Hagar and Miriam, an Israeli organization that helps Eritrean women to navigate through the Israeli system of antenatal and delivery care. Here, Abigail reflects on how Eritrean women’s circumstances may push their use of antenatal services to the side. This quote touches upon an understudied subject, namely Eritrean women’s use of Israeli antenatal and delivery services. The current study is devoted to an analysis of this particular subject.
1.1 Eritrean Refugees in Israel
As for Eritrean refugee women residing in Israel, what urged them to flee from Eritrea and what urged them to flee to Israel? In 1991, Eritrea became independent after a four years armed struggle with Ethiopia (Sharan et al., 2011). In the spring of 2016, the Human Rights Council concluded that since its start, the newly established Eritrean government has committed crimes against humanity such as enslavement, imprisonment, enforced disappearance, torture or other inhuman acts (HRC, 2016; HRW, 2014b). These crimes against humanity cause(d) the young
generation to flee to surrounding countries (HRW, 2014b). Bordering Africa, Israel is the only
democracy in the region, has a strong economy and is reachable by foot (Kritzman-Amir & Berman, 2011; Paz, 2011). This made many Eritrean refugees heading for Israel. In 1997, the first Eritrean refugees entered Israel, together with other African refugees. For 15 years,
thousands followed with the highest peak of 55,180 new African refugees in 2012 (HRW, 2014b;
Nathan, 2015). Since Israel is a non-Muslim dominated country, particularly Eritrean Christians came (Paz, 2011). In order to prohibit the influx of African refugees, high fences were
constructed at the border with Egypt in 2012 (HRW, 2014a). As a result, the number of new
entrances decreased annually (Nathan, 2015). Since the Israeli government developed new laws that allow deportation of African refugees back to their country, the number of African refugees that reside in Israel also decreased (Ibid).
Nevertheless, to date, still 33,057 Eritrean refugees reside in Israel (Population and Immigration Border, 2015). They live in the cities Tel Aviv, Arad, Ashdod, Ashkelon, Eilat and Jerusalem were most of them work as housekeepers in hotels. Taken that Israel granted less
9 than 1 percent of the African asylum seekers a refugee status in the last ten years (Ha’aretz, 2015), most of the Eritrean refugees have no official refugee status yet. Rather, they receive a Conditional Release Visa which temporarily protects them from deportation back to Eritrea, but does not provide any formal rights (ARCD, 2015; Stephen & Schmautz, 2011). As such, Eritrean refugees are not officially entitled to social services and cannot claim any support from the government. Thus, Eritrean refugees in Israel are left to fend for themselves.
1.2 A Focus on Antenatal and Delivery Services
The laissez-faire attitude of the Israeli government towards Eritrean refugees’, is thought to have severe consequences for Eritrean refugees’ use of social services (HRW, 2014a). In 2014,
Human Rights Watch(2014a) reported that Eritrean refugees have difficulties with accessing
Israeli health services. Hence, their use of Israeli healthcare is thought to be low, although details lack (Ibid). When zooming in on different types of health services, antenatal and delivery care are highly relevant for Eritrean refugees. That is, the Eritrean population in Israel mainly consists of young (i.e., 20-35 years old)married couples and grows steadily with an average parity of 4.4 compared to an average parity of 3.1 for the Jewish population (The United Nations Population Fund, 2015). Therefore, the current study will zoom in to Eritrean refugees’ women’s use of antenatal and delivery services.
Although Human Rights Watch expects that Eritrean women’s use of antenatal and delivery services is low (HRW, 2014a), exact numbers are missing. And although Human Rights Watch
(Ibid) states that it is probably the lack of financial means that constrains Eritrean refugees to make use of Israeli health services, no research examined Eritrean refugees’ experiences with Israeli antenatal and delivery services in order to explain their use of these services. The current study will embark on this gap by examining how Eritrean refugees’ experiences with Israeli antenatal and delivery services explain their use of these services.
In order to perform such an analysis, particular theoretical strands have to be taken into account. The limited literature available on Eritrean refugees in Israel targets them as being one homogeneous group. However, several studies on health care for refugees show that there is usually considerable diversity within refugee populations, which affects refugees’ use of
healthcare (e.g., see Carolan et al., 2012; D’Avanzo, 1992; Szajna & Ward, 2015). Hence, sources of heterogeneity within the Eritrean population deserve attention as potentially affecting Eritrean women’s use of Israeli antenatal and delivery services.
When discussing refugees’ experiences with healthcare provided by host countries, the current literature focuses on the availability, accessibility, acceptability and adaptability of these health services for refugees. Of these four dimensions, the problematic implementation of the dimensions availability, accessibility and adaptability is often addressed, while the importance
10 of the dimension acceptability (i.e., extent to which users appreciate the offered services) is overlooked. This results in a disregard of a potentially fundamental key to service use. Moreover, the current literature displays a lack of self-awareness at host countries’ side concerning their mental constructs that underpin the services they provide. That is, while refugees’ believes and ideas on healthcare are thoroughly investigated, host countries’ subjectivities (i.e., health
believes and images on refugees) are mostly taken for granted and uncritically appraised. Such a lack of self-awareness may hinder host countries in offering acceptable and adaptable care to refugees, yet pushing them to side. Thus, in order to fully understand how Eritrean women experience the acceptability and adaptability of the Israeli antenatal and delivery services, there is a need for unveiling host countries’ mental constructs.
To address the abovementioned gaps of knowledge, the current study will first perform a theoretical exercise in which 1) The importance of the dimension of acceptability will be established, and 2) Host countries’ mental constructs will be analyzed. After a solid theoretical ground is laid, a case study will 1) Examine Eritrean refugee women’s user rates of Israeli antenatal and delivery services, 2) Explore Eritrean refugees’ experiences with the availability, acceptability, accessibility and adaptability of these services, and 3) Analyze how diversity within the Eritrean population is related to their use Israeli antenatal and delivery care. In exploring Eritrean refugees’ experiences with different dimensions of antenatal and delivery services, particular attention will be paid to the proposed importance of the dimension
acceptability and how host countries’ mental constructs affect the dimensions acceptability and adaptability. Together, this may ultimately reveal how Eritrean refugees’ experiences with Israeli antenatal and delivery services explain their use of these services.
1.3 Research Relevance
The theoretical relevance of the current study is fourfold. First, by addressing
acceptability as a very fundamental dimension for refugees’ use of healthcare, this dimensions receives attention and the theoretical debate on the relative importance of each dimension may be encouraged. Second, by unveiling host countries’ mental constructs that underpin the
services they offer to refugees, this study embarks on the theoretical conceptual gap concerning host countries mental constructs and the impact these mental constructs may have on refugees’ use of healthcare. Third, by examining how Eritrean women’s experiences with Israeli antenatal and delivery care explain their user rates of these services, both concepts as well as
interrelations will be theoretically established for the particular context of Eritrean refugees in Israel. Lastly, by including heterogeneity analyses, this study may encourage the theoretical debate on diversity within refugee populations and the extent to which diversity affects refugees’ use of healthcare.
11 The practical relevance of the study is threefold. First, an employee of the Ministry of Health pointed me at the complete lack of exact numbers on Eritrean refugees’ use of and
experiences with Israeli antenatal and delivery care, which hinders them to develop constructive policies. The results of this study may help the Israeli Ministry of Health to adapt and strengthen policies on the provision of antenatal and delivery care for Eritrean refugees. Second, by
including refugees’ experiences with antenatal and delivery care, this research may offer useful insight to other host countries for refugees as to why refugees may or may not make use of the healthcare that these countries provide. Third, by unveiling host countries’ mental constructs, this study encourages self-awareness among policy makers and providers of antenatal and delivery care to Eritrean refugees. Self-awareness may encourage policy makers and provider to uncover biased assumptions on refugees and help them to tweak destructive policies and behaviors.
As for the structure of the current study, first a Conceptual Framework will be presented, including the research questions and a Conceptual Scheme. Next, a Theoretical Framework will be presented, that includes the theoretical ground for the future analyses. Following, the epistemology, research location, sampling strategy, the final sample, research methods, data analysis and ethical considerations will be discussed in a Methodological Chapter. After this, the results will be discussed in three empirical chapters. A Conclusion concludes the study,
limitations, and recommendations for future research and practical implementation of the results.
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2. Conceptual Framework
Before establishing the theoretical ground of the current study, I will present a Conceptual Scheme in which the aims, concepts and theoretical strands of the current study – as presented in the introduction – are visualized. To this end, I will first list the research questions and following, explain how these questions and underlying theoretical strands are translated into the Conceptual Scheme.
2.1 Research Questions
The overarching research question runs as follows: ‘How do Eritrean women’s experiences with Israeli antenatal and delivery services explain their user rates of these services?’ To answer this question, the following sub-questions will be investigated:
1. What are Eritrean women’s user rates of Israeli antenatal and delivery services? 2. How do Eritrean women experience the availability, acceptability, accessibility and
adaptability of Israeli antenatal and delivery services?
3. How does heterogeneity within the population of Eritrean refugee women affects their use of Israeli antenatal and delivery services?
2.2 Conceptual Scheme
For a visualization of the proposed research, see the Conceptual Scheme in Graph 1. The vertical line crossing the scheme, separates the mainstream approaches from the critical approach I embrace in studying refugees’ use of host countries’ health services. The horizontal line crossing the framework separates the concepts that constitute the fieldwork questions from a deeper analyses of mental constructs as affecting different dimensions of services use.
The first research question (i.e., targeting Eritrean refugee women’s use of Israeli antenatal and delivery services), is represented by the inner white circles within the greenish and bluish circles in the upper halve of the framework. The smaller white circle in the left halve, points at the lack of actual numbers on refugees’ user rates, opposed by a bigger white circle in the right halve which points at the current focus on actual user rates. The second research question (i.e., targeting Eritrean women’s experiences with the availability, acceptability, accessibility and adaptability of Israeli antenatal and delivery services) is visualized by the greenish and bluish circles in the upper halve of the scheme that embed Eritrean women’s user rates. The closer these bluish or greenish circles lay to the white circle of Eritrean women’s use of services, the more fundamental this dimension is for service use. The order of dimensions in both halves of the scheme shows that contrary to the mainstream approaches, the current study
13 regards the importance of the dimension acceptability over the dimension accessibility. The third research question, targeting how heterogeneity within the population of Eritrean refugee women may affect their use of services, is represented by four ladies of different height and color in the inner white circle of service use in the right halve. The one lady in the left halve shows how mainstream approached regard refugees’ as a homogeneous group. The overall research question (i.e., explaining Eritrean women’s use of Israeli antenatal and delivery services by means of their experiences with these service), is visualized by means of the greenish and bluish arrows in the upper right circles that illustrate the potential effects of each dimension for Eritrean women’s use antenatal and delivery services. The absence of arrows in the left halve, shows that mainstream approached deal with refugees’ experiences with
healthcare and their use of this care as being two independent domains.
The bottom part illustrates the theoretical exercise that will be performed in the Theoretical Framework. The type of mental constructs mentioned in the bottom halve of the scheme and the colored circles next to which these are place, indicate that mainstream
approaches only investigates refugees’ mental constructs on healthcare as impacting refugees’ experiences with the acceptability of healthcare. Contrary, the current study focuses on host countries’ health believes as impacting the acceptability of healthcare for refugees, and host countries’ images of refugees as affecting the adaptability of healthcare for refugees. The dotted horizontal line, with arrows in-between stresses how Israeli providers’ mental constructs may exert influence on Eritrean women’s use of antenatal and delivery services.
Graph 1. Conceptual Scheme
AVAILABILITY ACCESSIBILITY AVAILABILITY ACCESSIBILITY ACCEPTABILITY ADAPTABILITY THEORY MENTAL CONSTRUCTS MAINSTREAM APPROACHES HOST COUNTRIES’ HEALTH BELIEVES: BIOMEDICAL HOST COUNTRIES’ IMAGES OF REFUGEES: MEDICALIZATION & DISEMPOWERMENT
ACCEPTABILITY ADAPTABILITY
REFUGEES’ EXPECTATIONS OF HEALTH CARE: ‘DIVERGENT’ & ‘UNFAMILIAR’,
CURRENT CRITICAL APPROACH
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3. Theoretical Framework
The theoretical ground for the current case consists of two main building blocks. In the first part,. In Building Block 1, the main concepts of the case study will be theorized in order to understand and interpret the research questions guiding the fieldwork. That is, first literature will be analyzed for theories on refugees’ use of host countries’ healthcare (theoretical
foundation sub-question 1). Second, theories on refugees’ experiences with host countries’ health services will be identified (theoretical foundation sub-question 2). In order to structure these theories, I will introduce, apply, and adapt Tomasevski’s (2001) 4-A Scheme. This scheme that targets four different dimensions of service use, namely availability, accessibility,
acceptability and adaptability. Following, current literature will be analyzed for theories on how heterogeneity of refugee populations affects their use of health services (theoretical foundation sub-question 3). A reflection on how the identified theories apply to the current case study will conclude each section.
In Building Block 2, I will move beyond a technical analyses of how available, accessible, acceptable and adaptable the provided services are by reaching for host countries’ mental constructs that underpin the care they provide. First, I will discuss the need for analyzing host countries mental constructs as I regard particular mental constructs affect the acceptability and adaptability of host countries’ healthcare. Following, the host countries’ actual mental constructs will be analyzed through unveiling their health believes and images of refugees. Third, I will elaborate on how these mental constructs translate to the current case study of Israeli antenatal and delivery services are for Eritrean refugees.
As for the data sources of both building blocks, limited literature is available on (Israeli) antenatal and delivery services provided to (Eritrean) refugees. Hence, the scope of the
Theoretical Framework is rather broad, concerning any physical health service provided to any refugee population in any host country. Thus, the current case study will be theoretically framed in the wider context of health services for resettled refugees in general. Each section will be concluded by a reflection as for how the wider theoretical frame applies to the current case study.
BUILDING BLOCK 1 3.1 Refugees’ Use of Host Countries’ Healthcare
To theoretically ground the question ‘What are Eritrean women’s user rates of Israeli antenatal and delivery care’, it is important to analyze the extent to which refugees utilize host
15 countries’ health services. In a meta-review on refugees’ use of health care, Szajna & Ward (2015) conclude that service utilization is rather low. Smith (2003), offering an overview of refugees’ use of host countries’ health services, argues that refugees hardly access any health services. From a literature review on undocumented migrant women’s use of antenatal and delivery services in particular, results that their use of prenatal care lacks, is low, or starts only late in the pregnancy (Munro, 2013). Next to these meta-analytical data sources, there is an enormous amount of case studies available to discuss refugees’ problematic and low use of host countries’ health services (e.g., see Asgary & Segar, 2010; Choi et al., 2015). Thus, the current literature displays a rather problematic picture concerning refugees’ service utilization of host countries’ health services. However, the aforementioned studies hardly include hard numbers on refugees’ use of host countries’ health services. Instead, general and rather vague conclusions prevail.
For the current case study, this theoretical ground suggests that Eritrean women’s user rates of Israeli antenatal and delivery care are rather low, although the lack of actual numbers does not allow for more detailed elaborations on what ‘low’ exactly means.
3.2 Refugees’ Experiences with Host Countries’ Healthcare
The former section shows that refugees’ use of health services is generally reported to be low. A large number of studies– meta-reviews and case studies – focus on refugees’ experiences with health care in order to explain these low user rates. In order to build the theoretical ground for the second sub-question ‘How do Eritrean refugees experience Israeli antenatal and delivery care’, Thomasevski’s (2006) so-called ‘4-A Scheme’ will be used to structure refugees’
experiences with services use. I will first introduce the ‘4-A Scheme’, than apply the ‘4-A Scheme’ and lastly, suggest an adaption of the original ‘4-A Scheme’.
3.2.1 The ‘4-A Scheme’ Introduced
According Thomasevski (2001), there are four dimensions of service use that determine how children can enjoy the right for education. That is, for all children to make use of educational services, services first need to be available, then accessible, then acceptable and lastly, adaptable (Ibid). In order to visualize the ‘4-A Scheme’, Thomasevski (2001) introduced the circle diagram as presented in the left upper halve of the Conceptual Scheme (see Section 2.2). Since
Tomasevski (2001) also operationalized the ‘4-A Scheme’ by listing the necessary ingredients for each dimensions, the ‘4-A Scheme’ offers hands-on tools as for how to properly implement the right to education.
Tomasevski’s ‘4-A Scheme’ (2001) is originally meant to study different dimensions of the use of educational services, though I believe its application is also useful for studying (refugees’)
16 use of health services. Many authors reflecting on (refugees’) use of health services have already picked up one or more of these four dimensions over the years (e.g., see Asgary & Segar, 2011 [accessibility]; Elmardi et al., 2009 [acceptability]). Moreover, in 1987, all four dimensions were already discussed in relation to the use of a health services in a study of Anyinam (1987). Tomasevski (2001) does not refer to this study of Anyniam (1987) and rather, applies the four dimensions to the use of healthcare. Nevertheless, Anyniam (1987) clearly shows how the dimensions availability, accessibility, acceptability and adaptability are four different attributes of health services that determine user rates of these services. Hence, I believe it is justified to use the ‘4-A Scheme’ in order to structure refugees experiences with different properties of the health services that host countries provide to them.
3.2.2 The ‘4-A Scheme’ Applied
To build the theoretical ground for assessing Eritrean refugees’ experiences with Israeli antenatal and delivery care, existing literature on refugees’ experiences with healthcare is analyzed for each dimension of service use as presented in the 4-A Scheme. According to Tomasevski (2001), the first requirement for service use, is that these are available. He describes ingredients for the dimension availability as free and government-funded services, with adequate infrastructure and trained professionals available to support service delivery (Ibid). Different studies show that health care for refugees is not always free or government-funded (Ascoly et al., 2001; Asgery & Segar, 2011; Carolan, 2010; Johnson et al., 2008; Smith, 2013). Also, the availability of adequate medical workforce and interpreters appears to lack regularly (Correa-Valez & Ryan, 2012; Johnson et al., 2008;, Sjana & Ward, 2015; Ziersch & Burgess, 2008). Thus, the adaptability of services provided to refugees hampers in different ways.
According to Tomasevski (2001), the second prerequisite of refugees’ use of health services is that these are accessible. Ingredients for the dimension accessibility are a
non-discriminatory system that is accessible to all, and includes the most marginalized. Many studies show that refugees’ actual access to health care is hindered by financial barriers (Ascoly et al., 2001; Asgery & Segar, 2011; Carolan, 2010; Johnson et al., 2008; Michaan et al., 2014; Smith, 2013), logistic concerns such as commuting to the clinic (Sjana & Ward, 2015), and difficulties with navigating through the health system (Ascoly et al., 2001; Carolan, 2010; Sjana & Ward, 2015). Moreover, language difficulties are frequently mentioned to barriers refugees’ access (Ascoly et al., 2001; Carolan, 2010; Johnson et al., 2008; Joshi et al., 2013; Michaan et al., 2014; Sjana & Ward, 2015). In sum, many different barriers hinder the accessibility of health services for refugees, resulting in a system that does not include the most marginalized.
17 Acceptability refers to the extent to which users of services judge the content of service delivery to be relevant, culturally appropriate and of good quality (Tomasevski, 2001). Some studies refer to refugees’ lack of trust in, or unfamiliarity with host countries’ health system, which suggest that host countries’ health service as not always acceptable for refugees (Asgery & Segar, 2011; Joshnson et al., 2008; Michaan et al., 2014; Pavlish et al., 2010; Smith, 2003). Besides, studies stress that refugees have different expectations regarding the doctor-patient relationship in comparison with providers (Ascoly et al., 2001; Pavlish et al., 2010). Refugees’ are also mentioned to have different beliefs on disease causation than their providers (Johnson et al., 2008; Pavlish et al., 2010). Together, this shows that in different ways, ingredients for acceptability lack.
Adaptability refers to the capacity of a service delivery system to evolve with the
changing needs of society and contribute to challenging inequalities within society (Tomasevski, 2001). From the literature review appears that in offering health services to refugees, providers may lack cultural sensitivity (Ascoly et al., 2001; Asgery & Segar, 2011; Carolan, 2010; Correa-Valez & Ryan, 2012; Herrel et al., 2004; Joshi et al., 2013). Next to this, a lack of knowledge on refugees’ specific health issues is mentioned (Ascoly et al., 2001; Johnson et al., 2008). Thus, also the fourth prerequisite of refugees’ use of health care, namely adaptability of health services, hampers.
In sum, it seems that different ingredients for the dimensions availability, accessibility, acceptability and adaptability miss. These absent ingredients run the risk of driving a negative cycle of consecutive dimensions not being met. Applied to the current study, this suggests that Eritrean women may experience difficulties with many different aspects of Israeli antenatal and delivery services, which may distort their user rates of Israeli antenatal and delivery care. However, before applying Tomasevski’s (2001) ‘4-A Scheme’ to the proposed case study, I believe one essential change has to be performed in the order of the dimensions.
3.2.3 The ‘4-A Scheme’ Adapted
Before being able to apply Tomasevski’s ‘4-A Scheme’ to the current case study, I believe it is necessary to perform one change in the order of the dimensions of the 4-A Scheme, namely to swap the dimensions accessibility and acceptability. I will present two arguments to support the change, the first argument leaning on logic reasoning and the second argument leaning on theory.
To build my first argument, I will perform an imagination exercise. Imagine that I want to study how an Eritrean lady, Amheres, experiences the use of Israeli ultrasounds. According to Tomasevski’s ‘4-A Scheme’(2001), I first ought to study Amheres’ experiences with the availability of Israeli ultrasounds. If there is no ultrasound to make use of, studying how
18 acceptable, accessible or adaptable Amheres finds this non-existing service is simply impossible. With this first condition, I totally agree. With the order of the next two conditions, I agree less. According to Tomasevski’s ‘4-A Scheme’ (2001), I secondly ought to study Amheres’ experiences with the accessibility of Israeli ultrasounds. That is, if Amheres knows where to receive the service, she has the time to visit a medical facility, and she understands the people that explain about the ultrasound, the service is not only available, but also accessible for Amheres.
According to Tomasevski’s ‘4-A Scheme’ (2001), the third necessary condition is that Amheres appreciates Israeli ultrasounds as an acceptable service. Hence, in third place, I ought to study Amheres’ experiences with the acceptability of Israeli ultrasounds. Here the logic behind
Tomasevski’s (2001) order of dimensions becomes diffuse. If Amheres regards an ultrasounds to be the perfect tool for monitoring the progress of her little baby (acceptability comes first), she will actively pursue access of this service (accessibility follows). To make my point clear, I will imagine the opposite. If Amheres doesn’t believe in the value of ultrasounds and perceives the service to be culturally unacceptable, she will not pursue actual access. Suddenly, her experiences concerning the accessibility of ultrasounds are no longer relevant, as she is not planning for accessing an ultrasounds. Thus, studying Amheres’ experiences regarding the accessibility of an ultrasound seems only relevant after she has proven its acceptability. In other words,
acceptability seems to be a prerequisite of accessibility rather than the other way around. With the order of adaptability as fourth dimension I agree. Only after an ultrasound is available, Amheres proves this service to be acceptable and actually accesses the service, she will be able to judge the adaptability of un ultrasound. Together, this imagination exercise leads me to argue that the order of the dimensions accessibility and acceptability in Tomasevski’s ‘4-A Scheme’ (2001) needs to be swapped.
As for the second argument, theory supports my suggestion that acceptability comes before accessibility. For example, in rural Tanzania, user rates of a biomedical treatment for
convulsions in children with malaria increased significantly between 2004 and 2007, after the acceptability rates of this particular type of biomedical treatment increased (Dillip et al., 2012). Hence, the authors suggest that there is a causal link between acceptability and user rates, in that higher rates of acceptability increase people’s willingness to pursue access of the services (Ibid). In Sudan, significant increases in the acceptability of home-based malaria treatment were followed by a 26.7 percent increase of actual user rates of the same project (Elmardi et al., 2009). Again, the authors suggest for a causal relationship between acceptability and accessibility, namely that acceptability determines accessibilty. That is, once home-based malaria treatment was proven acceptable by Sudanese patients, their actual access increased.
Together, both the imagination exercise and the studies mentioned above these studies support the importance of the dimensions acceptability. rather than the other way around.
19 Hence, whereas in the former sections, accessibility was mentioned before acceptability, this order will be swapped from now on. For the current case study on Eritrean refugees’
experiences with antenatal and delivery services, this entails that I will pay particular attention to the dimension acceptability and examine how acceptability prerequisites accessibility.
3.3 Heterogeneity Within Refugee Populations
The theoretical ground for the question ‘How does heterogeneity within the Eritrean population influences their use of and experiences with Israeli antenatal and delivery care’ is thin. That is, most studies on refugees’ use of health care target the refugee population as being one homogeneous group, of which particular group characteristics determine their use of health services. However, Szajna & Ward (2015) warn for ‘generalization of the refugee population’, particularly when it comes to their access to health care. There is evidence to suggest that as much as being a refugee determines service use, diverse characteristics within the population determine individual refugees’ experiences with service use too. For instance, for Vietnamese immigrants in the United States, time of arrival in the host country determined their experiences with the accessibility of health care (D’Avanzo, 1992). That is, the earliest arrivals experienced difficulties with organizing translation, feeling understood and understand written and verbal instructions of the health care provider. Later arrivals reported significantly less problems with these issues. Also, African women’s acceptability of Australian antenatal care is found to vary according to cultural background (i.e., Amharic, Dinka or Christian), residential status (i.e., refugee visa, family reunification visa, permanent visa), educational level (i.e., primary school, secondary school, college) and prior experience (hardships during migration)(Carolan et al., 2010). These two studies show that diverse characteristics within refugee populations indeed influences refugees’ experiences with host countries healthcare. However, there seems not to be one fixed set of heterogeneity indicators as both studies reflect on different indicators for heterogeneity. For the current study, this entails this I will pay particular attention to how indicators of heterogeneity within the population of Eritrean refugee women influences their use of Israeli antenatal and delivery services, though I will not use an a-priori fixed set of heterogeneity indicators. Rather, I aim for a fluid and multifaceted set of heterogeneity indicators as coming forward from the fieldwork data.
BUILDING BLOCK 2
3.4 The Need for Analyzing Host Countries’ Mental Constructs
The previous sections show that the accessibility, acceptability, accessibility and adaptability of health services for refugees hampers, which may explain refugees’ generally low use of health
20 services. However, a critical look at the current literature shows that in order not to push
refugees’ subjective reality to the side, refugees’ mental constructs (i.e., ideas and expectations) that define their experiences with service use are thoroughly discussed. However, host
countries’ mental constructs are taken for granted, suggesting that host countries’ subjective reality does not affect refugees’ use of host countries’ services. I will first offer several examples to illustrate this dubious tendency and following reflect on the potential problematic
consequences of disregarding host countries’ mental constructs.
A study on Somali women’s appreciation of American health services shows that Somali women’s believes on healthcare do not confer with the Western biomedical model that
underpins American healthcare (Pavlish et al., 2010). In this study, Somali women’s beliefs are unraveled, but the ‘biomedical model of Western health care’ is not subjected to critical analysis. A study on antenatal care perceptions of African refugee women in Australia, shows that African women undergo a five-staged process of adjustment (Carolan et al., 2010). That is, they travel from a view of pregnancy as ‘not special’ to valuing continuous Australian antenatal care (Ibid). Again, African women’s perceptions (i.e., mental constructs) and how these evolve are
investigated, but the Australian mental constructs to which the African women adjust are not examined. One study assessed how Australian general practitioners’ experience offering healthcare to refugees (Johnson et al., 2008). The term ‘general practitioners’ experiences’ suggest, that possibly, this research will target mental constructs of providers such as their images of refugees or their ideas about health care. However, rather technical language prevails. The authors conclude that general practitioners have difficulties in dealing with 1) the specific health issues of refugees, 2) the interaction with refugees, and 3) the work structure.
Surprisingly, providers’ underlying mental constructs are completely disregarded. Together, these three studies exemplify how the current literature tends to thoroughly investigate refugees’ subjective reality, while taking for granted host countries’ subjective reality.
The question rises why the lack of targeting host countries’ mental constructs is
problematic. If all humans have subjective conceptualizations through which they interpret and filter reality (Turton, 2003) and if our reality is constrained by the metaphors where we live by (Lakoff & Johnson,1980), not only refugees’ subjectivities influence their use of healthcare, but also host countries’ mental constructs. Moreover, if health care frameworks are appraised without being critical, major conceptual flaws in offering health services cannot be identified (Holmes & Gastaldo,2004).The problematic consequences of such a displayed lack of self-awareness on host countries’ side, are twofold. Self-self-awareness consists of two dimensions, the first being examination of one’s own cultural beliefs and the second uncovering biases towards other cultures (Annamalai, 2014a). Hence, it is argued that only after host countries have
21 suggests that analyzing mental constructs is particularly relevant for the dimensions
acceptability and adaptability. If host countries examine their own health beliefs that underpin the care they offer to refugees, they encourage a more balanced examination of how refugees experience the acceptability of host countries’ health services. That is, instead of only targeting refugees’ ‘alien’ health believes, host countries will present their own health believes and
discuss the extent to which refugees judge these acceptable. Moreover, if host countries critically examine their potential biased images towards refugees, they increase the adaptive capacity of the services they offer. That is, instead of blindly adapting the services towards refugees’ needs as perceived by host countries, host countries will first examine whether their pictures of refugees and refugees’ needs are correct, resulting in more grounded adaptive behaviors. Thus, based on the argument of Annamalai (2014a) on self-awareness, I expect that host countries believes on
health feed the acceptability of the services they provide, whereas their images on refugees’ needs feed the adaptability of the services they offer. Hence, when analyzing how refugees’ experience host countries’ health services, there is the need to reach beyond a technical investigation of the availability, acceptability, accessibility and adaptability of health care, and unveil the mental constructs that I regard to particularly influence the dimensions acceptability and adaptability.
3.5 Host countries’ Mental Constructs Unveiled
As argued above, host countries’ mental constructs that are regarded to be particularly relevant for refugees’ use of health services concern health believes and images of refugees. Below, both mental constructs will be unraveled by analyze the current literature on health care for refugees.
3.5.1 Biomedical Health Believes
As for host countries’ health believes, today’s most common approach to health care is a biomedical approach (Holmes & Gastaldo, 2004; Zini et al., 2009). This approach stems from medicine , an approach that finds its roots in Western countries (Pavlish et al., 2010; Zini, et al., 2009). Medicine refers to the theory and practice of healing, in which manipulations are used to restore and/or maintain human’s internal equilibrium (Berliner, 1982). Medicine rests on certain assumptions. The first assumption concerns the non-existence of a ‘social’ aspect in medicine, where society and medical knowledge are regarded to be independent and
autonomous domains. The second assumption concerns the believe that diseases are entities that exist prior to and independently of their isolation or designation by doctors. The third assumption is that medical knowledge (i.e., definitions of sicknesses and proposed cures) is self-evident because science has proven its effectiveness (Ibid; Wright & Treacher, 1982). Thus,
22 proponents of a biomedical approach regard it to be a purely intellectual golden standard and unquestioned truth for healing (Ibid). Over the years, biomedicine became worldwide the most dominant approach to healthcare and simultaneously, other types of knowledge on health are increasingly hold as intellectually subordinate and there for not relevant (Sochan, 2011). Biomedical interventions concern surgeries – often with complicated mechanic equipment –, or administering medicine, produce by the pharmaceutical industry. Some studies on health care for refugees do explicitly state to embrace biomedicine (e.g., see Anyinam, 1987; Dilip et al., 2010; Pavlish et al., 2010). Other authors don’t refer to the type of care they provide, although descriptions of the content of care clearly show that these services stem from biomedical principles (e.g., see Ascoly et al., 2001; Carolan et al., 2010). As for Israeli in particular, two articles on refugees’ use of Israeli healthcare, as well as a glance at the health services offered by the Ministry of Health, show that the type of healthcare offered is clearly biomedical (see
Chernin et al., 2012; Michaan et al., 2014; Israeli Ministry of Health, 2015).Thus, together, literature indicates that the health service host countries offer stem from biomedical principles.
3.5.2 Images of Refugees: Medicalization and Disempowerment
The images on refugees that come forward from the current literature are twofold. I perceive the first image as one of medicalization. With medicalization, I refer to the tendency to describe refugees as fragile people with many sicknesses that are heavy burden for host
countries’ health system. In analyzing models of refugee maternity care in Australia, authors argue that “medical issues are prevalent among women from refugee backgrounds” (Corea-Velez & Ryan, 2012, p. 12). In a so-called ‘Essential medical guide’ on health care for refugees, 9 of the 17 chapters deal with specific diseases that are common among refugees. The other chapters deal with how to treat these diseases (Annamalai, 2014b). In assessing the perinatal outcomes of
African refugees in Israel in particular, the authors conclude that “the financial impact of the phenomenon of African immigrants delivering at our center can no longer be overlooked or disregarded” (Michaan et al., 2014, p. 372). In a meta- review on health care for undocumented refugees in Europe and the United States, the authors conclude that refugees burden host countries’ health and health costs (Munro et al., 2013). These statements are very
de-personalized, picturing refugees as medical units that complicate and burden host countries’ healthcare. Whereas literature on mental healthcare for refugees’ also stresses their resilience and mental strength (e.g., see Watters, 2001), literature on physical healthcare lacks such an empowering and positive perspective and instead, displays a medicalized picture of refugees.
I perceive the second image as one of disempowerment. With disempowerment, I refer to the tendency to picture refugees as having inadequate knowledge on health and lacking agency. In an article on maternity care for pregnant women in Australia, the authors argue that “many
23 participant in this study had a limited understanding of the normal physiology of pregnancy”, and “little idea of pregnancy care in developed countries” (Carolan et al., 2010, p. 199). In a literature review of the pregnancy status of Sub-Sharan refugee women in resettlement
countries, it is stated that there iss “low health literacy among refugees” (Carolan, 2010, p. 412). In one study, researchers asked former Somali refugees which childbirth education topics they would prefer to receive in America (Herrel et al., 2004).There was no answering option that enabled the refugee women to indicate that they had no appetite for childbirth education. This suggest that the researchers assumed that Somali refugees need to be educated concerning childbirth, disregarding the question whether Somali women want to be educated at all. One study provides an overview of what healthcare for refugees should consist of. Under the heading ‘the role for advocacy’, it is argued that “medical bodies and individual health professionals should advocate for more humanitarian government policies toward refugees” (Smith, 2003, p. 73). Interestingly, advocacy is fully laid in the hand of the medical practitioners that need to fight for the refugees. Obviously, my argument is not against medical practitioners pleading for refugees’ right. Rather, my argument entails the lack of advocacy that is attributed to refugees. Concluding, together with the recurrently stresses lack of refugees’ knowledge on health issues, this feeds a picture of disempowerment.
Concluding, when analyzing the current literature on health care for refugees, it appears host countries’ health believes are predominantly biomedical. Concerning host countries’ images on refugees, negative pictures prevail, which I refer to as images of medicalization and
disempowerment.
3.6 Mental Constructs and the Current Case Study
The previous sections of Building Block 2 prove the need for unveiling host countries mental constructs by arguing how host countries’ health believes and their images on refugees may distort the acceptability and adaptability of the services they provide to refugees. Host countries health believes appear to be biomedical, while their images on refugees seem to feed a picture of medicalization and disempowerment. As the description of these mental constructs is also based upon articles from health care for refugees in Israel, I assume for now that these mental constructs underpin the services that Israeli providers offer. Nevertheless, in the case study, I will validate the existence of these mental constructs by analyzing the type of services offered and Eritrean women’s accounts of Israeli providers behaviors. After being validated, these mental constructs can then be used as a backdrop for the case study in two ways.
First, the unraveled mental constructs will make it possible to start a balanced
investigation of how acceptable Eritrean women judge the antenatal and delivery services they receive to be. That is, instead of only targeting Eritrean refugees potentially ‘alien’ health
24 believes, I will perform an analysis of how Eritrean refugees’ subjectivities on proper health care do or do not align with the biomedical subjectivities that underpin the health care Israel offers. Thus, Eritrean refugees’ are the subject of study, though their experiences will be analyzed against the backdrop of the health believes of Israel as a host country. By doing so, I regard that both providers and users have subjective realities, without uncritically appraising either one. As such, I will move beyond a technical investigation of how acceptable Eritrean women find practical aspects of Israeli healthcare, and reach for the underlying mental constructs instead.
Second, the unraveled mental constructs will make it possible to start an investigation of how adaptable Eritrean women judge the services that Israeli health care providers offer to be. That is, if refugees are pictured as medicalized and disempowered, Israeli health care providers may translate these pictures into adaptive behaviors that try to alter the medical and
disempowered status of refugees. Through opposing health care providers mental constructs to refugees’ mental construct, refugees’ may provide a perspective that counters providers’
potentially biased assumptions and may give insight in how providers adaptive capacities miss the mark. Thus, Eritrean refugees are subject of study, though their experiences will be analyzed against the backdrop of the images of refugees that Israel as a host country embraces.
Together, the two building blocks of the Theoretical Framework first stress the need for investigating actual user rates of Eritrean women’s use of Israeli antenatal and delivery services. Second, they illustrate the relevance of analyzing Eritrean women’s experiences with four dimensions of service use, of which the fundamental importance of the dimension acceptability needs to be stressed, as well as the influence of host countries’ mental constructs on the
dimensions acceptability and adaptability. And third, they show that there is a need of analyzing how diversity within the Eritrean population affects women’s user rates of and experiences with Israeli antenatal and delivery services.
25
3. Methodological chapter
In the current chapter, I will translate the proposed research into methods. In order to position this research, I will first reflect on the epistemological assumptions that underpin the methodological approach of the current study. Next, the research location will be discussed. Following, I will reflect on the sampling strategy and present the final sample. Then, I will elaborate on the methods used and present the data analyses procedures. Lastly, I will reflect on the ethical considerations of conducting the proposed study.
4.1 Epistemological Stance
The design of the study is inspired and determined by the epistemological assumptions I embrace. These clearly rest on constructivitic principles (Cresswell & Clark, 2011). That is, I first acknowledge that reality is complex and fluid subjective construct. This appears from 1) How I explicitly refer to the potential impact of host countries’ subjective mental constructs on Eritrean women’s use of Israeli antenatal and delivery services, and 2) How I examine what indicators of heterogeneity may influence Eritrean refugee women’s use of Israeli antenatal and delivery services. Second, I see Eritrean women’s use of Israeli antenatal and delivery services as a social and relational interaction. This appears from how I regard Eritrean women’s service use to be dependent of their experiences with different dimensions of service, while I expect that Eritrean women’s experiences with services are influences by host countries’ mental constructs.
4.2 Research Location
In the Introduction, I reflected on the importance of conducting the current research in Israel, as there is a lack of detailed information on refugees’ user rates of Israeli health services. The current research focuses on the cities Tel Aviv and Eilat in Israel.
Two reasons support my choice for a focus on Tel Aviv and Eilat. First, the population of Eritrean refugees is largest in these two cities, as the hotel owners in Tel Aviv and Eilat are known to recruit African refugees for low-paid jobs in housekeeping (HRW, 2014a). The second
reason is practical, namely that I personally knew gate-keepers in both cities (see section 4.3). Tel Aviv is a liberal, vibrant city with about 418.600 inhabitants, situated halfway the west-coast of Israel (Municipality of Tel Aviv, 2015). The Eritrean refugees mainly live in South Tel Aviv, known as one of the poorest and most criminal neighborhoods of Tel Aviv (HRW, 2014b). Blurred concrete buildings – with shadowy hallways leading to stuffed one-room
apartment – constitute the neighborhood and drug-and alcohol addicts find their dwelling in the parks and alleys. During daytime, the neighborhood is full of commuters, tourists and street
26 vendors that cross Tel Aviv’s central bus station located in the heart of South Tel Aviv. In the evening, after work in the hotels is finished, the Eritrean refugees dominate the streets by taking their children from school or crèche and doing their grocery shopping. The schools, medical facilities, and crèches in South Tel Aviv do mainly serve the Eritrean population, as most of the Israeli citizens left South Tel Aviv for better neighborhoods. Many of the shops, restaurants and Internet cafes are run by Eritreans.
Eilat is the most Southern city of Israel. It counts 45.800 inhabitants and is a popular holiday destination for Israeli’s and foreigners (Municipality of Eilat, 2015). Eritrean refugees in Eilat live in different neighborhoods, although East-Eilat is known for a relatively high
concentration of Eritrean refugees. In East-Eilat, most Eritreans live in one apartment block of over 50 old, shadowy and tiny apartments, which is named ‘sing-sing’ (which means ‘jail’). After work is finished, ‘sing-sing’ is full of Eritrean families and friends gathering together and the scent of Enjerra, traditional Eritrean food, can be smelled outside. Since Eilat is a small town, Eritrean refugees and Eilat’s Israeli citizens visit quite the same schools, crèches, shops and health facilities.
Concluding, Eritrean refugees in Tel Aviv live separated from Israeli citizens in a run-down neighborhood. In Eilat, Eritrean refugees and Israeli citizens live in the same
neighborhoods, while visiting the same governmental facilities. The locations within
neighborhoods were participants for the current study are approached are diverse, which will be discussed in more detail in the Sampling Strategy. For an impression on both neighborhoods, see Image 1.
Image 1. Impression of the neighborhoods in Tel Aviv and Eilat where the research is conducted
4.3 Sampling strategy
The units of analyses of the proposed research are Eritrean women that made use of Israeli antenatal and/or delivery services at least once. Since I aimed to address the Eritrean
Terem Clinic, South Tel Aviv Apartment, Tel Aviv
Apartment building, Eilat Park main street
South Tel Aviv
Yoseftal Hospital, Eilat Main street East Eilat
27 women themselves (see section 8.5 on the methods), they are the unit of observation and
proposed sample. Below I will reflect on the sampling strategy that I regarded as most suitable for the current research and discuss the limitations that went along.
To obtain a sample of Eritrean women that made use of Israeli antenatal and/or delivery services at least once, I used convenience sampling, a strategy based on easy access and
availability of the participants (Cresswell & Clark, 2011). As for the easy access to participant, I did not personally know Eritrean women, neither did they speak English. Hence, I was depended on others for approaching Eritrean women. However, there is no single organization that is officially ‘in charge’ of the Eritrean population and allows me to retrieve every tenth women on the list. Rather, Eritrean women run their lives independently and appear in many different public places. In order to still approach Eritrean women, I used an easy-access strategy of relying on gate-keepers. I particularly profited of the networks of two gatekeepers that I knew before the fieldwork started. Dr. S. Tenenboim is an oncologist in the Social Clinic of the Sheba Medical Center, where she offers cheap cancer-treatment to refugees. She introduced me to numerous organizations that work with Eritrean refugees in Tel Aviv and gave me contact details of her Eritrean friends. R. Pex is a midwife in the Yoseftal hospital in Eilat. She introduced me to the head doctor of the delivery ward of Eilat’s hospital and gave me contact details of the Eritrean women she met. When approaching the organizations and individuals suggested by these gatekeepers, I often received new suggestions for more organizations and individuals to contact.
As for the availability of the participants, it is important to realize that I conducted the current research as an independent researcher, not on behalf of an Israeli organization working with Eritrean refugees. Thus, organizations did not allow me to conduct the research as part of their own program. Hence, I had to depend on Eritrean women’s availability during their free time. The availability of Eritrean women was strongly influenced by their busy schedule, which is illustrated with the following quote of an Israeli healthcare provider: “All day long they work. At 7 o’clock they take their child out of the kindergarten and you know, the women has to feed him and bathe him and put him to sleep and then make food for the husband and if the husbands friends come over or her friends come over, than she has to stay up later and clean the house and this and that”.
Taking Eritrean women’s
low availability, I had to approach them through all possible channels. In total, I contacted over 15 organizations and many different individuals. See Table 1 for an overview of theorganizations that allowed me to approach participants through their channel. For each channel, a reflection is provided on the (dis)advantages that go along.
Table 1. An overview of the channels through which participants are approached
CHANNEL DESCRIPTION ADVANTAGE DISADVANTAGE Eritrean Women Community Centre (EWCC), An Eritrean grassroot project to empower and
-A safe environment where
women feel free to be critical -Official programs take long, women leave immediately afterwards.
28
South Tel Aviv support Eritrean
women -Less representative of the Eritrean population; most visitors are single mothers
Kuchinate, South
Tel Aviv A collective project of African women to produce handmade baskets
-A safe environment where women feel free to be critical -Natural interviews, happening in a peaceful and quiet setting while the women work
- Less representative of the Eritrean population; most visitors are single mothers
-Signing informed consent or filling out a survey on paper not allowed; considered by the staff as too disturbing and threatening to the women
Individuals,
South Tel Aviv Friends or translators that approach Eritrean women they know personally
-Women are more eager to participate when a familiar person approaches them -Easier access to women that do not attend public places
-Potentially less representative of the Eritrean population; only friends are interviewed -Responses may be less honest out of fear for a friend getting to know the answer
Yoseftal Hospital,
Eilat The delivery ward of the hospital in Eilat
-It makes sense to participate in a questionnaire on services that are just received
-Women may like to participate in order to kill time
-Responses are fresh as they concern events that just happened
- Critics may remain hidden out of fear for the medical staff walking around
-Women may feel to exhausted from the delivery or to excited about their new child to fully focus
Eritrean church,
Eilat An Eritrean Greek Orthodox church in the old centre of East-Eilat
-Many Eritrean women together in one place: addressing a network of people that also meet in the afternoons
-Participants have more time; they attend church during their day off on saturday
-Participants invite me to visit them and their friends in the afternoon
- Only Eritreans present: natural setting
-Women may feel too tired of the past week full of work or have no appetite for participating on their day off
-Less privacy: church members are curious to see and hear how participants respond
-Potentially less representative of the Eritrean population: only believers interviewed
Hotels, Eilat Human Resource rooms in the hotels of ‘Isrotels’
-Many Eritrean women work in
hotels -Eritrean women fear their employers: afraid to to refuse participation and to answer freely -Heavy workload: survey filled out at home and often not returned.
Concluding, all channels were benevolent in some ways, while disadvantageous in other ways. Therefore, I tried to use all channels equally intensive, except for the hotels. Taking the marginal advantage and serious disadvantages of this channel, I approached hotels after I could no longer find new participants through other channels.
4.4 Sample
This section discusses the final sample that resulted from the sampling strategy. First the sample for the quantitative method (see Section 4.5.1) will be presented, after which I will
29 discuss the samples for the qualitative methods (see Sections 4.5.2 and 4.5.3). For the qualitative and quantitative methods, different Eritrean women were approached.
The final sample for the survey consists of 63 Eritrean women. Graph 1 presents the distribution of the main demographic characteristics of the women, as well as the channels through which they were approached. Appendix II list these characteristics for every single participant. Graph 2 shows that most Eritrean women participating are part of young and small nuclear families that mainly emerged in Israel. The sample is diverse, including young and old mothers, that delivered one to three children either recently or several years ago. Hence, this sample should be diverse enough to allow for investigation of how diversity within the Eritrean population affects Eritrean women’s user rates of, and experiences with Israeli antenatal and delivery services. The sample is relatively equally divided over the cities and approached through different channels. Hence, the sample seems to be representative for the Eritrean women that live in Tel Aviv and Eilat.
Graph 1. Distribution of the sample characteristics. N = 63.
As for the sample of qualitative interviews, this was initially targeted at Eritrean women only. When discussing the methods in Section 8.5, I will elaborate on how I also included Israeli health care providers in the sample. In total, eight providers were interviewed and ten Eritrean women, the so-called users. For both groups, exactly halve of the participants were from Tel Aviv and the other halve from Eilat.
As for the providers, they cover many different professions in antenatal and delivery care. For Eilat, the sample includes the head of the Ministry of Health, a manager of the Tipat Halav (i.e., centre for pregnancy care), and a gynecologist and nurse of the Yoseftal Hospital. In Tel Aviv, the sample includes a manager and a nurse of the Terem Clinic (i.e., clinic for uninsured
AGE ERITREAN WOMEN:
22 UNTIL 42 YEARS OLD, MEAN = 28
MOST RECENT DELIVERY:
1-4 YEARS AGO: 77% 4-8 YEARS AGO:23%
MARITAL STATUS: SINGLE: 2% RELATIONSHIP:2% MARRIED: 88% DIVORCED: 9% NUMBER OF CHILDREN: 1 UNTIL 3, MEAN = 2 STAY IN ISRAEL:
3 UNTIL 8 YEARS, MEAN = 5
CHILDREN BORN IN ISRAEL :
1 UNTIL 3, MEAN = 2
CURRENT CITY OF RESIDENCE:
TEL AVIV: 56% EILAT:44%
APPROACHED THROUGH: -ERITREAN WOMEN COMMUNITY CENTER ~ 19% -INDIVIDUALS TEL AVIV: ~ 30% -YOSEFTAL HOSPTIAL: ~ 11% - ERITREAN CHURCH: ~ 35% -HOTELS ~ 5%
STAY IN OTHER COUNTRIES OF ASYLUM:
