Methods
Study design
We designed a qualitative method study with a phenomenological focus and a variety of data-gathering techniques [
41]. The phenomenological focus allows a description of experiences and an awareness of the facts, without looking for causes [
42]. The study was carried out in Girona (Spain), from March to July 2014 in a work preparedness program for women, a project of the Girona office of Caritas, the international Catholic Charities organization that works with unemployed and homeless individuals and families and with immigrants.
Recruitment
One of the researchers explained the project to participants in the Caritas program, in clear, uncomplicated terms, and responded to all of the questions the women wanted to ask, as a group and individually as needed. Those who agreed to voluntary participation in the project understood that the only potential benefit was the opportunity to better understand themselves [
43]. A convenience sample of 8 immigrant women aged 25 to 50 years was recruited to participate in the study. According to some authors, qualitative studies can reach data saturation with 7 or 8 participants [
44].
Participants
The participants were residents of Catalonia from 6 different countries of origin in three regions of the world. Three were from sub-Saharan Africa: the youngest of all the participants (JF) is Senegalese, without a stable partner and unemployed for 1 year; another (SM) is from Burkina Faso, has 2 daughters, her husband is employed half-time, and she works a few hours a week cleaning a house; the third (HS) is from Ghana and has lived in a city shelter for 2 months because she has no source of income. Three were from Central America: the oldest of the whole group (CM) is unemployed and all her close family members remain in her home country, Ecuador; another from Ecuador (LA) has a husband and son in Girona and although her socioeconomic level is higher than the rest of the group, she has had problems with social integration; a married woman from Honduras (XB), with three children younger than 10 years, is active in the protestant Evangelical Church in Girona. Two of the participants were from Morocco: one (KS) is divorced and lives with her daughter in an apartment offered by Caritas; the other (BD) lives with her husband, who has been unemployed for almost a year, and two children in their own house.
Data collection
The research was carried out in a community room at the town hall, in order to dissociate the study from Caritas and communicate to participants that they could express their opinions and feelings without fear of judgment, with total trust, and with confidence that their participation would not affect their relationship with the work preparedness program. All participants gave signed informed consent and agreed to maintain the confidentiality of everything that was said during the focus group sessions. The study was carried out in accordance with the Declaration of Helsinki and Council for International Organizations of Medical Sciences CIOMS guidelines for research in vulnerable populations [
45]. The Committee on Clinical Research Ethics of Dr Josep Trueta University Hospital in Girona (Spain) approved the study (2014/029).
Data were collected using conceptual, metaphoric language, and information was captured in a flexible and unstructured fashion, using procedures that are more inductive than deductive and a holistic orientation that leads to a broader and deeper awareness of the topics of interest [
46]. Given the difficulty of identifying health assets for each individual, we also chose to apply several different qualitative techniques –a focus group, photovoice session, and in-depth interview– in order to encourage self-awareness, surface information, and collect the data of interest [
41]. In order to establish greater trust and empathy with the participants, all of these techniques were carried out by the same researcher. All participants understood that no information they provided would be shared with Caritas, their comments would be identified by randomly generated initials (not their own), and the study results would not be published until they had completed the work preparedness program.
First, we carried out 2 focus group sessions with all participants, lasting from 1.5 to 2 h. Two sessions were required because of some participants’ limited proficiency in Spanish, which required more time to allow them to express themselves to the group. These open-ended sessions dealt with various themes: life goals and plans, family and social relationships, their own roles and contributions, and other topics that arose spontaneously and generated interest among the participants. For some, a focus group enriches the discourse in multicultural settings [
47,
48], and it is also valued as a co-learning tool for participants that facilitates clarification and understanding of the phenomenon being studied [
49].
In addition, an adapted photovoice session was held. This technique is defined as “a process by which people can identify, represent, and enhance their community through a specific photographic technique” [
50]. It has three goals: it enables the use of photographs to show the needs and assets of a community, which increases individual empowerment regardless of the participant’s language skills [
51], it promotes critical thinking, and it offers participants a means to reach policymakers. Some authors have described it as a process that allows people to put words to images, helping the most vulnerable to narrate their own stories and describe the realities of their daily lives [
52].
In the context of the present study, photovoice allowed discussion of participants’ views and perceptions of topics such as their role in the family and community and their goals and plans for the future. The photovoice session began with the participants sharing three photographs taken on their cell phones to show what was most important in their life. Next, they discussed their choices with the group, explaining the importance of each photo to them and the dreams reflected in each one.
Finally, in-depth interviews were carried out with each participant. These open-ended conversations allowed each woman to comment further, and more privately, on topics that surfaced during the focus groups and photovoice session, or to raise new topics of her own. During each interview, the researcher attempted to achieve a high level of empathy with each individual, control the emotional tone at all times, and ask the most sensitive or difficult clarifying questions at the opportune time [
53].
The researcher kept a field diary during the study, where memos on all of the steps taken were kept, along with personal observations that might be considered relevant. The collected data were not included in the results because they were considered relevant only during the process itself.
Data analysis
The focus group sessions, adapted photovoice session, and in-depth interviews were all self-recorded and transcribed verbatim. Data from the focus groups and photovoice session were analysed in a first phase, and personal interviews were carried out and analysed in depth in a second phase, until data saturation was achieved.
All sessions were categorized and analysed using Atlas Ti v.7 software. Data analysis was carried out by 3 researchers, who independently integrated all qualitative techniques in 4 phases: general analysis, definition of codes, line-by-line coding, and disaggregation of certain codes (Table
1). Consensus was reached on all coding decisions. A second analysis of the results was carried out to identify relationships between the assets identified.
Table 1
Phases of qualitative analysis
Phase 1: | General analysis of each interview to establish sociodemographic data for each participant and preliminary general coding of the most notable characteristics of the interview |
Phase 2: | Definition of the codes applied, based on previous knowledge and the study objectives |
Phase 3: | Line-by-line coding of each interview |
Phase 4: | Review of Phase 3 coding to disaggregate codes as appropriate. |
Discussion
Basing our analysis on the salutogenic approach [
26] in a population of immigrant women, the results corroborate the SOC definition, both in general and in each of the three dimensions:
1.
Comprehensibility allows a person to have a life that is structured, predictable and explainable. In contrast, the immigrant woman’s life is unpredictable and full of uncertainties, both economic and social, such as whether the immigrant will ever see her family or home country again.
2.
Manageability, described as the resources that make it possible to have this life, consists of the resources participants possess: they know how to sew and/or cook great food, they are good managers of the household economy (maximizing every cent), and they know how to seek out external resources such as the public library and other institutional resources and support.
3.
Meaningfulness, understood as challenges to be met and ways to remain motivated in life, could also be described in our population as challenges and dreams: learning, having a job, and making a home in the most decent conditions they can manage to provide for the family.
These results coincide with factors identified by other authors that favour or protect a woman’s wellbeing. These include describing what they know in terms of their life skills, not based only on their formal education, and knowing the importance of their role and responsibilities as mothers [
40,
55].
Our main finding was that, despite the many challenges they face, the immigrant women from many cultures who participated in our study have many self-described assets: optimism, capacity for struggle and for initiative, religious beliefs, and social support. They have assumed an essential family role as caregivers for their children, always prioritizing family over the working world, and clearly considered their children the motivators or the objective of many of their dreams.
The optimism and perception of control described by study participants are aligned with the factors reported by Grote et al. as protectors against stress in a study of women with socioeconomic problems [
56]. Our study reaffirms the social support of family and friends as protective factors against mental health problems and the importance of high-quality affective relationships (husband, friends and neighbours) previously reported by other authors [
40,
55], and supports Cohen’s observation that not only the quantity but also the quality of this social support must be taken into consideration [
57]. In addition, the role of mothers and caregivers was an important motivation that encouraged participants to carry on, not only for themselves but to fight for a better future for their children, which was one of their dreams – as in earlier studies [
58].
At the same time, participants reported that their religious beliefs help them to accept and/or to confront the acculturative stress they experience as immigrants. This result coincides with a finding that Latin American immigrants in California report an inverse relationship between perceived stress and religious faith [
59]. The assets model allows the creation of new strategies to promote health, based on knowledge of individual capabilities and community resources [
35].
As Kretzmann and McKnight point out, however, a focus on the assets or GRR of vulnerable groups does not mean that a group has all the external resources they need [
60]. The idea is not only to highlight the needs of these groups but also to recognize –and help them recognize in themselves– their own internal, external and community resources, in order to make better use of them and increase their self-esteem and SOC. Antonovsky discussed the need for holistic and integrated study of each individual, and for individual and community empowerment to reduce health inequities and provide a different –positive– view of immigrant women. However, we would emphasize that as of 2013 only 12 % of European countries had national policies designed to address these inequities [
12]. According to Morgan and Ziglio, describing the assets available to immigrant women should enable a new approach to social and health policies oriented toward this group and serve as a tool to gain a better understanding of the causes of health inequities and the mechanisms by which they occur, in order to develop the new strategies required to remove them [
61]. Some authors have described the need to reinforce policies, not only to cover the basic needs of vulnerable individuals and families, but also to empower them to meet their own needs [
62]. One approach would be to reorient health promotion policies toward a salutogenic perspective, using asset models in the most vulnerable groups to empower the whole person by creating networks and synergies among all the different agents involved in supporting them. In addition, new policies designed to move toward equity in health resources require multi-sector interventions that encompass various determinants of health. These include reducing long-term unemployment, improving workplace conditions, reducing social segregation and increasing social participation in civic life, improving the physical environment and public transportation, ensuring equal access to healthcare services, and encouraging community-based capacity-building in health promotion. It is also important to include the affected communities, and specifically immigrant women, in the design and development of these policies from the outset, focusing on their needs but also on their assets.
The main limitation of the present study was the very basic level of Spanish language skills of many participants; if a participant had difficulty expressing her thoughts or feelings, this could have affected part of the study. This also complicated data analysis and interpretation because the participants tended to use very short sentences, which could have lost some meaning when extracted from the broader context. To address this limitation, multiple qualitative techniques were used, adapting them to the characteristics of the study participants in an effort to achieve the overall research objective. However, the linguistic aspect of the study was both a challenge and a strength because it was an opportunity to apply best practice research techniques used in populations with language-related difficulties. A major strength of the theoretical framework was that it allowed new constructs of “sources of health” to surface, rather than focussing on a diagnosis of the well-known challenges faced by immigrant populations. As these women were not strangers to each other, the first phase of the study seemed to help them encourage each other, particularly when language was a barrier. In particular, the photovoice session was very helpful in encouraging the women with the most limited language skills to express themselves. In future research with this population, photovoice methodology could be the first approach, and could be expanded somewhat. Once a rapport had been established with the researchers, the personal interviews were very useful in allowing each individual participant to have her own “last word” on the subjects that most interested her. A final strength of the study was the diversity within the group of immigrant women who participated. They were not only from different countries in North Africa, sub-Saharan Africa and Latin America but also differed in their cultural and educational backgrounds, marital status, and immigrant situation in Spain.
Conclusions
From a salutogenic perspective, we can classify the main GRRs or assets of immigrant women as individual, community, and institutional. Individual resources included the ability to manage difficult situations, the capacity for initiative, the importance of religious belief, and high levels of optimism, personal motivation, and feeling useful to others. Community GRRs include the importance of children, family, and interpersonal relationships. In the institutional group, participants highlighted the support they had received.
The women who participated in this study provided evidence that immigrant women have assets and know how to use them, shedding light on a new asset-based approach to health promotion interventions to reduce health inequities, rather than focusing only on the needs of the groups involved. The results indicate the necessity of investing more effort and resources in social, educational, and health policies and gathering in-depth evidence of the effectiveness of interventions based on this new approach.
Acknowledgements
Elaine Lilly, Ph.D., provided guidance in the translation and assistance with final English language revision of the article.