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South Asian immigrant women’s access to and experiences with breast and cervical cancer screening services… Habib, Sanzida Zohra 2012

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SOUTH ASIAN IMMIGRANT WOMEN’S ACCESS TO AND EXPERIENCES WITH BREAST AND CERVICAL CANCER SCREENING SERVICES IN CANADA  by Sanzida Zohra Habib B. A., Rajshahi University, 1996  M. A., Simon Fraser University, 2003    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The Faculty of Graduate Studies (Women’s Studies)   THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)   July 2012   © Sanzida Zohra Habib, 2012    ii  ABSTRACT   A qualitative feminist study, informed by social constructionist epistemology, antiracist theories and intersectionality perspectives, was conducted in order to understand South Asian immigrant women’s access to and experiences with breast and cervical cancer screening services in Canada. Particular attention was paid to the wider context of their lives and their experiences of migration, resettlement, integration and general access to the Canadian healthcare system. The study also explored how the broader systems, structures and policies in Canadian society shape South Asian immigrant women’s participation in and access to cancer screening services. Thirty one South Asian immigrant women were interviewed in individual, couple and group settings in greater Vancouver. Research findings indicated that women’s age, length of stay since immigration, educational and generational status, not/having a family history or symptoms impact their use or lack of use of cancer screening services; but these factors also intersect in complex ways with various systemic and structural issues including not/having a recommendation from physicians, women’s financial in/stability, access to income, employment, settlement services and community resources, levels of socioeconomic integration and familiarity with the Canadian healthcare system, and gender roles and responsibilities. Women’s narratives also showed that the immigration factor amplify the intersecting forms of inequities and the social determinants of health such as gender, class, poverty, racialization and discrimination, and affect women’s physical and mental health and access to healthcare services, cancer screening being one of them. An intersectional analysis revealed that the gendered and racialized immigration and integration policies, multicultural discourses and neoliberal ideologies and practices intersect to situate South Asian immigrant women into racialized and disadvantaged situations as the ‘other’ wherein access to preventive cancer screening services becomes especially challenging. South Asian women’s access to cancer screening and other healthcare services needs to be understood beyond the attempts to know their cultural health beliefs and practices, and beyond the neoliberal ideas of ‘self-care,’ ‘individual responsibility,’ ‘patient empowerment,’ and ‘culturally sensitive care.’ Also, equitable access to health care cannot be ensured without resisting these women’s racialized position as the ‘other’ and addressing the social, political, historical, material and structural inequities in Canadian society.   iii  PREFACE   The dissertation research received an approval of the UBC Behavioural Research Ethics Board (UBC BREB NUMBER: H08-02121) on November 3, 2008. A shorter version of Chapter 2 “Review of Existing Literature” was published as “Culture, Multiculturalism and Diversity: A Feminist Antiracist Examination of South Asian Immigrant Women’s Utilization of Cancer Screening Services” in The International Journal of Diversity in Organizations, Communities and Nations 8, no. 4:187-196. © 2008 Sanzida Habib.      iv  TABLE OF CONTENTS  ABSTRACT .................................................................................................................................... ii PREFACE ...................................................................................................................................... iii TABLE OF CONTENTS ............................................................................................................... iv LIST OF TABLES ....................................................................................................................... viii LIST OF FIGURES ....................................................................................................................... ix ACKNOWLEDGEMENTS ............................................................................................................ x DEDICATION .............................................................................................................................. xii CHAPTER 1:  INTRODUCTION AND OVERVIEW .................................................................. 1 Setting the Research Context ...................................................................................................... 1 Defining South Asian Women .................................................................................................... 2 Outline of the Research Problem ................................................................................................ 4 Research Purpose and Questions ................................................................................................ 7 Original Contributions and Scopes of the Research ................................................................... 8 Organization and Overview of the Thesis ................................................................................ 11 CHAPTER 2: REVIEW OF EXISTING LITERATURE ............................................................ 14 Introduction ............................................................................................................................... 14 Women’s Health Research and South Asian Immigrant Women ............................................. 15 Existing Knowledge of South Asian Immigrant Women’s Participation in ............................. 19 Reproductive Cancer Screening ................................................................................................ 19 Rates of Participation in Cancer Screening ....................................................................................... 20 Determinants of Participation in Cancer Screening .......................................................................... 23 Culture and South Asian Women’s Cancer Screening ....................................................................... 29 South Asian Women’s Cancer Screening and the Health Belief Model ............................................. 31 Removing Barriers and Enhancing Access to Cancer Screening ....................................................... 33 Developing Theoretical and Conceptual Frameworks .............................................................. 35 Critical Feminist and Antiracist Theories .......................................................................................... 37 Intersectionality and Immigrant Women’s Health ............................................................................. 39 Antiracist and Feminist Critiques of Culture, Multiculturalism and Culturally Sensitive Care ........ 45 Conclusion and Rationale of the Theoretical Framework ........................................................ 49 CHAPTER 3: METHODOLOGY AND RESEARCH METHODS ............................................ 51 Introduction ............................................................................................................................... 51 Paradigms of Women’s Health Research ................................................................................. 52 v  Situating Knowledge Production .............................................................................................. 56 Research Design and Procedure ................................................................................................ 59 Method of Data Collection: In-depth Interviewing ............................................................................ 64 Sampling and Procedure .................................................................................................................... 68 Ethical Considerations ....................................................................................................................... 76 Analysis of the Data .................................................................................................................. 79 Representing the Voices of South Asian Women ................................................................................ 82 Feminist Objectivity/Subjectivity ........................................................................................................ 89 CHAPTER 4:  SOUTH ASIAN IMMIGRANT WOMEN’S PARTICIPATION IN CANCER SCREENING ................................................................................................................................ 91 Introduction ............................................................................................................................... 91 The Nature and Extent of Women’s Participation in Cancer Screening .................................. 92 Intersecting Influences on Women’s Participation in Cancer Screening.................................. 98 Women’s Age, Literacy and Length of Stay in Canada ...................................................................... 99 Understandings and Knowledge of Pap smear and Mammogram ................................................... 100 Having Symptoms or a Family History ............................................................................................ 105 Physician Practices: “Some Doctors Let You Know, Some Don’t!” ............................................... 108 Receiving Regular Reminders .......................................................................................................... 112 Belief in the Importance of Cancer Screening and Reliance on Physician's Advice ........................ 114 Access to Community Support and/or Community Service Agencies ............................................... 115 Faith in God and Inevitability of Illnesses ....................................................................................... 116 Perceptions of Risk Factors and Need of Cancer Screening ............................................................ 118 Gender Roles and Time Constraints ................................................................................................. 120 Fear or Stigma of Reproductive Cancer and Cancer Screening ...................................................... 121 Experiences and Embarrassment of Undergoing Sensitive Physical Examinations ........................ 123 Gender, Age and Ethnicity of Physicians: ‘A Doctor is a Doctor, Right?’ ...................................... 125 Understanding the Complexities of South Asian Women’s Participation in .......................... 133 Cancer Screening .................................................................................................................... 133 CHAPTER 5: THE IMPACT OF IMMIGRATION AND SETTLEMENT EXPERIENCES ON WOMEN’S HEALTH AND ACCESS TO HEALTH CARE .................................................... 141 Introduction ............................................................................................................................. 141 Immigration, Gender and Health ............................................................................................ 143 Gendered Experiences of Migration and Settlement ........................................................................ 144 Challenges of Immigration and Settlement ...................................................................................... 149 vi  The Impact of Immigration and Settlement Status on Women’s Health ........................................... 156 South Asian Immigrant Women’s Access to Health Care and Cancer Screening Services ... 166 Availability and Quality of Primary Care ........................................................................................ 169 Long Waiting Time ........................................................................................................................... 172 Unfamiliarity with Existing Services ................................................................................................ 174 Cultural Barriers and Ethnicity/Gender Matching .......................................................................... 176 Language Barriers............................................................................................................................ 180 Beyond the Cultural and Language Barriers: Understanding the Diverse Contexts of South Asian Immigrant Women’s Lives ........................................................................................... 183 CHAPTER 6: UNDERSTANDING THE SOCIAL CONSTRUCTION OF SOUTH ASIAN IMMIGRANT WOMEN AS THE ‘OTHER’ THROUGH THE LENS OF INTERSECTIONALITY ............................................................................................................ 187 Introduction ............................................................................................................................. 187 A Legacy of South Asian Women as the ‘Other’ ................................................................... 189 A Critical Overview of the Multicultural Policy in Canada ................................................... 193 The Socioeconomic Marginalization of South Asian Immigrant Women.............................. 198 Politics of Community/Organizations and Social Capital ...................................................... 203 Multiculturalism, Neoliberal Ideologies and Healthcare Reforms ......................................... 212 The Impacts of Healthcare Reform on Immigrant Women ............................................................... 214 Liberal Individualism and Self-care ................................................................................................. 217 Women’s Agency and Empowerment .................................................................................... 220 South Asian Immigrant Women as the ‘Other’ and Their Access to Cancer Screening ........ 228 CHAPTER 7:  CONCLUSIONS, DISCUSSIONS, AND IMPLICATIONS ............................ 234 Introduction ............................................................................................................................. 234 A Review of the Key Findings and Analysis .......................................................................... 234 Study Limitations and Directions for Future Research........................................................... 245 Implications and Recommendations ....................................................................................... 246 Theoretical Implications ................................................................................................................... 247 Methodological Implications ............................................................................................................ 250 Practical Implications and Recommendations ................................................................................. 251 Re/Framing Research ....................................................................................................................... 252 Developing Economic and Social Policies that Support Health ...................................................... 253 Improving Services and Clinical Practices ...................................................................................... 255 Conclusion .............................................................................................................................. 257 vii  REFERENCES ....................................................................................................................... 260 APPENDICES ............................................................................................................................ 277 Appendix A: Letter of Consent & Consent Form ................................................................... 277 Appendix B: Recruitment Messages ....................................................................................... 279 Appendix C: Letter to Agency ................................................................................................ 280 Appendix D: Interview Guide & Demographic Data Sheet ................................................... 282 Appendix E: List of Codes ...................................................................................................... 285   viii  LIST OF TABLES  Table 3.1 Number and Types of Interviews ……………………………………………......62 Table 3.2 Demographic Characteristics of the Participants ………………………………..73 Table 4.1 Level of Utilization of Breast and Cervical Cancer Prevention/Detection Processes in Canada ……………………………………………………………..93  Table 4.2 Preventative and Diagnostic Use of Pap smear and/or Mammogram in Canada ...................................................................................................................94  Table 4.3 Use of Cancer Screening in Canada among Women Under and Over the Age of 40 ………………………………………………………………………...96  Table 4.4 Use of Cancer Screening in Canada among Recent and Long-Time  Immigrants.............................................................................................................96  Table 4.5 Use of Cancer Screening in Canada and Women’s Level of Education …….......97  Table 4.6 Physicians’ Role Influencing Women’s Participation in Cancer Screening in Canada ………………………………………………………………………….111  Table 5.1 Comparative Demographic and Sponsorship Status of New Immigrants and Long- Time Residents ………………………………………………………….151  Table 5.2 Prevalence of Chronic Health Conditions among South Asian Immigrant Women …………………………………………………………………………157  ix  LIST OF FIGURES    Figure 7.1 Women’s Participation in Cancer Screening and the Intersections Among Personal and Structural Issues …………………………………………………236  Figure 7.2 Women’s Access to and Experiences with Cancer Screening: Intersections of Factors in Personal, Social and Structural Contexts of Women’s Lives ………243  x  ACKNOWLEDGEMENTS   As I approach the completion of my PhD program I feel the need and urge to thank a number of people who have been involved in this long journey in many different ways. I am very fortunate and grateful to have a wonderful supervisory committee who offered me unlimited time, energy, guidance and assurance. I would like to offer deep gratitude to my supervisor Dr. Sunera Thobani who has always inspired and supported me to continue and eventually finish the research work. Without her presence, patience, mentorship and expertise in critical feminist antiracist and postcolonial theories it would not have been possible for me to do the kind of research I have done. I am deeply appreciative of her thoughtful comments and insightful questions on this work, and her continuous support at every steps of the PhD program. I will be forever grateful to Dr. Colleen Varcoe for the enormous contributions she has made to my work through sharing her extensive and profound knowledge and experience in the area of women’s health research. I am especially thankful to her for the thoughtful and sharp analytic comments and painstaking editing on the drafts of the thesis. I am immensely indebted to Dr. Wendy Frisby for her constant presence as a crucial committee member and for her genuine interest in and unending encouragement for my work. I gratefully appreciate all the resources and ideas she shared and all the challenges she brought through her critical comments which have significantly improved the quality of my work.  The financial support of the UBC Graduate Fellowship, the Pacific Century Graduate Scholarship, Western Regional Training Center for Health Services Research Affiliate Studentship, and Women’s Health Research Network Trainee Research Fund has been instrumental in carrying on the research as well as in continuing my higher studies at UBC. I also gratefully acknowledge the funding received from Dr. Colleen Varcoe through a Doctoral Fellowship under a CIHR funded New Emerging Team grant at UBC School of Nursing.  I wish to extend my thanks to the graduate advisors and faculties at the CWGS (Center for Women’s and Gender Studies) for practicing feminist pedagogy and creating an overall supportive environment for graduate students. I must thank CWGS staff Wynn Archibald and Jane Charles for helping me through the intricacies of administrative processes at numerous steps during the long journey. Also thanks a lot to the fellow students at CWGS, especially Bianca xi  Russ, Rupa Bagga, Gemma Hunting, Naomi Loyd, Xin Huang and Almas Zakiuddin for their friendship, generosity and in/tangible input at different phases of the PhD program. Very special and warm thanks to Benita Bunjun for her thoughtful personal as well as organized support through the student network at RAGA (The Centre for Race Autobiography Gender and Age).  Special thanks are also due to my friend Arno Kamolika for patiently offering her computer graphics skills in developing the diagram on intersectionality. I am immensely thankful to my young and energetic Bangali friends at UBC for all the great time we spent together singing and sharing fun and laughter; this has been therapeutic for me during the stressful and depressing times. My heartfelt thanks go to my beloved husband Mazhar Haque for his endless encouragement, empathy, care and sacrifice. My children have blessed my life with love, courage and hope, and provided me with the strength and determination needed to finish the project. My parents have never stopped supporting and praying for me no matter how far away they are – I am eternally indebted to them for their love and blessings.  Finally, this acknowledgement would be incomplete without appreciating the women participants who open-heartedly shared their experiences and stories that became the heart of this work. I hope their contributions will be truly appreciated by policy makers and service providers through their efforts to making Canada a more egalitarian and equitable society.   xii  DEDICATION  To my parents who have blessed me with immense love and support 1  CHAPTER 1:  INTRODUCTION AND OVERVIEW    Setting the Research Context  Breast and cervical cancers are two major life-threatening illnesses for women in Canada as in anywhere in the world. Over the lifetime, approximately one in nine Canadian women will develop breast cancer and one in 28 Canadian women will die from it, the second leading cause of mortality among women after lung cancer (Canadian Cancer Society 2009). While cervical cancer is the tenth most common cancer among Canadian women of all ages, it is the third most common among women aged 20 to 49 (ibid.). Mammogram and Pap smear screening are considered the best currently available methods of secondary prevention through early detection and reduction of mortality of breast and cervical cancers respectively. Mammograms are x-rays of the breasts and a screening mammogram looks for an unsuspected, hidden cancer in women who are healthy and who have never had breast cancer (BC Cancer Agency). The Papanicolaou (Pap) smear test is used to detect changes to cervical cells, and women are recommended to have regular Pap tests in order to detect cell changes while treatment can be effective or before they become cancerous. The BC Cancer Agency's Cervical Cancer Screening Program (CCSP) has succeeded in reducing cervical cancer incidence rates by over 70 percent (ibid.).  However, a substantial number of studies on cancer screening behaviour among women in Canada reveal that immigrant women, women with lower socioeconomic status, Aboriginal women and South Asian women in particular, are less likely to participate in mammogram and Pap smear services as compared to Caucasian and non-immigrant women (Ahmad and Stewart 2004; Bottorff et al. 2001; Bryant, Browne, Barton and Zumbo 2002; Chan 2002; Choudhry, Srivastava and Fitch 1998; Gupta, Kumar and Stewart 2002; Grewal, Bottorff and Balneaves 2004; Hislop, Mumick and Yelland 1995; Hislop, Bajdik, Regier and Barroetavena 2007; Johnson et al. 1999; Ogilvie et al. 2004; Lofters, Moineddin, Hwang and Glazier 2011; Lofters, Moineddin, Hwang and Glazier 2010; Woltman and Newbold 2007). While the underutilization of reproductive cancer screening among South Asian immigrant women is a well known fact, little is known about the ways in which their lack of access to these services is affected by the broader systems, structures and policies that shape the life circumstances of these women. 2  Defining South Asian Women  Statistics Canada (2008) reported that in both 2001 and 2006, India and Pakistan represented the second and fourth leading source county respectively of newcomers to Canada. Thus South Asians surpassed Chinese people as the largest ‘visible minority’ group in Canada in 2006. Although fully 14% of recent immigrants who arrived between 2001 and 2006 came from the People's Republic of China, India and Pakistan represented 11.6% and 5.2% of new immigrants correspondingly in 2006 (ibid.). According to the 2006 Census report, ‘visible minorities’ made up about a quarter (24.8%) of British Columbia’s total population, the highest among all provinces and territories in Canada (WelcomeBC 2008). The same source also showed that South Asians (26% of ‘visible minority’ population and 6.4% of the total population) constituted the second largest ‘visible minority’ group in the province. Apparently, the growth of ‘visible minority’ population is mainly attributed to high rates of immigration to Canada from non- European countries. In 2006, fully 75% of recent immigrants who arrived since 2001 were ‘visible minorities’ compared to 72.9% in 2001 and 74.1% in 1996 (Statistics Canada 2008).  The term ‘visible minority’ is defined in the federal Employment Equity Act as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour” (WelcomeBC 2008). Hence, this is a category labelled against the ‘non-visible’ or dominant white populations in Canada. Such processes of categorization reinforce white domination which is viewed as the standard, and also standardize people of diverse ethnic, linguistic, religious, educational, geographical and cultural backgrounds as the ‘other.’ Similarly, women from India, Pakistan, Bangladesh, Sri Lanka, and Nepal, and women with Indian origin coming from Fiji, East Africa, and the Caribbean are usually grouped together in the common discourse in Canada as South Asian women. A South Asian academic and social worker in Canada, Usha George (1992), made an interesting remark that the only characteristic these women share in common is that they come from tradition oriented patriarchal societies with strong extended family ties. This, however, tends to create stereotypes about South Asian women who are most often represented in mainstream health research and particularly in cancer screening research as the cultural ‘other’ and the ‘victim’ of their culture and tradition. Their otherness is maintained through the multiculturalist discourse of culture and community that tends to ascribe a static notion of subjectivity, geography and culture on ethnic minority people while ignoring the 3  gender, class and other power imbalances among South Asian people. Through the multicultural discourse “ethnic communities are imagined as pre-modern, tradition bound, and culturally backward” (Thobani 2007, 163). Dominant assumptions about ethnic minority communities as homogenous and bounded spaces tend to promote ghettoization of racialized immigrant women and hinder their integration into the broader Canadian society perpetuating their ‘otherness.’ The multiple and diverse realities and needs of South Asian communities are ignored through the homogenization and stereotypical representation of these communities. The current study attempted to resist such culturalization of ethnic minority communities and instead promote a critical understanding of community as a political category made up of complex and diverse power relations rather than as a fixed category, and as a source of both oppression and emancipation for South Asian women (Ponic 2007; Vissandjee, Apale and Wieringa 2009).  Popularly, culture is interpreted and essentialized as “values, beliefs, knowledge, and customs that exist in a timeless and unchangeable vacuum outside of patriarchy, racism, imperialism, and colonialism” (Razack 1994, 896); but critical antiracist and postcolonial feminists have resisted the oversimplified notions of culture and community as pre-given or natural constructs. They have rejected the essentialist conceptualization of ethnic communities as homogenous cultural groups and emphasized the internal variations within communities based on gender, class, age, ability, sexuality and other dimensions. Critical perspectives have contextualized health and healthcare practices of ethnic minority women within the broader political, economic, historical, and social contexts, and the existing structural inequalities of Canadian society. Similarly, in this study, I have problematized the notion of a distinctive or monolithic ‘South Asian culture’ that is predominantly used in literature as the explanation for the health inequities experienced by racialized immigrant women. I recognize culture as a dynamic way of living that is shaped and transformed by migration processes as well as by changing historical, social, economic and political relations. I also appreciate culture as an important health determinant that intersects with other social relations of power to influence people’s health practices and access to healthcare services.  The South Asian women in the current study were born in India, Pakistan, Bangladesh, Sri Lanka, Fiji and Canada, were predominantly first generation immigrant women who had migrated to Canada from these countries as well as from the UK and the USA, and were living in 4  the greater Vancouver area as either citizens or permanent residents. Only one self-identified South Asian immigrant woman was born in Canada. Broad categories, such as South Asian immigrant women apparently tend to lump together women of diverse classes, religions, languages, educational, employment or immigration statuses, ages and generations, while the experiences of these women with the Canadian health care and other systems are likely to vary according to their varied backgrounds. Nonetheless, such social and political identities provide certain standpoints or common grounds for antiracist solidarity, activism, and the struggle against domination (Agnew 1996; Mohanty 1991). In the current research I tried to conceptualize and represent South Asian immigrant women not as a homogenous cultural group but as “a sociopolitical designation … oppositional political relation to sexist, racist, and imperialist structures that constitutes … potential commonality” (Mohanty 1991, 7, emphasis original).  Outline of the Research Problem  Existing critical feminist and antiracist literature on South Asian immigrant women’s socioeconomic and health status reveals that several intersecting policies and structural factors situate these women into the position of the ‘other,’ wherein they are perceived as incompatible with the national (bilingual and bicultural) characteristics of white Canada (Anderson and Kirmham 1998; Bannerji 2000; Dossa 2005; Thobani 2001, 2007; Zaman 2006). It is from such a position that they try to access health care and other services. But research on South Asian immigrant women’s access to cancer screening services rarely takes into account the broader political, economic, historical, and social contexts within which these women access healthcare services. Most studies on these women’s use of cancer preventative health care maintain a focus on cultural barriers while viewing these women’s cultural understandings of health and illnesses such as breast and cervical cancer as the most important determinants of their under-participation in cancer screening. A number of studies have also examined these women’s cultural beliefs and knowledge about and attitudes towards breast and/or cervical cancer and screening processes. These studies recommend culturally sensitive service delivery by healthcare providers and increased awareness about these cancers and screening services among South Asian women. Culture is framed in such literature as the main problem or barrier to these women’s access to cancer screening services, rather than as one of the many contextual aspects that influence women’s lives and health. Such a culturalist approach not only views culture as pre-given, static, 5  and independent of the social, historical, economic and structural contexts, it also deflects attention from systemic racism and discriminatory practices of the health care and other institutions in Canada while attributing the problem of inequitable access to the culture of these women. This approach also constructs South Asian women as a homogenous group or as the ‘other’ while overlooking their internal differences and complex and diverse social locations. A dominant focus on the cultural barriers to health care results in a lack of consideration of how systemic and structural barriers in Canadian society (such as, racial discrimination and class inequities, poverty and social isolation faced by immigrant women) influence the accessibility of cancer screening and other health services. A lack of focus on the systemic and structural factors also tends to result in blaming individual women for their own poor health, or for failing to take responsibility for prevention of illnesses, or cancer in the present context.  These problems were addressed in my research on South Asian immigrant women and cancer screening.  The existing literature has also failed to capture the unique gendered and racialized experiences of these women as immigrants, especially the dynamics of migration and relocation in their lives. Thus there was a particular need for further research in the area that is “sensitive to the experiences of migration above and beyond the recognition of cultural diversity” (Vissandjée, Thurston, Apale and Nahar 2007, 222). Only a few studies have examined how some of the systemic issues within the Canadian healthcare system influence South Asian women’s participation in cancer screening. Further research seemed to be still necessary to critically explore how the broader structures, policies, discourses and processes intersect to shape these women’s access to and experiences with cancer screening services.  Understanding health disparities, according to Weber and Parra-Medina’s insightful argument, requires that we examine the broader social, cultural, economic and political processes of social inequities that control or influence the nature and extent of these disparities. Critical feminist health researchers have used antiracist and postcolonial theories to examine the deeper and broader structural forces (such as gender discrimination, racial and class exploitation, colonization, poverty, globalization) that determine the health and the illness of marginalized people (Anderson 2000). Antiracist perspectives and especially the intersectionality paradigm explicate healthcare practices of racialized and marginalized people within larger interlocking political, economic, historical and socio-cultural contexts. And such perspectives were still 6  missing or lacking in the research area of South Asian immigrant women’s cancer screening. My research therefore used a critical feminist and antiracist approach to explore these immigrant women’s access to and experiences with the Canadian healthcare system in general and cancer screening services in particular. It attempted to produce more complex understandings of South Asian immigrant women’s engagements with cancer screening from their own perspectives, with a special focus on their experiences of migration, relocation and resettlement in Canada that are shaped by the complex intersections of their race, gender, age, class, generation, educational and immigration status.  I undertook a qualitative research to capture the lived experiences and complex realities of these women as shaped by multiple intersecting political, economic, historical and social structures and policies. A shift from the emphasis on South Asian culture to that on the challenges and stress of migration and settlement in a new country helped me gain a better understanding of the systemic racism and poverty, institutional, structural and socioeconomic barriers faced by South Asian immigrant women in accessing health care and other services. It produced a deeper knowledge of how these women’s gendered, racialized and classed experiences of migration and resettlement in Canada intersect to situate them into marginalized positions from where it becomes difficult to access health care, especially preventive health services such as cancer screening. A significant gap in this area of health research is that very few have explored the ways in which race, class, age, and gender relations intersect with immigration and settlement status to shape immigrant women’s experiences with cancer screening services. An intersectionality framework in the current research was timely and necessary in order to explore the broader contexts of South Asian immigrant women’s health, and particularly to uncover the complex interrelationships between the larger structures and these women’s subjective experiences of use or lack of use of breast and cervical cancer screening services. The lens of intersectionality was also needed to uncover how the historical as well as current policies, institutionalized practices and structural inequities in Canada interact with each other to marginalize these women in both discursive and material ways, thereby shaping their health and access to cancer screening services and other healthcare services.  7  Research Purpose and Questions  The broad purpose of my study was to understand women’s access to and experiences with cancer screening services within the broader political, economic, historical and social contexts of their lives. One of the main objectives was to explore and depict the complex and multiple intersecting influences on South Asian immigrant women’s access to cancer screening within the larger frame of their diverse life-contexts in Canada. I wanted to gain fresh insights about how these women’s experiences of migration and resettlement in a gendered, racialized and classed as well as a multicultural and neoliberal society in Canada play into shaping their use or lack of use of cancer screening services. In other words, my research aimed to look for the links between South Asian women’s access to healthcare system including the cancer screening services, and their socioeconomic and structural positions in Canada as shaped by the broader and interlocking systems and policies related to race, class, gender, immigration and health inequities. The ultimate goal was to enhance South Asian women’s access to not only cancer screening services, but the Canadian healthcare system in general, through influencing research, policy and practice towards reducing the socioeconomic, political and systemic inequalities leading to health inequities.  The following key questions guided the research and its objective to acquire more complex and deeper understandings about the women’s access to and experiences with cancer screening services: 1. What are the patterns and extent of South Asian immigrant women’s engagements with breast and cervical health, prevention, and screening of breast and/or cervical cancers? 2. What shapes these women’s use or lack of use of the breast and cervical cancer screening processes? 3. What are these women’s experiences with the healthcare system in general and the cancer screening processes in particular and how are their experiences related to immigration processes? 4. How do the broader systems, structures and policies in Canadian society shape South Asian immigrant women’s participation in and access to cancer screening services?  8  Original Contributions and Scopes of the Research The research in hand has filled a number of gaps in the existent knowledge and scholarship about South Asian immigrant women’s health and access to health care, especially reproductive cancer screening. My research used a critical feminist antiracist approach and the lens of intersectionality, which has not been previously employed to understanding South Asian immigrant women’s access to and experiences with cancer screening services. Such an approach with its focus on structural issues and power relations that create health inequities, instead of that on an essentialist notion of culture, has produced a thorough and critical understanding of the issues concerning South Asian women’s access to cancer screening services, and has provided the much needed support to make structural changes that promote health equity and equitable access to health care.  Vissandjee, Apale and Wieringa (2009) argued that although migration is increasingly being recognized as an important contributor to health and health iniquities among women in Canada, more extensive research is still needed to clarify the health effects of migration. The current project’s spotlight on these women’s diverse experiences of migration, integration and racialization not only produced new and more complex knowledge about South Asian women’s participation in cancer screening, but also about the general relationship or connection between immigration, health and access to health care for ethnic minority women.  The present study viewed the issue of access to health care beyond South Asian women’s cultural practices and personal attitudes and understandings about health, cancer and cancer screening. I examined these women’s access to cancer screening within the broader contexts of their overall experiences with the Canadian healthcare system – experiences that intersect with their immigration processes as well. Very few studies have considered South Asian women’s perspectives on the quality of cancer preventive care in examining the barriers to such services. I also viewed the issue from the perspectives of these women as rightful agents deserving equitable access to the state funded services including health care and cancer screening. This social justice approach and intersectionality framework allowed me to consider the issue of access from the perspectives and experiences of South Asian immigrant women within the larger contexts of their lives as well as within the historical and existing structural inequities of the Canadian society. The present study was also ground breaking in its adoption of an intersectional analysis of the issue of South Asian women’s access to cancer screening services. 9  As such, my research has made important theoretical and methodological contributions through using feminist antiracist theories and intersectionality paradigm in designing the research and interpreting the data. The use of intersectionality perspectives in exploring South Asian women’s experiences and access to health care helped to view the women as active agents rather than passive ‘victims’ of culture as well as other structural forces, and to resist their predominant representation as the cultural ‘other’ in the literature. I also tried to examine and understand ethnic minority or racialized women’s access to cancer screening and other health services from an intersectionality perspective rather than simply in contexts of the geographical, organizational and financial aspects of health services, or in terms of women’s personal understandings, attitudes, cultural beliefs and practices around health and illnesses. An exploration of how the Canadian immigration policies, multicultural discourses and neoliberal economic restructuring processes shape South Asian immigrant women’s access to cancer screening services showed that women’s personal health issues and access to health care cannot be understood as isolated from the larger social, political, historical, material and discursive contexts of their lives. I have offered a theoretical map (Figure 7.2) to show how South Asian immigrant women’s access to and experiences with cancer screening were shaped by the complex intersections of broader systems, structures and policies and their diverse impacts on women’s personal, material and everyday lives and on their interactions with physicians or healthcare providers. The intersectionality framework and analysis reflected the need to theorize the notion of health care access more critically and holistically as a process that reveals how gender, racialization, immigration and socioeconomic status, and historical as well as current positioning of South Asian women as the ‘other’ intersect to shape their participation in cancer screening and other preventive healthcare practices. Also equitable access to health care cannot be ensured simply through providing services, free of financial expenses, in a culturally sensitive manner without addressing the social, political, historical, material and structural inequities experienced by racialized immigrant and other women in Canada.  An exploration of South Asian immigrant women’s personal experiences as shaped by their historical and ongoing positioning as the ‘other,’ with the help of antiracist analyses and critiques of the Canadian immigration policies, multicultural discourses and neoliberal economic restructuring processes, facilitated the understanding of how the historical as well as current policies, institutionalized practices and structural inequities intersect with each other to shape 10  these women’s health and access to health care. Such a rich intersectional analysis should be useful in designing future research, policies and healthcare practices intended to bring about ideological, social and structural changes necessary for creating an equitable society and healthcare system in Canada. I have also offered some suggestions and recommendations for researchers, policy makers and health care and other service providers as to how to improve South Asian and other racialized women’s access to cancer screening and other healthcare services.  No studies are known to have looked at the common problems of South Asian women’s poor access to both breast and cervical cancer screening, or to have explored their participation in clinical breast examination and breast self-examination together with their use of mammogram and Pap smears. I examined breast and cervical cancer screening together because both are female cancers related to the reproductive system involving the most private parts of women’s body. Both practices are similar components of preventive health and should be studied together more frequently (Bryant, Browne, Barton and Zumbo 2002). Although these are rarely studied together, interestingly, literature on both types of cancer screening for South Asian women share a common culturalist and uncritical focus on women’s health beliefs and understandings, and cultural and language barriers. As such, the current study also addressed another significant gap in cancer preventative health research with South Asian women because it considered the common issues involved in accessing both breast and cervical cancer screening. However, I did not explore the healthcare providers’ perspectives on the issue, choosing instead to highlight the women’s standpoints.  In order to ensure equitable health care for immigrant and ethnic minority or other marginalized women, my research supports the removal of structural and systemic barriers, and calls for healthcare policies and primary healthcare practices that are framed both by an understanding of the complex material, everyday life practices of these women and by an analyses of the socio-political and historical processes beyond the clinic/healthcare system. And by doing so, this research contribute to the existing body of work informed by feminist antiracist and critical cultural perspectives, and enriched by the critiques of the multicultural, neoliberal and individualistic approaches to healthcare research and practice. Although I have used antiracist critiques of the cultural essentialism, cultural reductionist approach to health 11  research and culturally sensitive model of health service delivery, my research however, do not intend to completely throw out the notion of culture and its influence on health. Instead, viewing culture as a power relation co-constituted by multiple other intersecting power relations and inequitable social relationships, it recognized culture as one of the many important and intersecting social determinants of health.   Organization and Overview of the Thesis  Having outlined the general research context, background facts and information, purpose, questions and contributions, the rest of this chapter presents an overview of the thesis. Each chapter of the dissertation serves to illustrate the research in hand from its inception to gradual progression and conclusion. The next chapter is the review of relevant literature in which I situate my research within the larger field of immigrant women’s health and cancer screening research, and explain the rationale of the current study by identifying major gaps in the available literature on South Asian women and cancer screening. It also describes the theoretical and conceptual approaches informed by feminist antiracist theory and intersectionality perspectives that emerged in contexts of the existing work pertinent to the research topic, and shaped the research questions, design and analysis.  In chapter three, I outline the methodology and research method employed in the study. The chapter begins with a discussion of the philosophical underpinnings of particular methods including the ontological and epistemological issues around knowledge production. Then it illustrates the research design and procedure followed in generating and analyzing the data. It also unpacks the ethical dilemmas with a reflexive account of my own location within the research project, especially encountered in reporting and representing in this dissertation the voices of South Asian immigrant women involved in this feminist qualitative research.  Chapters four, five and six document the analyses and discussions of the research findings or data in light of the research questions. I demonstrate the varied levels of South Asian immigrant women’s participation in breast and cervical cancer screening processes in chapter four. I go on to discuss the various intersecting factors that influenced in a very complex way the 12  women’s use and lack of use of these services. Women’s experiences revealed that their participation in cancer screening was not simply a matter of their individual attitudes or cultural health beliefs. Among the multiple intersecting factors that shaped women’s various levels of utilization of cancer screening services, two of the systemic and structural issues including women’s gendered and racialized experiences of migration and settlement, and their experiences with the primary care contingent on physician practices, are explored and discussed in chapter five. In this chapter, I situate the issue of South Asian women’s cancer screening within the broader contexts of their migration, settlement, gender and health statuses and their general access to and overall experiences with the Canadian healthcare system. I discuss how women’s health and access to health care, including cancer screening, were shaped by their varied life circumstances and intersecting socioeconomic and settlement conditions as well as structural factors within and beyond the Canadian healthcare system. The analysis of women’s narratives showed that South Asian immigrant women encountered more than cultural and language barriers in accessing cancer screening services in Canada.  Chapter six presents an antiracist analysis, inspired by an intersectionality framework, about how the broader systems, structures and policies affect South Asian immigrant women’s status and position as the ‘other’ in Canada and shape their access to and experiences with the cancer screening and other healthcare services. I discuss the historical as well as current positionings of South Asian women as the ‘other’ with an overview of the Canadian immigration and multicultural policies and neoliberal ideologies.  I also analyze the ways in which contemporary health care restructuring as informed by neoliberal discourses and policies govern clinical practices and affect South Asian women’s participation in Canadian healthcare system, especially reproductive cancer screening. I go on to discuss how the larger socio-political and discursive contexts influence women’s different levels of abilities and agencies to negotiate with the gendered division of labour and structural barriers embedded in health care and other systems in Canada, and to make certain health enhancing choices and actions.  The final chapter wraps up the key findings and arguments in light of the research objectives and questions, and by doing so, makes links between and among the research questions, findings and the earlier chapters. It also considers the broader theoretical, methodological and practical implications along with an acknowledgement of the limitations of 13  this work and some ideas for future research in the area. Lastly, in this chapter, I offer some suggestions and recommendations for South Asian women’s improved and equitable access to cancer screening and other healthcare services in Canada.   14  CHAPTER 2: REVIEW OF EXISTING LITERATURE   Introduction 1    A broad review of the existing literature pertinent to the current research topic is presented here. First, I locate South Asian immigrant women within women’s health research and within the studies of breast and cervical cancer screening. Then in context of the existing knowledge of South Asian immigrant women’s participation in cancer screening, a theoretical framework and methodological approach is developed in order to explore the research questions laid out with the broad objective of understanding South Asian women’s access to cancer screening services in the larger contexts of their immigration and settlement experiences. In other words, the research questions, objectives, theoretical and methodological perspectives used in the study are situated within and justified against the broader field of the study, particularly in view of some of the gaps in the existent knowledge about South Asian women’s cancer screening.  A range of literature is discussed in what follows – from South Asian and other immigrant or non-immigrant women’s general health issues in brief, to the issues of South Asian women’s cancer screening at length. I consider the antiracist work on South Asian and other ethnic minority women’s experience of health inequities and access to health care and other social services. I also examine the feminist antiracist theoretical frameworks along with the postcolonial theoretical perspectives, especially in relation to immigrant women’s health research. Also integrated in the discussion is a review of Intersectionality theory, with a particular focus on intersectionality and health scholarship, and of how the interactions among the systems of gender, race, class and immigration shape experiences of health inequities for South Asian women. These constituted the central conceptual or theoretical constructs used in  1  Parts of this chapter have been published by the author (Habib, 2008) as “Culture, Multiculturalism and Diversity: A Feminist Antiracist Examination of South Asian Immigrant Women’s Utilization of Cancer Screening Services” in The International Journal of Diversity in Organizations, Communities and Nations 8, no. 4:187-196.       15  the current research. Also feminist and antiracist critiques of the Canadian state’s multicultural and neoliberal approaches to health care and, of the culturalist framework used in healthcare research and practices involving ethnic minority immigrant women are quite relevant to the current research. These issues and critiques are discussed here, because they were central in framing the research questions and shaping the analysis.   Women’s Health Research and South Asian Immigrant Women  Raphael (2004) noticed that significant inequities in health among citizens persist despite general improvements in the health of Canadians since 1900. Although Canada has a relatively high standard of living and health, and a publicly funded universal healthcare system, Varcoe, Hankivsky and Morrow (2007) observed that considerable social and health inequities persist for all women, and particularly for women disadvantaged by multiple forms of oppression. Egan and Gardner (2004) pointed out that several studies found that immigrant, refugee and racial minority women have obvious healthcare needs, but they utilize healthcare services at a significantly lower rate than other women in Canada. First nations, refugee and visible minority women often face racism, along with language and cultural barriers to maintaining health and accessing health care (Anderson 2000; Anderson and Reimer Kirkham 1998; Anderson, Blue and Lau 1991; Armstrong 2004; Dyck 2004). Along with other ethnic minority immigrant women, South Asian women experience inadequate and inequitable access to health care and many other social services (Agnew 1996, 2009; Bannerji 2000; Jiwani 2006; Thobani 2000; Varcoe, Jaffer and Kelln 2002). While there is much recognition of the impact of socioeconomic inequities, disproportionately suffered by racial minority immigrant and refugee women, on their health and access to healthcare services, Vissandjee, Thurston, Apale and Nahar (2007) pointed out that women’s experiences of migration were essentially invisible in health and migration research throughout the 1960s and 1970s, and that recent research efforts are in the process of integrating migration, especially the gendered experiences of migration as an important contributor to health and health iniquities among women. Women have long remained absent from history of immigration and literature on South Asians in Canada (Agnew 1996). And South Asian women only started to gain attention from feminist immigration and health scholars during the last few decades. However, Vissandjee, Apale and Wieringa (2009, 190) insisted that more extensive 16  research is needed to clarify the health effects of migration, especially how the relationship between migration and health may be strongly influenced by the diverse experiences previous to, during, and after migration.  Feminist health researchers emphasize the importance of examining and understanding women’s health within the larger social, economic, cultural, and political contexts of their lives. As Ruzek, Olesen, and Clarke (1997) claimed, feminist models of health research place women at the centre of analysis and emphasize how gender as well as other social roles and rules affect women’s health. However, they admitted that such models have not always adequately addressed health issues of women whose life circumstances vary by race, class, or a variety of status characteristics, locations, or identities.  So they called for research that would acknowledge and understand the complexities and differences in women’s health in a “multicultural society” in order to adequately address their inequitable access to health care as well as to other resources and working and living conditions that promote health. Similarly, Varcoe, Hankivsky and Morrow pointed out that a critical analysis of women’s health should not be limited to gender alone, “but rather [should] contextualize women in their diverse social and economic circumstances and understand gender as inseparable from other forms of social difference such as race, ethnicity, culture, class, sexual orientation, gender identity and ability” (2007, 3). On the other hand, Narayan (1998) pointed out that attempts in feminist scholarship to avoid gender essentialism, or universal generalization about ‘all women,’ are often replaced by an essentialist generalization about cultural differences between Western and non-Western cultures, which reinforces colonialist assumptions and stereotypes about ‘non-Western culture’ as ahistorical and homogenous – undifferentiated by class, ethnicity, language and geographical location. For example, through a critical textual analysis of the representation of Indian women in Canadian newspapers with respect to their use of reproductive technology, Henry found that South Asian women were stereotyped as “fatal victims of a ‘traditional,’ ‘unethical,’ and ‘violent’ culture” (2006, 245). Henry also argued that the racialized representation of South Asian immigrant women and the meanings produced through such representations reinforce various unequal social positions, such as “the Western ‘elite’ as ‘superior’ to Eastern and masses” (245). Thus ethnic minority women are often constructed or represented in health research as well as in immigration and multicultural discourses as the cultural ‘other’ in Canada, and  viewed as a ‘burden’ on state- funded services (Agnew 1993; Razack 1998; Thobani 1999). 17  As feminist medical geographer Isabel Dyck (2004) noted, two major models have been used in analyzing the health status and health care access issues of minority immigrant groups: one accords primacy to culture and the other focuses on the socioeconomic and political marginalization of immigrants. Reimer Kirkham (2003, 764) also noticed that health care and nursing literature in Canada generally has been silent on matters such as inequities in health, marginalizing healthcare practices, racialization, and racism. Instead, there has been a pervasive tendency to focus on culture as an influence or barrier to health and illness in an effort to account for differences in health outcomes. However, feminist antiracist health scholars, such as Anderson (2000), Dossa (2004), and Jiwani (2006) have studied the impact of the structural and socially constructed relations of power on the health of immigrant women. As Anderson and Reimer Kirkham (1998) rightly argued, the absence and marginal positions of some groups within the so-called Canadian mosaic need to be examined in order to uncover the reasons behind the underutilization of the country’s health services by these marginalized people. They also suggested the importance of examining marginalized groups of people’s access to health care in broader socioeconomic and political contexts.  Anderson and Reimer Kirkham (1998), and Browne, Smye and Varcoe (2007), among others, used antiracist and postcolonial feminist approaches to examine how the history of colonization and systemic racism in Canada shape immigrant and Aboriginal women’s access to healthcare services in the country. These scholars also emphasized the importance of examining how the organization of the Canadian healthcare system affects these women’s health and access to health care. Although there are several critical studies of immigrant women’s health, especially in the areas of mental health (Dossa 2004; Guruge and Khanlou 2004; Guruge and Collins 2008), violence against women (Agnew 1998; Jiwani 2001, 2006; Varcoe, Jaffer and Kelln 2002), and chronic illnesses and general health status (Anderson, Blue and Lau 1991; Anderson 2000; Dyck 1992, 1998, 2004; Vissandjee and Hyman 2011), other areas of health, such as reproductive health, preventive care and acute illness, tend to be ignored. These critical perspectives are relatively new and rather infrequently employed in mainstream health research on immigrant women and they have not been fully extended to the area of cancer screening and other preventive care. Instead, culture has become an easy explanation for immigrant and ethnic minority women’s underutilization of preventative healthcare services.  18  South Asian immigrant women’s health, especially breast and cervical cancer screening practices, are quite often viewed through a culturalist lens where culture seems to be the central focus and the core analytic tool of the research. A couple of relatively recent quantitative studies (McDonald and Kennedy 2007; Woltman and Newbold 2007), for example, took a culturalist approach by explaining the difference in uptake of cervical cancer screening by immigrant women in terms of their cultural origin or ethnicity. Such an approach reinforces cultural stereotypes and homogenizes these women’s experiences. It also ignores the processes of immigration, settlement, integration and racialization, and hides the racism and other systemic barriers in Canadian society and the healthcare system. A culturalist framework, as Jiwani powerfully argued, [P]athologizes immigrant women of color from different ethnic backgrounds. At the backdrop of systemic and everyday racism, the focus on culture quickly becomes one of implicitly or explicitly comparing a backward, traditional, and oppressive cultural system to the modern, progressive, and egalitarian culture of the West. Such an approach again results in the production of cultural prescriptions or culturally sensitive approach that further reifies stereotypic representations of particular ethnic groups (2006, 161). The antiracist literature on South Asian and other immigrant women’s lives and experiences indicates that various socioeconomic, political and structural processes place South Asian women as the ‘other’ into unequal and complex positions from where they are to access health care, including cancer screening services. But research on South Asian immigrant women’s participation in cancer screening largely remains more focused on cultural and language barriers, and still seems to lack any prominent antiracist and critical perspectives that explicate healthcare practices in broader political, economic, historical and social contexts. Furthermore, efforts to integrate the gendered experience of migration and its impacts on South Asian women’s health and access to health care are still absent in the research area of South Asian women’s use or inadequate use of breast and cervical cancer screening. Further research is required to explore whether and to what extent immigrant women under-utilize preventive services such as Pap smear and mammogram, due to systemic and structural barriers in and outside of the healthcare system, rather than only due to cultural differences in concepts of health, cancer and importance of cancer screening.   19  Existing Knowledge of South Asian Immigrant Women’s Participation in Reproductive Cancer Screening  In order to conduct a review of current knowledge in the area of South Asian immigrant women and cancer screening in Canada, I searched the literature and found rather limited number of studies as this is a relatively new area of research starting back in the early 1990s. It may be noted that the Screening Mammography Program of British Columbia was the first province- wide breast cancer screening program in Canada and has been operating since 1989 (British Columbia Provincial Health Officer 2003; Bryant, Browne, Barton and Zumbo 2002). Although BC was the first jurisdiction in the world to institute a screening program for cervical cancer using Pap smears in 1955 (British Columbia Provincial Health Officer 2003) research related to utilization of Pap smears by ethnic minority women seemed to be a relatively new field. Research on cervical and/or breast cancer screening seemed to have started in the 1980s, but the studies were done on general populations of women, which were presumably comprised primarily of white women. Research on specific ethnic groups of women became more common in the late 1990s. While my research remained centered around South Asian immigrant women’s participation in cancer screening in Canada, in some instances, studies that covered cancer screening more generally among immigrant or ethnic minority women in North America, and to a limited extent, in the UK, were also considered in the review of literature because the study findings and approaches seemed relevant to the topic of the current project.  Although considerable numbers of studies have analysed breast and/or cervical cancer screening among different groups of women and identified factors related to under/utilization of Pap smear and/or Mammogram by immigrant women of different ethnic backgrounds such as Chinese, Korean, Vietnamese, Filipino women in the US, UK and Canada, relatively few have examined the cancer screening practices of South Asian immigrants in particular in Canada and in the province of British Columbia. Generally two different types of research were identified in the area of South Asian women’s cancer screening. The first one consisted of quantitative analyses of population based health surveys involving large samples, often comparing the rates of cancer screening uptake among women of different ethnicities or national and cultural origins, ages, socioeconomic status, geographic or rural/urban locations and immigrant or non-immigrant backgrounds. Some have measured the level of acculturation and knowledge about reproductive 20  cancer and screening processes among South Asian women and their association with the level of utilization of the screening services. Such quantitative studies have clearly overlooked the voices and lived experiences of women. The second type included qualitative and ethnographic studies that have tried to understand cultural beliefs, expectations and values that influence health practices of South Asian women in attempts to uncover the culturally specific barriers and to ensure more culturally suitable ways to improve these women’s access to cancer screening services. Both quantitative and qualitative research alike generally have taken a rather culturalist approach in predicting, locating and interpreting the barriers to cancer screening services mainly in the light of South Asian and other ethnic minority women’s linguistic and cultural differences. The only known exception was a couple of qualitative studies by Bottorff et al. (2001) and Grewal, Bottorff and Balneaves (2004) which shifted the main focus from cultural barriers to the structural issues and challenges in establishing and maintaining a community based specialized women-centered Pap test clinic for South Asian and other Asian immigrant and First Nations women. But the literature also has completely ignored the complex perspectives and realities of South Asian women’s lives in Canada – realities that are shaped by their gendered, classed and racialized experiences of immigration and settlement. Relatively few studies have examined determinants of both Pap test and mammography together, which Bryant, Browne, Barton and Zumbo (2002) identified as a gap in preventative health research. Considering that both practices are similar components of preventive health, they insisted that these should be considered as equal and related components of preventive health.  However, the main observations and findings of the review of existent research could be categorized into the following themes: rates of participation in cancer screening, determinants of participation in cancer screening, culture and South Asian women’s cancer screening, South Asian women’s cancer screening and the Health Belief Model, removing barriers and enhancing access to cancer screening.  Rates of Participation in Cancer Screening  Published and conclusive findings about South Asian women’s cervical and breast cancer prevalence, mortality and survival rates in Canada are quite scarce; however, there is sufficient data to clearly indicate their low rate of participation in cancer screening processes. Although there is limited data available to show that the incidence of cervical cancer is any higher among South Asian women living in Canada compared with non-South Asian women, the literature 21  suggests that cervical cancer in immigrant women in general, is less likely to be detected early than it is in the general population, because immigrant women tend not to take advantage of screening (Oelke and Vollman 2007). Ogilivie et al. (2004) found that women with low socioeconomic status, visible minority and immigrant women in Canada were over represented among women with cervical cancer and also had higher rates of non-attendance for screening Pap smear and colposcopy services for follow up of abnormal Pap smears. Recommended cervical cancer screening was significantly lower among women who were older, living in low- income areas, or recent immigrants in Toronto, Canada (Lofters, Moineddin, Hwang and Glazier 2010). A population based study by Lofters, Hwang, Moineddin and Glazier (2010) compared the use of recommended cervical cancer screening among screening-eligible immigrant and native-born women in Ontario, Canada between 2006 and 2008. And the study found that screening rates were lowest among women from South Asia, especially older women living in the lowest-income neighbourhoods and not included in a primary care enrolment model, when compared to the Canadian-born women and immigrants who lived in Canada for 25 or more years. Also, women from South Asia, the Middle East and North Africa were the most vulnerable to lack of screening.  The incidence of invasive cervical cancer was reported by Hislop, Mumick and Yelland (1995) to be 1.5 – 4.5 times higher for South Asian women over the age of 34 years, compared to all women in the province of British Columbia, Canada. A more recent study by Hislop, Bajdik, Regier and Barroetavena (2007) found that while survival rates for female cervical cancers have improved over time in Chinese and South Asian women as compared to the BC general population, South Asian women still had a lower survival rates for cervical cancer as compared to Chinese and all other BC women. One of the potential explanations of the differences in the observed survival rates was the variations in screening and early detection. In general, immigrant, less educated and single women were found to be more likely to have never had a Pap test in Prince George of British Columbia (Bryant, Browne, Barton and Zumbo 2002). BC Provincial Health Officer’s Annual Report (2003) published that in 2000/01, about six in ten BC women, age 20 to 69 years had a Pap smear in the last thirty months and that some women, particularly Aboriginal women, recent immigrants and women from low-income households, have lower than average participation rates. Thus Grewal, Bottorff and Balneaves (2004) seemed to have rightly recognized that South Asian women are at high risk for invasive cervical cancer 22  and that the clinically observed high incidence of invasive cervical cancer among South Asian women in British Columbia may be related to their low participation rates in cervical cancer screening programs.  Canadian data on South Asian women’s breast cancer incidence and mortality rates are even more limited than those on cervical cancer. Some relevant and broad information about breast cancer incidence and mortality of South Asian and Asian women in general in other countries were identified. Breast cancer was reported to be one of the most frequent cancers among Asian Indian women living in India (Sadler et al. 2001). Moreover, one recent study showed that the incidence of breast cancer in Asia is rising and is associated with increased mortality while in the West although the incidence is increasing, the mortality rate is decreasing (Leong et al. 2010). On the other hand, South Asian immigrants in the US as well as in the United Kingdom and Canada have been found to have lower rates of cancers of all types compared to the native born population; however, for breast cancer, Caucasians were found to have slightly better survival rate than Asian Indians and Pakistanis in the US (Goggins and Wong 2009). Survival after breast cancer was also found to be poorer among first generation Chinese, Japanese, Filipino, Korean, Vietnamese, and South Asian immigrant women compared to US-born Asians (Scarlett et al. 2010). In Canada, however, Hislop, Bajdik, Regier and Barroetavena (2007) found that South Asian women had similar survival rates to all BC women for breast cancer as the female breast cancer survival rates have improved over time in Chinese and South Asian women.  Although breast cancer is the most commonly diagnosed cancer among North American women, breast cancer screening programs are underutilized by ethnic minority women in North America (Ahmad and Stewart 2004). Bottorff et al. (1998) noted that data regarding the incidence of breast cancer among South Asian women living in Canada is limited, but there is some evidence that South Asian women are not excluded from the risk of getting breast cancer. A few studies have reported low breast cancer screening rates among South Asian immigrant women in Canada (Choudhry, Srivastava and Fitch 1998; Gupta, Kumar and Stewart 2002). Monthly breast self-exam adherence rates among 57 first generation immigrant women aged 40 and over from India and Pakistan in Toronto were reported to be 12%, while 49% had undergone at least one clinical breast exam during their lives; however, 47% had never had a mammogram 23  (Choudhry, Srivastava and Fitch 1998). BC Provincial Health Officer’s Annual Report (2003) showed that despite the increased participation rate from 44% in 1998 to 49% in 2001 among women age 50 to 74 years, the province was still far from reaching the recommended 70% participation rate. Only 39% of women in BC aged 70 to 79 and 50% of those aged 60 to 69 years had a screening mammogram in 2000/01. Considering the literature on South Asian women’s inadequate participation in screening, this seems to be an important health problem for South Asian women in Canada.  Determinants of Participation in Cancer Screening  The extant literature indicates that participation in cervical and/or breast cancer screening following immigration is influenced by complex and interacting factors including limited experience with and knowledge of testing, lack of knowledge about cervical and/or breast cancer, language barriers, and cultural beliefs and values that influence health practices (Grewal, Bottorff and Balneaves 2004).  Some structural factors within the Canadian healthcare system (such as gender and ethnicity of physicians, lack of referral from a physician) have also been found to be important in the context of Pap testing (Bottorff et al. 2001). Other dynamics found to be influencing women’s receptivity to Pap testing include the combined effects of ethnicity, gender, social class and values, women’s beliefs and values related to Pap testing, and the influence of other health and social concerns on women’s likelihood of engaging in screening behaviours such as Pap testing (Bottorff et al. 2001). Very little research has examined how the complexities and intersectionalities of various structural and ideological processes and discourses, and broader socioeconomic policies shape South Asian immigrant women’s engagement in cancer screening. A few studies have examined migration as a predictor of low cervical cancer screening, but migration is understood only in terms of length of stay.  Several demographic and socioeconomic factors such as age, educational status and income of women have been associated with the participation of South Asian and other ethnic minority immigrant women in cancer screening. Ahmad and Stewart (2004) pointed out that several large-scale North American survey studies examining the relationship between demographic variables and participation in screening have reported that higher education and income increase women’s likelihood of having breast or cervical cancer screening while 24  increasing age decreases the likelihood of clinical breast exams. Lofters, Moineddin, Hwang and Glazier (2011) found that although many international studies have shown older age to be associated with lower rates of cervical cancer screening among both immigrants and the general population, they found that being younger than 35-49 years and living in the lowest-income neighbourhoods were related to screening disparities for immigrant women. On the other hand, Choudhry, Srivastava and Fitch (1998) found no statistically significant association between South Asian women’s age, education, or mother tongue and the breast health practice scores in Toronto although proficiency in English language and number of years in Canada had a significant relationship with the breast health practice scores.  Results of quantitative studies based on analysis of large scale population health survey data have found important associations between length of stay since immigration and immigrant women’s use of cancer screening services. A number of studies found a markedly lower use of Pap smear testing among recent immigrant women, especially among those of South Asian and other Asian backgrounds (Lofters, Moineddin, Hwang and Glazier 2010; McDonald and Kennedy 2007; Woltman and Newbold 2007). Lofters, Moineddin, Hwang and Glazier (2010) observed that within a system of universal health insurance, cervical cancer screening was significantly lower among women who were recent immigrants, older or living in low-income areas. On the other hand, Gupta, Kumar and Stewart’s study with South Asian women (2002) found that a low level of acculturation, rather than simply shorter length of residence, was a more important characteristic of women who underutilized and demonstrated low knowledge of Pap testing. McDonald and Kennedy’s (2007) study found that most immigrant women exhibited increasing usage rates for cervical cancer screening with years since migration, except for women of Asian backgrounds; this finding held even for second-generation Asian Canadians and those who arrived as children. Even though such survey data cannot actually identify the causal factors behind low Pap smear testing rates exhibited by immigrant and ethnic minority women, the authors assumed that social or cultural factors, rather than access barriers, underpin the lower utilization rates for immigrants of Asian ethnicity, because second-generation immigrants and immigrants who arrived as children were less likely to encounter other access barriers (e.g., lack of English skill or familiarity with the system). Similarly, some immigrant women’s cultural origin (such as, South Asian, Chinese and other Asian) was predicted by Woltman and Newbold (2007) as the factor creating a difference in those women’s uptake of cervical cancer screening 25  from other immigrant and non-immigrant women.  Such culturalist explanations of potential barriers to cancer screening faced by ethnic minority immigrant women fail to take into account the broader contexts of their lives (such as race-based discrimination in health care, social, education and other settings) and the financial and other challenges faced by non-white recent immigrants. 2   However, a number of qualitative studies reported limited breast health knowledge among South Asian immigrant women. And limited use of breast health practices has been shown to be related to not only a lack of knowledge about and access to screening facilities, but as well to particular cultural beliefs and values that tend to influence health practices among South Asian women. Choudhry, Srivastava and Fitch (1998) explored knowledge, attitudes, beliefs, and practices regarding breast cancer detection practices among South Asian women in Toronto and found that overall, women with minimal knowledge of breast cancer in that study did not engage in breast cancer detection practices. Gupta, Kumar and Stewart (2002) examined the knowledge and use of Pap smears in South Asian women in Canada, and whether the level of acculturation or formal education among these women influenced their knowledge and use of Pap smears. Low levels of knowledge about the Pap test and a low prevalence of Pap testing behaviour were significantly correlated with a low level of formal education, education taking place outside of Canada, and a low index of acculturation.  Several studies on South Asian immigrant women have revealed certain culturally based norms, beliefs and values likely to hinder their uptake of breast cancer screening (Ahmad, Cameron and Stewart 2004; Bottorff et al. 1998; Choudhry et al. 1998; Johnson et al. 1999). Findings from the study by Bottorff et al. (2001) suggested that these cultural beliefs inform decisions about whether to engage in screening behaviours, when to seek medical advice, and which treatments to accept. Bottorff et al. maintained that participation in screening in the  2  Although whether second generation visible minority women face any special or different barriers to accessing cancer screening services than first generation women is beyond the scope of the current research, a 2011 report in the Globe and Mail stated the racialization and discrimination faced by Canadian-born visible minorities and those migrating to Canada as young children who earn less than their similarly qualified white counterparts (Friesen 2011).  26  absence of symptoms does not readily fit with South Asian women’s holistic views of health and health promotion. Several studies (Bottorff et al. 1998; Choudhry, Srivastava and Fitch 1998; Johnson et al. 1999) also stated that South Asian women tended to seek advice from health professionals or engage in breast screening practices if they had symptoms, were particularly worried or were instructed to do so by others. Other studies described many South Asian women’s strong beliefs about cancer as a stigmatizing, painful, and untreatable disease (Choudhry et al. 1998; Johnson et al. 1999). Such beliefs deter them from participating in cancer screening and make it difficult for women to readily accept healthcare professionals’ concerns about early detection of cervical cancer (Bottorff et al. 2001). Ahmad and Stewart (2004) reported that breast cancer was viewed by South Asian women in their study as a disease that would not affect them. Other qualitative studies (Bottorff et al. 1998; Johnson et al. 1999) with South Asian immigrant women also described their low perceived risk of breast cancer and high fear, fatalistic beliefs, belief in inevitability of suffering due to fate (karma), and embarrassment in undergoing sensitive physical examinations. These cultural beliefs, misperceptions and limited knowledge have been suggested in these studies to be barriers likely to hinder women from performing or seeking breast or cervical examinations. While offering important information, such a narrow focus on cultural barriers obviously tends to overlook how immigration, structural and healthcare system related factors also influence health seeking patterns of marginalized and racialized immigrants.  Some studies have looked at barriers rooted in the healthcare system and how factors such as language barriers, gender and cultural origin of the family physician performing the Pap test influence cervical cancer screening among South Asian immigrant women in Canada. Health care related factors, such as not being registered in a primary care patient enrolment model, and having either a male family doctor or a family doctor from the same country of origin were independently associated with lower rates of screening for immigrant women across most or all regions of origin including South Asia, suggesting that these variables tended to negatively affect screening for immigrant women regardless of their cultural or ethnic origin (Lofters, Moineddin, Hwang and Glazier 2011). The lower proportion of female practitioners in the medical profession has been implicated with lower use of health services including cancer screening by women who prefer female physicians. Ahmad, Gupta, Rawlins and Stewart (2002) pointed out that several studies on women’s preventive health behaviours such as breast and cervical cancer 27  screening demonstrated that women’s lower compliance and/or satisfaction with the recommended medical services depended on the male gender of the physician. A qualitative descriptive study by Oelke and Vollman (2007) found that health-provider issues such as, physician’s gender, language barriers, lack of trust and confidentiality, along with other factors such as lack of knowledge about the importance of prevention and influence of family and community affected South Asian Sikh women’s access to cervical cancer screening in urban areas in Alberta.  Physician recommendation has been found to be the primary predictor of regular participation in mammography screening among ethnic minority, immigrant and Aboriginal women to the point that it is likely to overcome many of the factors associated with low participation, including socioeconomic factors (Johnson et al. 1996; Bryant, Browne, Barton and Zumbo 2002). Johnson et al. (1999) pointed out that common barriers that have been found to prevent South Asian women’s participation in breast screening programs include language, cultural beliefs, low socioeconomic status and the lack of referral from a physician. Bottorff et al. (2001) found that South Asian women do not consistently receive a physician’s recommendation even though there is evidence that such recommendation for Pap testing is highly influential in South Asian women's participation in cervical cancer screening (Choudhry, Srivastava and Fitch 1998; Johnson et al. 1999). This was also confirmed in Oelke and Vollman’s (2007) study with Sikh South Asian women who reported that their physicians were not informing them about the Pap test and its importance.  Thus Bottorff et al. (2001) realized that South Asian women’s access to Pap testing was not only restricted by their health beliefs and cultural values, but influenced by a complex interplay between cultural issues and structures within the healthcare system. Their study illustrated that the barriers embedded in opposite-gendered interactions and the gendered structures of the medical system complicate women’s access to Pap testing because under the current fee-for-service model of reimbursement for cervical screening, the majority of Canadian women are limited to receiving their Pap tests from family physicians, oftentimes a male physician (Bottorff et al.). Therefore, in BC a specialized Pap test clinic specifically for these women was started as a joint community project sponsored by local health authorities in May 1995 in response to high rates of cervical cancer within the South Asian population (Grewal, Bottorff and Balneaves 2004). Efforts were made to ensure that the clinic provided health services in a sensitive and culturally appropriate manner by female Punjabi/Hindi-speaking 28  nurses or physicians. To ensure physician support for the clinic, the mandate of the South Asian Pap Test Clinic was limited to breast and cervical cancer screening, and results of the Pap tests were forwarded to women's family physicians who remained responsible for follow-up care and treatment. But structural factors within the Canadian healthcare system were found to create challenges in maintaining the specialized screening programs. The authors reported that not only were there very few female South Asian family physicians in the community, but there was also a reluctance by some male physicians to refer their patients to female physicians because of concerns about losing patients to another physician’s practice. In addition, other female healthcare providers (e.g., nurses) who could potentially offer cervical screening did not have billing privileges. The end result was that many South Asian women were not told about Pap test screening or provided with an acceptable alternative for obtaining this health service.  The BC Provincial Health Officer’s Annual Report (2003) pointed out that one factor underlying the lower than desirable participation rate of breast screening may lie in the continued high profile scientific debate about the relative merits of mammography screening which has been highly controversial and confusing for both the medical community and women in general. But no research so far has explored this issue and particularly how it may impact participation of South Asian women in breast cancer screening. Physicians’ perspectives and barriers encountered by health professionals in conducting Pap test and clinical breast exams for South Asian women have not been adequately investigated either. Again, very little research has explored how the broader structures and policies related to immigration, socioeconomic and political integration of immigrants and healthcare reform shape women’s participation in cancer screening. No attention is paid to the complex and intersecting processes through which various factors such as immigration category, age, financial in/stability, education level and English skills at the time of immigration, access to employment and other resources shape the experiences of immigrants and challenge and/or facilitate their access to cancer screening services. Further research, especially with a critical feminist and antiracist framework, still seemed to be needed to bring the gendered and racialized processes of immigration and integration to the center of analysis in order to improve South Asian immigrant women’s access to quality health care including cancer screening, and as well, to further counter the culturalist and essentialist approach predominant in this field of research and scholarship.  29  Culture and South Asian Women’s Cancer Screening In much of the existing literature on South Asian women’s use of cancer screening, culture is understood in an essentialist way and framed as the main reason for their lack of utilization of these services. A cultural reductionist approach overemphasizes cultural determinants and hides structural inequities and power relations. For example, according to one study, A nurse’s understanding of culture influences effectiveness of health teaching…[and] little is known about how culture affects their [South Asian immigrant women’s] health practices [related to breast cancer detection] (Choudhry et al. 1998, 1699, emphases added).  Culture, here, is deemed the determinant of health practices abstracted from the broader social, economic, historical, political and structural factors. Culture in this way is viewed as fixed in “a timeless and unchangeable vacuum outside of patriarchy, racism, imperialism, and colonialism” (Razack 1994, 896). Another study overemphasizes the importance of culture in advocating culturally sensitive care: It is widely recognized that health beliefs differ across cultural groups and that health professionals, if they are to provide appropriate heath care, need to be cognizant and sensitive to the diversity of these beliefs (Johnson et al. 1999, 243, emphases added).  This exemplifies the “essentialization of culture” which assumes that every culture has an essence that defines it and that every culture is homogeneous. It also focuses on differences between or across supposedly internally coherent groups ignoring internal variations within cultural groups based on gender, class, age, ability, sexuality and other dimensions, and maintains “the idea of consistent and coherent cultural groups with defined sets of beliefs and health behaviours” (Culley 2006, 150). In a similar fashion, “South Asian” (as well as Chinese and Asian) has been represented in the following example as merely a cultural identity, and such cultural origin has been explained as the factor creating the difference in uptake of cervical cancer screening. It also underscores the importance of information and awareness (rather than removal of structural inequities of gender, racialization and poverty), a common feature of culturally sensitive care: [A] woman’s immigrant status and cultural origin appear to be significantly associated with ever having had a Pap test. In particular, the uptake of cervical cancer screening is less common among recent immigrant women and women of Chinese, South Asian and other Asian backgrounds…Findings point to the role of cultural origin, which largely 30  accounts for these differences…This indicates the need to promote greater information and awareness of public health services for cervical cancer screening, especially among recent immigrant women with such backgrounds (Woltman and Newbold 2007, 470, emphases added).  Such a culturalist approach decontextualizes immigrant women’s lives and overlooks their gendered experiences of migration and everyday racism, and as well the discriminatory and racialized practices within health care and other institutions in Canada. The very absence of the notion of racialization, and the centeredness of the term culture within the literature and discourse of South Asian women’s breast and cervical cancer detection practices seem to perpetuate the “culturalization of racism” – a process whereby the notion of cultural inferiority established on the basis of socio-cultural and technological inadequacy or “backwardness” is utilized to appropriate racism and sexism (Razack 1998). Within such discourse, culture is viewed as the barrier to equitable and effective healthcare service delivery, and South Asian women are viewed as a “challenge” creating special problems or requiring special attention and solutions. For example, in the following excerpt, “South Asians” are constructed as the problem: The growing South Asian community in Canada creates challenges in providing health services, and this has been the stimulus for research to understand the health needs and health-seeking practices of this community (Grewal et al. 2005, 243, emphases added).  In this way, white Western culture is constructed as the standard against which the needs and health-seeking practices of the “other” are to be judged and understood. Thus, the following excerpt advocates the importance of research that can help understand the cultural beliefs and practices (of the ‘other’) around particular health issues (such as breast health) so that “culturally suitable health care” can be provided: It is vitally important that factors such as ethnicity and cultural differences not preclude women from seeking and engaging in breast health practices. Indeed, we must ensure that services and educational messages are offered in culturally suitable ways (Bottorff et al. 1998, 2076, emphases added). The prevailing literature also recognizes South Asian immigrant women’s lack of proficiency in dominant languages and cultures (English and French) as a crucial roadblock to accessing health care and therefore, advocates for dissemination of information about these services in the languages of these women and in a culturally appropriate manner. While these are important to ensuring better accessibility of healthcare services, the state’s bilingualism and 31  multiculturalism policies (which seem to contradict each other) also need to be questioned. Bilingualism has established English and French as the two official languages in Canada and in effect, has relegated all other languages of the minority people as an unofficial or cultural matter, hence under the umbrella of multiculturalism (Bannerji 2000). The extant research on the barriers to South Asian women’s access to cancer preventive services, thus seem to use an under-theorized concept of culture that fails to grasp that “culture is complex, diverse, and grounded in social and political contexts” (Krane 2001, 406). Moreover, a central focus on these women’s cultures seems to construct them as the ‘multicultural other’ in Canada. In fact, such an approach is likely to maintain stereotypes about these supposedly ‘traditional’ women, and present them as a ‘problem’ or ‘challenge’ to mainstream healthcare service providers. A few studies have examined whether the lack of knowledge and use of Pap testing among South Asian and other ethnic minority immigrant women is related to a low level of acculturation. The notion of acculturation assumes that immigrants are supposed to adopt Canadian values or lifestyle after living a certain period of time in Canada. But the concept of acculturation imagines the bounded-ness and distinctiveness of South Asian and Canadian culture, and also views white European culture as the benchmark for understanding or measuring ‘other’ cultures. Not only does it reflect an assimilationist approach to understanding women’s access to health care, but also underestimates the structural and systemic barriers to ethnic minority women’s socioeconomic integration and access to healthcare system in Canada.  South Asian Women’s Cancer Screening and the Health Belief Model  Much of the research on South Asian and other ethnic minority women’s participation in cancer screening is heavily focused on understanding and controlling health behaviour of individuals or communities. Such research has predominantly used the Health Belief Model (HBM). Based on theories of health behaviour and originally developed by social psychologists in the US, this model tends to theorize how people’s beliefs about whether or not they are susceptible to disease, and how their perceptions of the benefits of trying to avoid it, influence their readiness to act (National Institutes of Health 2005). As a widely used model for health promotion and research, it attempts to address problem behaviours or risk factors that evoke health concerns (e.g., high- risk sexual behaviour and the possibility of contracting HIV) and design both short-term and 32  long-term behaviour change strategies (National Institutes of Health). Health motivation is its central focus and it can be particularly useful for developing strategies to deal with noncompliance in individuals (National Institutes of Health). The HBM has frequently guided nursing research in an attempt to increase knowledge of health-related behaviours, but the social behaviourist approach of this model does little to examine power issues (Thomas 1995).  The HBM has been used explicitly in a number of studies (e. g., Ahmad and Stewart 2004; Ahmad, Cameron and Stewart 2004; Choudhry, Srivastava and Fitch 1998; Johnson et al. 1999) to examine and understand how South Asian immigrant women’s beliefs and knowledge about and attitudes towards breast and/or cervical cancer and cancer screening methods such as Pap smear or breast self-exam are influenced by their culture, and how these cultural beliefs impact their health behaviour and practices. These cultural beliefs and understandings are viewed as factors that influence the women’s engagement in cancer detection and prevention practices. For example, one study (Johnson et al. 1999, 243) states, “One of the most powerful factors that influence health beliefs is culture.” As it signifies the importance of examining health beliefs – Beliefs about symptoms, diseases, and health have a strong influence on how individuals make sense of their vulnerability and respond to illness ... Their [women’s] explanations inform their perceptions of risk for breast cancer and the type of action that they would take to minimize risk ... Perceptions of risk, in turn, influence health-seeking behaviour and compliance with recommendations (ibid., 251 – 252).  Such research focuses on identifying and improving individual health behaviours influenced by culturally specific perceptions of risk factors. In fact, the HBM is based on individual health behaviour theories that seek to interpret or analyze health behaviours at the individual level, and emphasize the rationality of a patient’s behaviour assuming that he/she can freely and successfully take a recommended health action (DeBarr 2004). Thus such research emphasizes improving awareness and motivating individuals to adopt healthy behaviours rather than creating environments and social changes that support healthy lifestyles and health practices, especially for those belonging to the margin (Anderson 1996). And the ways in which individual health behaviours become strongly influenced by social structures, norms and policies are generally overlooked.  33  Removing Barriers and Enhancing Access to Cancer Screening Most studies that related South Asian women’s cultural knowledge, beliefs, values and understandings with their lower than expected level of utilization of cancer screening services, recommended culturally appropriate care and increased health literacy about cancer and cancer screening for these women in order to enhance their participation in breast and cervical screening. Bottorff et al. (1998) examined breast health practices from the perspective of South Asian women to provide a foundation for the development of culturally suitable breast health services for this group. Similarly, Johnson et al. (1999) recommended developing culturally suitable counselling strategies through informing practitioners about how culture influences women’s explanations about cancer or breast cancer in particular. They believed that a study focusing on the beliefs of South Asian women regarding breast cancer could inform the development of strategies to improve participation in breast health practices. A number of studies (Ahmad and Stewart 2004; Choudhry, Srivastava and Fitch 1998; Gupta, Kumar and Stewart 2002) highlighted the need for educational interventions on breast cancer and screening directed to South Asian and other ethnic minority and recent immigrant women in Canada.  Ahmad and Stewart (2004) suggested community education among South Asian recent immigrant women about early detection of breast cancer through screening and effective health promotion initiatives to address women’s perceived barriers to motivate their uptake of breast cancer screening. While Choudhry, Srivastava and Fitch (1998) suggested that South Asian immigrant women be better informed about breast cancer and the benefits of breast cancer detection practices, Ahmad and Stewart (2004) recommended that healthcare providers try to enhance their efforts toward promotion of preventative health examinations, including clinical breast exam among South Asian women. Ahmad, Cameron and Stewart (2004) advocated and evaluated socio-culturally tailored intervention to improve knowledge, beliefs and clinical breast examination among South Asian immigrant women. The intervention comprised a series of socio-culturally tailored breast-health articles published in Urdu and Hindi community newspapers. The results of their study were reported to have supported the effectiveness of written socio-culturally tailored language-specific health education materials in promoting breast cancer screening within the targeted population. Lofters, Moineddin, Hwang and Glazier (2011) emphasized that targeted patient education campaigns should particularly focus on younger and older women and women of low income. 34  On the other hand, a few studies recommended changes in the healthcare system and removing structural barriers rather than just increased awareness and targeted cancer control for improving screening rates among South Asian immigrant women. Lofters, Moineddin, Hwang and Glazier (2011) stressed the importance of interventions within the healthcare system, and called for efforts to ensure that immigrant women get connected with the healthcare system after arrival and find a regular source of primary care. They also suggested that settlement agencies may play a substantial role toward this goal. A centrally organized Pap smear screening system with periodic invitations instead of the current system of opportunistic screening, as Lofters, Moineddin, Hwang and Glazier insisted, might also be beneficial for increasing screening rates among under-users. While there is a shortage of female family physicians preferred by many immigrant women, these authors suggested that some primary care models may also make it feasible for male physicians to have female nurses, physician assistants or nurse practitioners available to provide cervical cancer screening. This point has been reiterated by Bottorff et al. (2001) as they thought the use of clinics staffed by nurse practitioners could be valuable for providing preventative health care or cancer screening to women in ethnic minority groups. Lofters, Moineddin, Hwang and Glazier prescribed targeted education campaigns for physicians trained abroad because they found a lower screening rate among ethnic minority immigrant women when a physician and patient had the same ethnicity, although future research is needed to explore the underlying issues.  After studying the systemic challenges encountered in the South Asian Pap Test Clinic set up to increase the participation of immigrant women in screening practices, Grewal et al. (2004) came to the conclusion that access to Pap testing extends beyond simply providing culturally acceptable services. Bottorff et al. (2001) also maintained that while the establishment of special Pap test clinics for ethno-cultural groups seemed to have the potential to enhance participation of minority women in cervical screening, changes in health policy and the structures of health services are required to fully implement a women-centered health care. Clinical interactions that signify respectful encounters reflecting ethical values related to equality and the uniqueness and dignity of the individual were observed by Bottorff et al. to be important in women-centered care for ethno-cultural groups. And therefore, they realized, such care and service extend beyond cultural sensitivity. Both of these studies on the special ethno-cultural Pap test clinic echoed the important roles nurses can play in mobilizing and maintaining 35  collaborations with physicians as well as women, an essential factor to the continuing success of community-based programs.  In summary, the review of current literature reflected that South Asian immigrant women experience a number of barriers to accessing Pap smear and mammography screening and that interventions are required at multiple levels – from changing individual health behaviours to creating equitable and health enhancing policies and structures. In other words, simply understanding “the complexity of South Asian women’s beliefs” and sensitivity to these “women’s cultural understandings and beliefs” (Johnson et al. 1999, 253) will not suffice – structural changes are required to ensure equitable health care for all women.  Developing Theoretical and Conceptual Frameworks A comprehensive review and analysis of the current literature revealed the level and extent of South Asian immigrant women’s engagement in cancer screening, the various determinants of their poor participation, the conceptual and methodological approaches used in studying and understanding the barriers to their equitable access to cancer screening and the suggested ways to remove those barriers. It also pointed to the gaps in the extant knowledge, and to the areas that demand further research and investigation. Although a few studies considered some structural factors and systemic issues within the Canadian healthcare system in examining South Asian women’s cancer screening, further research is needed to critically explore how the broader structures, policies and processes both within and outside the healthcare systems shape South Asian immigrant women’s participation in and access to cancer screening services. South Asian immigrant women’s access to and experiences with the broader Canadian healthcare system have not been adequately linked to these women’s engagement in cancer screening. And the diverse effects on South Asian women of the gendered and racialized processes of migration and socioeconomic integration into Canada have not been considered within the scholarship of their participation in breast and cervical cancer screening. Antiracist scholars have connected the issue of racialization of immigrant women with the broader policy of immigration, integration and multiculturalism. Immigrant women’s health issues have also been linked with these broader policies and structures within such critical 36  scholarship. But such discussions have been absent in the literature of South Asian women’s access to cancer screening. Therefore I felt the need to use critical feminist works on immigrant and minority women’s health issues in examining South Asian women’s cancer screening, and to relate those works with the topic of the current study. My study was also informed by some general antiracist and feminist theories that may not be directly related to health or to immigrant women’s health but are useful for shedding light on the broader structural issues and policies that influence South Asian immigrant women’s experience of health inequities and inequitable access to quality health care. These theories and literature helped contextualize South Asian women’s cancer screening practices within the broader intersecting structures and processes of patriarchy, migration, poverty and racialization. For example, I have presented in Chapter Six an analysis of how the Canadian immigration and multicultural policies and neoliberal ideologies shape the historical and current positioning of South Asian immigrant women as the ‘other’ and how their status as the ‘other’ influences their access to health care and other services including cancer screening. I have included this discussion in Chapter Six instead of integrating it in the review of literature because I tried to connect the empirical data or the experiences of South Asian women with the historical as well as current policies and discourses that organize the material conditions for the very presence of South Asian women in Canada and the everyday lives including health issues of individual South Asian women – for the sake of an intersectional analysis and understanding of the issue. An exploration of South Asian immigrant women’s personal experiences as shaped by their historical and ongoing positioning as the ‘other,’ with the help of antiracist analyses and critiques of the Canadian immigration policies, multicultural discourses and neoliberal economic restructuring processes, facilitated the understanding of how the historical as well as current policies, institutionalized practices and structural inequities intersect with each other to shape these women’s health and access to health care.  Thus the current research employed feminist antiracist theories with an intersectional approach to explore how the processes of racialization intersect with gender, age, class and immigrant status in the everyday lives of South Asian immigrant women, and how the complex intersection of these factors situates them in marginalized, disadvantaged and stigmatized positions of the ‘other’ from where it becomes difficult for them to access healthcare services in general and cancer screening in particular. The next sections elaborate the central concepts and theories that shaped the designing, execution and analyses of the current research. 37  Critical Feminist and Antiracist Theories  Feminist and critical perspectives help us understand how women’s health and illnesses are embedded in complex layers of contexts, especially how socioeconomic and structural inequities determine the health and healthcare experiences of marginalized and racialized men and women (Anderson 1996). A critical feminist approach critiques the traditional biomedical model of health and the neoliberal approach to health care, and also challenges culturalist explanations of health conditions, health practices and health inequities. Such an approach works to contextualize health and health care within complex material, political, ideological and historical forces. Antiracist theories focus on how racism and power hierarchies operate both within and outside healthcare institutions, and they challenge Western biomedicine’s concern with the culturalistic and individualistic issues in explaining inequitable health conditions and health disparities among populations (Ahmad 1993). Critical and antiracist scholars also take a social justice approach to health that advocates for reducing social inequities which are at the root of health inequities and for creating health and social policies and economic structures that foster equitable health and quality health care for all citizens regardless of their social standings (Ponic 2007).  Antiracist scholars, such as Ahmed (1993) and Jiwani (2001) have offered important critiques of Western biomedicine as a racialized and patriarchal system of dominance. As Jiwani pointed out, Western biomedicine tends to regard and objectify a person as “a constellation of symptoms to be categorized, managed and processed” (2001, 15) and reproduce the hierarchical relations between patients and healthcare providers – relations that particularly render immigrant women of color as powerless victims. Ahmad insisted that the biomedical model of research and practice diverts attention from the production of ill health to its distribution among individuals, and perpetuates the ideology of victim blaming by relating health problems to individual lifestyles. As a result, Ahmad also argued, biomedicine “depoliticizes and individualizes ill health, treats the afflicted in isolation from their social, economic, and citizenship context and thus legitimates structural inequities and supports the status quo” (1993, 12). The biomedical approach promotes the ideologies of liberal individualism through its attempts to identify behavioural or genetic medical risk factors of ill health and to assume individuals’ responsibility for taking control of their health, and then to condemn those unable to meet their health needs as 38  deficient or failing (Anderson 1996; Fiske and Browne 2006). Rather than highlighting the health behaviour and lifestyle or cultural health practices of individuals within certain racialized groups, feminist antiracist health scholars (for example, Dossa 2004, 2005; Dyck 2004; Dyck and Dossa 2006; Jiwani 2006) have shifted the focus on race and gender, and studied the impacts of these socially constructed power relations and structural factors on the health of immigrant minority women.  Many critical feminist and antiracist health researchers have also used postcolonial theories in examining immigrant minority and other racialized women’s health issues (for example, Anderson 2000; Browne, Smye and Varcoe 2007; Culley 2006; Guruge and Khanlou 2004; Reimer Kirkham 2003). Feminist postcolonial theories, while retaining antiracist approach’s central focus on the issues of race and racialization, also explain how these processes intersect with gender, culture and class to structure human relationships within particular historical and neocolonial contexts (Browne, Smye and Varcoe 2007). Postcolonial analysis in the realm of women’s health, as Browne, Smye and Varcoe have noted, brings to increased attention the colonizing, racializing and neocolonial practices which continue to construct race and culture as taken-for-granted categories to locate non-European women as the essentialized, often inferior, and subordinate ‘other.’ Thus such theoretical perspectives bring to the forefront the “… socio-historical positioning, culture, race, and racialization as intersecting factors shaping the health and social status of women” (ibid., 134). Such perspectives can help understand how racialization, intersecting with other social categories including class and gender, perpetuates inequity in society and how these inequities of race, class and gender relations organize differential experiences of health and health care for ethnic minority women (Tang and Browne 2008).  Anderson (2000) asserted that postcolonial feminist perspectives provide tools for analysing how the intersecting social relations of power shape the experiences and meanings of health and illness of immigrant women of color in the diaspora, and organize their ability to manage episodes of illness. She has put forward the idea of a postcolonial feminist epistemology, grounded in the inclusion of voices from the subaltern and the recognition of their historical positioning, to construct knowledge for practice and praxis. Thus critical feminist perspectives 39  enriched by antiracist and postcolonial scholarship can help us understand healthcare practices within wider political, socioeconomic and historical contexts, particularly the way in which the historical and current positioning and racializing of South Asian immigrant women in Canada influence their health and access to health care. Postcolonial and antiracist feminists have critically examined the deeper and broader structural forces (colonization, gender discrimination, racial and class exploitation, poverty, globalization) that determine the health and the illness of marginalized people. Anderson (2000) further argued that research and knowledge of how globalization and healthcare reform negatively impact the health and health care of women of color and the poor must focus on gender, racialization, and health, especially on how gender and race intersect to put racialized women at a disadvantage. Intersectionality and Immigrant Women’s Health Although critical feminist antiracist and postcolonial theories provide important understandings of how structural inequities and power relations shape immigrant and racialized women’s health and healthcare experiences, the complexities of racialized women’s experiences of immigration and health inequities cannot be fully captured without considering the interlocking nature of the oppressive systems and the intersections of race, class, gender and immigration status in the lives of immigrant minority women. Interlocking oppression means gender, race and class work together or mutually construct one another and intersectionality refers to the dynamic social positions and identities of each individual and group within interlocking structures of oppression (Hill Collins 1995). The concept of intersectionality emphasizes that different dimensions of social life cannot be separated out into discrete and pure strands, and that different people experience the interconnected structures of power and inequalities differently depending on their relative positionings within the matrices of domination and privileges in particular historical, geographical and social contexts.  For immigrant women of color, Anderson (2000) correctly insisted that gender relations cannot be separated from the processes of racialization, class relations and other social relations that structure their lives, ghettoization in the low-paid sectors of the labour market, and exclusion from positions of power and privilege. Gender, race, immigration status and class intersect to put immigrant and minority women at a great disadvantage and impact their ability to manage health and well-being. Feminist researchers have opposed the traditional biomedical focus on genetic 40  and behavioural risk factors and disease prevention, and have increasingly located women’s health within the socioeconomic and broader contexts that affect or determine health and wellbeing. The social determinants of health, also known as health promotion and population health in Canada contrasts with the traditional focus on biomedical and behavioural risk factors and directs attention to economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole (Raphael 2004). The social determinants of health approach focuses on the quantity and quality of a variety of resources that a society makes available to its members such as, income, availability of food, housing, employment, health and social services, and such an approach views economic and social policies as more appropriate means of improving health and mitigating health inequities (ibid.). The Public Health Agency of Canada has adopted the population health framework which examines several social and economic factors that influence health behaviours and health outcomes including income, employment and working conditions, food security, environment and housing, early childhood development, education and literacy, social support systems, and access to health care (The Chief Public Health Officer's Report on the State of Public Health in Canada 2008). The critical feminist perspectives to the social determinants of women’s health view the health differences among Canadians as resulting from social forces such as poverty, education, food security, employment, housing, racism, social exclusion and neoliberal economic restructuring (Anderson 2000, 2006; Ponic 2007). 3   Raphael (2006) pointed out that the social determinants of health approach to public health, health research and public policy development continues to be secondary to traditional  3  A number of national and international texts and policy documents have advanced the population health or social determinants of health framework. For example, Ottawa Charter for Health Promotion (1986), Canada Health Action: Building on the Legacy (1997), and WHO to Establish Commission on Social Determinants of Health (2004) have played important roles in conceptualizing and organizing Canadian health care (Raphael 2006; Spitzer 2009). Although these primary documents are relevant and important to understanding the institutionalized barriers to South Asian women’s reproductive health and participation in cancer screening, the current research remained primarily focused on intersectionality and women’s health scholarship that helped to critically understand the intersecting nature of the social determinants of racialized immigrant women’s health including gender, race, class and immigration status. As Vissandjee, Apale and Wieringa (2009) have indicated, the immigration factor has been relatively ignored as an important health determinant in the social determinants of health literature and also in intersectionality and health literature. The impact of immigration processes on the health and healthcare experiences of the South Asian women in the current study has been elaborated in Chapter 5 and the ways in which Canadian immigration policy determine or impact women’s access to health care including cancer screening services have been discussed in Chapter 6. 41  medical and behavioral health paradigms. Also, much of the work lacks a “critical social science” perspective that illuminates the political, economic, and social forces that shape the quality of the health determinants (ibid.). On the other hand, intersectionality provides “a holistic, interactive, political-economic, and gendered perspective that is vital to understanding conditions of gender, migration and health” (Spitzer 2009, 139). The social determinants framework recognizes the socioeconomic discrimination and health inequities experienced by racialized women; however, the ever-expanding list of the health determinants may not recognize “the dynamic interplay between different levels of determinants” (Vissandjee and Hyman 2011, 259), or how the factors complicate and intersect with each other.  While the social determinants of health approach is foundational to the intersectional analysis and understanding of racialzied women’s health, the multiplicity and complexity of the determinants and the multi- dimensional nature of health inequality in vulnerable populations demand that we pay attention to the processes through which the complex intersections of gender, race, class, and other social relations operate in everyday interactions to determine women’s health (Anderson 2006; Kobayashi and Prus 2011). Therefore, Anderson suggested, “It is this complex interaction between racialization, gender, and class relations that we need to explore if we are to get a handle on the determinants of women’s health that are inclusive of all women who make up the Canadian mosaic” (2006, 12).  Some critical and antiracist feminists (such as Brah and Phoenix 2000; Hill Collins 1999) have argued that the seeds of intersectionality were sown in the antiracist movement during the 1800s. Their analysis of the legendary speech of Sojourner Truth with the lens of intersectionality shows how the ever-powerful question ‘Ain’t I a Woman?’ asked in the mid- nineteenth century challenged the essentialization and universalization of the category ‘woman.’ Hesse-Biberr and Yaiser (2004, 106) draw attention to the fact that feminist scholarship frequently failed to analyze the important “interrelationship” or “intersectionality” among the categories of race, class, gender, sexuality and nationality within specific historic locations leaving the experience of the ‘others’ outside the history and social processes in which they live their daily lives. On the other hand, social relations and oppression based on gender was often the central focus and while the issue of difference was acknowledged, there was still a lack of recognition of differences as being socially constructed and connected (ibid.). Intersectionality, a relatively new approach in feminist analysis, began to gain much attention and popularity in the 42  1990s. It attempted to examine how gender, race, class, and nation mutually construct one another rather than examining them as distinctive social hierarchies (Hill Collins 2000). Black feminist critiques (by hooks 1981; Crenshaw 2000; Hill Collins 1999 and others) provided important theoretical tools for critical inquiry into the intersection of race, gender and class in the lives of black women as well as other women of color who share the experiences of racism, capitalism and patriarchal oppression in a white male dominated society. The intersectional approach thus developed from the vantage point of the black women and other women of color, and paid attention to the multiplicity of experiences among women, and to the local or internal differences within a particular group or community. Black feminist critiques made it clear that prioritizing one aspect of oppression at the expense and exclusion of others fails to address the totality as well as multiplicity of oppression and experience, and that a synthesis of race, gender, class and sexuality through the lens of intersectionality may avoid inappropriate essentializing of women’s experiences and by so doing can provide a better understanding of the diversity, subjectivity and agency of women of color.  Hill Collins (1999, 161) has further stressed that the black feminist attention to the interlocking nature of oppression is significant because: first, it shifts the entire focus of investigation from one aimed at explicating elements of race or gender or class oppression to one whose goal is to determine what the links are among these systems; and second, it does not prioritize one form of oppression as being primary and then deal with the remaining types of oppression as additive or supportive variables within the most important system. The scholarship on the intersectionality of race, class, gender, and sexuality emphasizes these notions as social constructs, which, Weber (2004) insisted, cannot be understood outside the contexts of the real lives of real people. Weber also pointed out that macro social structural trends are often represented analytically as a set of “lifeless statistics about different populations” (129), which makes little sense about how they impact people’s lives. As she so powerfully pointed out, [R]ace, class, gender, and sexuality are not reducible to immutable personality traits or other seemingly permanent characteristics. Instead they are social constructions that often give us power and options in some arenas while restricting our opportunities in another…we cannot argue that we are all oppressed or that our oppressions can simply be added up and ranked to identify the most oppressed group of the most victimized individuals. […] No simple mathematical relationship can capture the complexity of the interrelationships of these systems (ibid., 131).  43  The concepts of race, gender and sexuality are not considered in intersectionality theory as permanent and unchangeable characteristics of individuals, and rather the historical specificity and the relational as well as conflicting nature of these inequalities in real lives are appreciated. Weber argued that in order to fully grasp the nature and significance of this intersectionality, the meanings of race, class, gender and sexuality must be examined as they are embedded in the structural or macro (community and social institutions) level, and as they are expressed and experienced in social psychological or micro (everyday lives of individuals) context. Weber’s argument resonates with Brah and Phoenix’s (2004) position that draws attention to the importance of conceiving the subjective aspects of the intersectionality of race, class and gender along with its social and structural content. Brah and Phoenix contended that the intersection of race, class and gender is subjectively lived, while it is also part of social structures and involves differential or discriminatory treatment of people. It is by studying these intersections, they insisted, that a more complex and dynamic understanding of gender, race, and class can be achieved than by a focus only on social class or race. The recognition of race, social class and sexuality as they intersect and differentiate women’s experiences disrupt notions of homogeneous categories, such as ‘woman’ along with its assumptions of gender universality.  A key aspect of intersectional analysis is to unpack the important linkages among the broad structures, trends and events and the ways that people in different social locations live their lives and resist oppressive forces. Intersectional theory’s attention to the ways in which race, gender, class and sexuality operate simultaneously in every social situation help to understand that people can exist at various locations simultaneously along all the dimensions of race, gender, class and sexuality and that people define their identities accordingly. Such simultaneity indicates that we can be dominant (privileged) and/or subordinate (oppressed) at the same time. Weber (2004) was keen to note that recognition of the history of subordination as well as examination of the actions, motivations and resistance of the subordinate group can help us to comprehend the human agency, resilience, creativity and strength of oppressed group members. Such a complex analysis not only avoids easy generalization, it also demands meticulous attention to the multiple dimensions of inequality, and to particular nuances and specificity of contexts because differences are never fixed and instead always relational.  44  The intersectionality approach in health research, informed by critical feminist theories, centres research around the lives of multiply oppressed groups, particularly women of color and sees activism for social justice in health for all people as part of the knowledge production process. Driven by goals of equitable health, this approach attempts to identify, analyze and address the health disparities created by broader economic and political structures and social relations of power. Intersectionality and health scholarship asserts a broader conception of health, situates health in communities and families (not simply in individual bodies), and emphasizes power relationships (not just distributional differences in resources) as central to social inequities and health disparities (Weber and Parra-Medina 2003). It calls for health research that simultaneously addresses the intersections of race and ethnicity with gender, class, age and sexualities, and their impacts on women’s health (ibid.). Such research and analyses of women’s health “contextualize women in their diverse social and economic circumstances and understand gender as inseparable from other forms of social differences such as race, ethnicity, culture, class, sexual orientation, gender identity, and ability” (Varcoe, Hankivsky and Morrow 2007, 9). Mullings and Schulz (2006) pointed out that intersectionality helps to understand the complex phenomena (social relationships and dynamics) underlying health, to apprehend the ways that these relationships of power are created and maintained, and thus to understand the ways that they may be modified to reduce disparities in health. Weber and Parra-Medina (2003) also elaborated the need for an intersectional approach to understanding and eliminating disparities in health and health care. They noted that there is a rising awareness within the traditional health disparities research about the need for new approaches, such as intersectionality, to address the problem of ongoing health disparities. Many of the complexities and richness of intersectionality and health scholarship are being increasingly emphasized and called for in mainstream or traditional health disparities research and intervention (Hankivsky 2011). Yet, as Weber and Parra-Medina accurately argued, since these models are not primarily designed to explicate and challenge the social systemic processes that constitute social inequality, and since they do not emerge from the perspective and experiences of multiply oppressed communities – the simple modification of these traditional models is unlikely to significantly change our understanding of health disparities.   45  Antiracist and Feminist Critiques of Culture, Multiculturalism and Culturally Sensitive Care  Antiracist theories have unpacked the ways processes of racism and racialization take on new and ever-changing forms and especially how the guise of ‘culture’ perpetuates the lack of focus on systemic racism in explaining social and health inequities. Several antiracist theorists (Castagna and Dei 2000; Gilroy 1987, 1993; Razack 1994) have demonstrated the complexity, fluidity, and interconnectedness of such concepts as race, ethnicity and culture. Castagna and Dei noted that contemporary critical race studies are characterized by a shift from biologistic and assimilationist conceptualizations of race to a discussion of race in the social, historical, ideological, and political sense. The new social meanings of race inform and interpret the practice of “cultural racism,” (2000, 28) which is characterized by the re-emergence of culture in debates about races, a politicized understanding of culture, cultural production and the politics of identity.  This is also about how different racisms are manifested today in definitions of citizenship, nationhood, and nationalism without an overt resort to notions of biological inferiority. Gilroy (1993) made a similar observation that prior to the consolidation of scientific racism in the nineteenth century, the term “race” was used very much in the same way the word “culture” is used today, particularly in cultural criticism. Racist arguments are made frequently by pointing not to supposed biological differences, but to cultural inferiority. In other words, differences are explained not overtly in racial terms but in the language of culture. Sherene Razack (1994) also referred to this new or “modern racism” which indicates a practice of domination encoded in the assumption of cultural or “acquired inferiority” of the ‘other’. It is also discerned, Razack insisted, by the way it is vigorously and consistently denied. The covert mechanism through which “modern racism” works has been phrased by Razack as “culturalization of racism” – within which, issues of power are subsumed under culture, and “we speak more of cultural and ethnic differences and less of race and class exploitation and oppression. […] Cultural differences are used to explain oppression; if these differences could somehow be taken into account, oppression would disappear” (897 – 898).  While Razack’s theory showed how notions of culture can be utilized to maintain and at the same time hide racism and sexism, Bannerji (2000) revealed how the state manipulates the issue of cultural differences and cultural representations in order to create and maintain people of color as ‘visible minorities’ and as the ‘other.’ Bannerji argued that non-English and non-French 46  people are “outsider-insiders” in Canada, situated only at the margins to the central problematic of the Canadian national identity – only as mediating factors between the fundamental conflict of the two founding nations – the English and the French (91). She argued that multicultural policy erases internal differences (for example, class and gender) and also homogenizes non-white people with a fixed ethnicized cultural/political identity. Through a process of “racialized ethnicization,” multicultural policy whitens the North Americans of European origins and blackens or darkens their ‘others’ in the same stroke (6), so that only people of non-white races are constructed as having an ethnicity. Antiracist scholars such as Bannerji (2000) and Thobani (2007) have pointed out that within the paradigm of multiculturalism, the structural, material and power differences among populations are reduced to the benign issue of cultural diversity. Ideologies of multiculturalism and diversity are also driven by the discourses of liberal individualism and equal citizenship – discourses that obscure how the processes of systemic racism and other unequal power relations construct certain peoples as the ‘other’ and restrict them from exercising their rights as equal citizens.  Culturally sensitive care, informed and shaped by the institution of biomedicine and the state multicultural policy, is a popular approach to addressing the needs of ethnic minority populations, or ‘multicultural others’ and managing diversity within the Canadian healthcare system. Several antiracist scholars (such as, Ahmad 1993; Anderson and Reimer Kirkham1998; Culley 2006; Razack 1994; Stubbs 1993) have revealed, critiqued and opposed the ways culturally sensitive approach oftentimes results in producing stereotypic assumptions and erroneous generalizations about marginalized people while keeping the unequal relations of power unchanged.  Providing culturally sensitive care involves learning about cultural groups, and this has “... in reality maintained the idea of consistent and coherent cultural groups with defined sets of beliefs and health behaviours” (Culley 2006, 150). Within the framework of culturally sensitive care women from certain ethnic communities and their culture are framed as ‘the problem’ or at best the target for change with the assumption that those cultures can be fully known and learned with effort. But such efforts frequently end up in creating and maintaining stereotypes about certain cultures.  The discourses of culturally sensitive care just as those of multiculturalism remove attention away from racism and other systemic barriers in the Canadian society while attributing 47  the problem of inequitable access to the culture of non-white women and maintaining their status as the ‘cultural other.’ A rejection of culturally sensitive care, however, does not disregard culture as an important health determinant. This fact is explained by Culley:  Abandoning the notion of fixed and homogenous ‘cultures’ does not mean rejecting cultural processes as one set of influences on health and health behaviours or rejecting the importance of ethnic identification in specific contexts. It rather means that we cannot ‘read off’ health status, health beliefs and behaviours from an individual’s designated ethnic status (2006, 150).  Bannerji’ (2000) also reminded us that it is the real social relations of power, not culture, that provide the contexts and contents for our differences and oppression. Therefore, culturalist explanations of inequitable health and healthcare access must be rejected. Bannerji’s insightful critiques of state multicultural policy unpacked how the lives and experiences of women of color as postcolonial and neoliberal subjects are socially organized along the lines of gender, race, immigrant status, and class. Such an analysis can also be useful in understanding how those experiences shape their health in the broader socioeconomic and political contexts. Culturalist views of health inequities decontextualize health and healthcare practices of women of colour from the broader political, economic, historical, and social contexts, and the existing structural inequalities of the Canadian society. For example, dominant understandings of South Asian immigrant women’s access to cancer screening services largely fail to locate their healthcare practices within the contexts of their gendered experiences of migration, relocation, and everyday racism, and racializing practices and cultures of biomedicine. But feminist antiracist and postcolonial perspectives have disrupted the notions of culture, ethnicity and community as pre-given or natural constructs, and challenged the multicultural and neoliberal approaches to health care. Antiracist perspectives deflect the attention away from the narrow focus on the individual and culture, and explicate health inequities as being produced by racialized practices that sustain structural and material inequities within and beyond the healthcare system. These perspectives can help understand how gender, culture, race and class intersect to shape South Asian women’s access to cancer screening and other healthcare services.  Some recent work in healthcare research has taken an explicitly antiracist stance and postcolonial framework to develop critical cultural perspectives. For instance, the notion of cultural safety has been used to advance a more critical understanding of “the historical, social, 48  and political situatedness of healthcare relations” (Anderson et al. 2003, 199). Rather than trying to understand the health beliefs and practices of different ethnocultural groups, the concept of cultural safety, Anderson et al. asserted, addresses the need to critically examine culture and health with a recognition of power imbalances and inequitable social relationships, a legacy of the postcolonial past and neocolonial present. Browne and Varcoe discussed critical cultural perspectives to understanding culture as a power relation located within a constantly shifting network of meanings enmeshed within historical, social, economic and political relationships and processes (2006, 162).  They acknowledged culture as an important health determinant and recognized the importance of developing awareness about cultural diversity among heath researchers and providers, but through emphasizing culture as a complex, shifting relational process, they also disrupted essentialist notions of ethnic communities as homogenized cultural groups or the ‘other.’ Such an understanding appreciates that “members of a culture are constituted through intersectional differences that go beyond culture-as-ethnic/nation/linguistic- Otherness” (Dhamoon 2004, 4). This critical perspective also views culture as co-constituted by multiple intersecting power relations and as inseparable from other social locations. As such, it shifts the essentialist focus on viewing culture as the most important or only determinant of health behaviour and health inequities to an attention on transforming the structural, political, historical and gendered relations.  Thus antiracist strategies, as suggested by Ahmad (1993), Anderson and Reimer Kirkham (1998), Culley (2006), Razack (1994), and Stubbs (1993), call for the removal of structural barriers, and for healthcare policies and public health initiatives to be framed by analyses of the complex material practices and socio-political and historical processes beyond the clinic or biomedical services. In order to ensure more equitable, effective, and accessible health care, it is not enough to ask for “cultural sensitivity” on the part of healthcare providers; structural inequities based on race, gender, class and immigration status, both inside and outside the healthcare system need to be acknowledged and addressed. Also the stereotypical and racist assumptions about minority cultures and the institutionalized culture of Western biomedicine, especially the hierarchies within the healthcare system need to be challenged. Jiwani insisted, “It is the hierarchies of power and their expression in routinized practices that require transformation if proper health care is to be accessible to all” (2006, 173). Such a change, Jiwani suggested, requires healthcare professionals to be aware of the impact of the larger structural 49  violence such as poverty, colonialism, and its influence on contemporary social processes. Structural changes will also involve elimination of systemic racism and the endorsement of a social justice model of health care which views health less as a commodity and more as a human right and substantive equity issue.  Conclusion and Rationale of the Theoretical Framework  Antiracist approach to health research advocates that the construction of knowledge about certain ethnic communities in certain political and culturalist ways (where culture is essentialized and overemphasized while hiding from view the structural and systemic barriers to health care) must be challenged. Critical feminist health scholarship suggests that strategies to promote health equity must consider the larger structural, social and political processes that produce disparities in health, and recognize the mutual interaction between race, gender, and class relationships that renders individuals and groups vulnerable to extreme injustice and suffering. The dominant strategies, guided by the ideology and policy of multiculturalism, that try to address health inequities through providing culturally sensitive care for particular marginalized groups, are neither adequate nor effective. Such approaches, as Varcoe (2008) powerfully argues, must be replaced with antiracist and social justice perspectives and strategies – strategies that address fundamental social inequities and organize and provide services in ways that take into account the inequities women experience and the impact of those inequities on women’s lives and communities. However, despite several studies that take critical feminist antiracist and postcolonial approaches and explore issues of racism, poverty, immigration experiences, and gender in the context of South Asian and other groups of immigrant women’s health, healthcare practices and policies remain largely unchanged.  Vissandjée, Thurston, Apale and Nahar insisted that Canadian healthcare policies and services have failed to take an integrated approach to the needs and interests of women experiencing migration (2007, 222). Therefore, health research that explores the ways in which race, class, age, and gender relations intersect with immigration and settlement experiences to shape South Asian immigrant women’s health and healthcare experiences still seemed timely and needed, especially in the area of cancer screening. As already mentioned at the beginning of this chapter, antiracist and critical perspectives have been used by several feminist antiracist health scholars in studying many different aspects of immigrant women’s health including chronic diseases, mental health and others. But as it 50  appeared from the review of existing knowledge, such critical perspectives have been scantily employed in the area of cancer screening among South Asian immigrant women. Therefore, I realized that a research informed by a feminist antiracist approach to understanding South Asian immigrant women’s access to and experiences with cancer screening services within the broader political, economic, historical, and social contexts of their lives, with a special focus on these women’s diverse experiences of migration, integration and racialization in Canada would fill a major gap in the field of South Asian women’s cancer screening. In order to avoid inappropriate essentializing about the women’s culture and to gain better understanding of their diversity, subjectivity and agency, the current study emphasized the women’s gendered and racialized experiences of migration and settlement in a new country, and the institutional, structural and socioeconomic barriers to accessing healthcare services faced by the women. The theoretical and critical approaches used in framing the current research topic and objectives, and in designing the study thus drew from feminist antiracist, postcolonial and intersectionality scholarships, particularly to understand the complex impacts of racialization and its intersection with South Asian women’s gender, age or generation, class, educational and immigration status, on their experiences of health and access to healthcare services in Canada. Such theoretical perspectives provided helpful insights about how to devise a study that could integrate South Asian immigrant women’s voices and everyday experiences to analyse and show the larger political, socioeconomic and healthcare policies, processes and discourses through which these women’s use of cancer screening services might be influenced.     51  CHAPTER 3: METHODOLOGY AND RESEARCH METHODS    Introduction   Ideally, a methodology is a coherent set of ideas about the philosophy, methods, and data that underlie the research process and the production of knowledge (McCall 2005). Methodology is a strategy or a course of action rather than simply a technique or method. It is the broader “… plan of action, a process or design lying behind the choice and use of particular methods and linking the choice and use of methods to the desired outcomes” (Crotty 1998, 3). It includes the logic or theoretical frameworks that shape and support the selection of data sources and data generating methods as well as analysis and interpretation of that data (Crotty 1998; Harding 1987; Mason 2002). While methodology governs the research method, and guides the research design, processes and the decisions taken about how to go about generating data, particular epistemological, ontological and theoretical perspectives inform the methodology. Thus methodology should reflect the theories that support actual implementation of the methods of acquiring knowledge or data that can help address particular research questions. It should also include accounts of the whole research processes – from generation of research questions to analysis and interpretation of research data and findings.  My research aimed to explore South Asian immigrant women’s health experiences in the contexts of their everyday lives shaped by the processes of immigration and settlement, which are shaped by complex intersections of such dynamics as age, race, gender, class, religion, education and language skills, and length of stay in Canada. The research questions guided the general inquiry about how these dynamics and broader social relations, structures and processes shaped these women’s experiences with the healthcare system, especially breast and cervical cancer screening services in Canada. In seeking answers to the particular research questions I undertook a qualitative feminist research informed by a non-positivist, social constructionist epistemology and antiracist theoretical framework. I used the method of in-depth interviewing enriched by some techniques of ethnographic and collaborative interviewing processes.  52  Paradigms of Women’s Health Research  Ramazanoglu and Holland (2002) insist that a feminist methodology cannot be independent of the ontology, epistemology, politics and ethics, subjectivity and social locations of the researcher. Epistemological issues are not only interconnected with methodology and choice of methods for research, but as Harding (1987) argues, they also have important implications for how general theoretical structure can be applied in a particular discipline of knowledge. Crotty (1998) further notes the importance of ontology, which along with epistemology informs the theoretical perspective used to justify certain methodology employed in a research. And Ramazanoglu and Holland (2002) insist that different ontological positions offer different theoretical and political implications and accordingly suggest different strategies for knowledge production and social transformation. My theoretical frameworks shaped and were shaped by my ontological and epistemological perspectives, and were influenced by the gaps or limitations in the existing literature on South Asian women’s cancer screening, which indicated a lack of feminist antiracist perspectives to understanding the issue.  Ontological perspective refers to how one views the world as it is constituted (Crotty 1998), and includes beliefs and assumptions about the nature of some aspects of social or natural world (Ramazanoglu and Holland 2002). It is a philosophical understanding about the nature of social reality – what constitutes reality, and where and how it exists. An epistemology is the philosophy or theory of knowledge – the principles and rules by which someone decides whether and how social phenomena can be known and how knowledge can be demonstrated or represented (Mason 2002). It answers questions about who can be a knower, what is legitimate knowledge, how things can be known (Harding 1987). As Crotty (1998) puts it rather simply: “It is a way of understanding and explaining how we know what we know” (1998, 3). Guba and Lincoln (1998) further explain that epistemological position examines whether knowledge is something we accumulate objectively or something we agree upon that changes over time, and ascertains what distinguishes ‘adequate’ knowledge from ‘inadequate’ knowledge. Feminist research is as diverse as feminist methods and epistemologies. As Hesse-Biberr and Yaiser accurately noted: 53  Feminism is broad in content, methodology, and epistemological positioning. Some feminists reject the scientific model of research known as “positivism,” particularly the concept “objectivity”…others assert that objective social science does have something to offer feminists and are not ready to dismiss positivism (2004, 4).  Such positivist paradigms are quite common in women’s health research, especially in traditional biomedical research. Empiricist research – both quantitative and qualitative, that emphasizes scientific or experimental evidence – has been widely applied (by men as well as women) in studying women’s health, especially in the fields of Epidemiology, Psychology and Public health. Empiricist research is concerned about issues of validity, reliability and generalizabiliy of the findings rather than the social, historical or cultural contexts in which knowledge is produced (Murray and Chamberlain 2000). Such research generally extends the biomedical model, as Weber and Parra-Medina (2003) note, to incorporate more psychological and behavioural traits, and psycho-social characteristics among individuals and also identify the many environmental, social, psychological, behavioural and biological processes and traits that determine health outcomes.  On the other end of the continuum of women’s health research lies the critical constructionist approach that considers gender, race and class as dynamic social relations of power and explores their impacts on people’s health (Murray and Chamberlain 2000). An example of this approach is the intersectionality model of health research. Feminist scholarship on the intersectionality and health examine the multiple intersections of race, gender, class, sexuality and other systems of inequality and their impacts on women’s health (Weber and Parra- Medina 2003). Centred in humanities, social sciences and interdisciplinary studies and driven by concerns about social justice, the intersectionality approach is used in research to identify, analyze and address the health disparities created by the intricately interconnected broader economic and political structures and social relations of power and control. Intersectionality and health scholarship (Weber and Parra-Medina) underscore the importance of contextualizing women’s health in their diverse social, economic, political, cultural and historical circumstances. McCall (2005), however, argued that methodological approaches to studying intersectionality range from empirical to critical or from post-positivist to poststructuralist, while recognizing that different methodologies produce different kinds of substantive knowledge and analyses of issues and topics surrounding intersectionality. In McCall’s analyses, while some approaches examine 54  and explicate intersecting social inequalities often through measuring the existing or already constituted social groups, others reject those categories, and still others fall in the middle of a continuum as they acknowledge the stable and even durable relationships that social categories represent at any given point in time while at the same time maintaining a critical stance toward those categories through interrogating the boundary-making and boundary-defining processes. From the empiricist and positivist research to critical feminist and intersectional analyses and a combination or blend of these – a variety of different approaches used in studying women’s health have broadened knowledge of the complexities of women’s health issues. Overall, feminist and antiracist critiques of the reductionist approach of most biomedical research have called for more holistic understandings of women’s health within the broader social, economic, cultural, and political contexts of their lives rather than only on the interior of their bodies (Dossa 2004; Doyal 1995). The designing and analysis of my research was informed and inspired by the feminist antiracist theoretical approaches and intersectionality lens to viewing and understanding racialized women’s health as shaped by the interlocking systems of gender, race, class and immigration.  As Mason (2002) succinctly points out, different ontological positions are expressed in different theoretical perspectives about how to conceptualize social entities or realities. Different philosophical paradigms of social sciences (positivist, interpretivist, feminist, realist, ethnomethodologist, postmodernist and so on) hold that there are many different versions of the nature and essence of social things, beings and realities. These different essential components of social realities may be located in different properties or elements, such as in people, bodies, socio-cultural practices, discourses and so on. As Mason illustrates, while a certain paradigm promotes an ontological position which sees social life or reality as a collection of social discourses, another paradigm may see an individual psyche or personality constituting empirical reality.  As such, women’s accounts of their lived experiences may provide important entry points to understanding their social realities. As I was trying to understand the broader social structures, processes and relations that shaped South Asian women’s experiences through in- depth interviews, I was also conforming to Mason’s position that “it is useful and possible to frame intellectual puzzles about the social world, and that these can be answered or addressed through empirical research rather than simply through abstract theorizing” (ibid., 22). Such a 55  perspective appears to presuppose a reality existing outside the mind or human consciousness, a main tenet of realism.  As Miles and Huberman (1994) have pointed out, realism has come to mean many things, and often been confused with objectivism. But as Crotty (1998) also pointed out, realism does not necessarily correspond to objectivism (positivism) which not only posits the existence of an objective world/reality but also views this reality to be independent from subjective reality. In realism, meanings about social and physical world are constructed though their interaction with human consciousness. Contrary to the views of objectivism, Ramazanoglu and Holland’s (2002) views maintain that knowledge of social life and world is produced in particular social, historical, political and intellectual conditions and situations. My research questions and methodologies are quite consistent with Ramazanoglu and Holland’s ontological position of ‘historical realism’ that views reality as shaped by gender, ethnicity, social, political, cultural factors that appear ‘real,’ and attempts to understand reality at any given time and context taking these factors into account (Guba and Lincoln 1998). This ontological position is also compatible with qualitative research methodology as well as feminist antiracist theories and epistemology.  While realism views the social and physical world to be constructed through the interaction between objects and human consciousness, constructionism, as an epistemology, maintains that there is no objective reality to be discovered and that meanings are attributed socially to the objects as a result of our subjective engagement with the objective/physical world. Although there are many strands of this epistemological view, as Crotty (1998) noted, one or other form of constructionism is claimed in most perspectives or paradigms other than positivist and post-positivist ones. Social constructionists do not believe in the objectivity of research findings or truth and rather believe in multiple interpretations or more than one perspective or argument about realities.  Closely connected with the epistemology of social constructionism, which believes in the interdependence of the subjective and objective worlds or realities, is my ontological position of historical realism. In fact, “Realism in ontology and constructionism in epistemology turn out to be quite compatible. This is an example of how ontological issues and epistemological issues arise together” (Crotty 1998, 11). It is also congruent with the critical feminist perspectives that 56  view gender along with race, class and other relations of power as socially constructed categories, and biomedicine and health as social constructions as well (Weber and Parra-Medina 2003). Constructionism as an epistemology also views all knowledge – quantitative or qualitative – alike on equal footings; all as some form of construction while maintaining the views about the impossibility of objective knowledge.   Situating Knowledge Production  Feminist methodology scholars, such as, Haraway (1988,1993), Harding (2004), and Bhavnani (2004), while realizing the impossibility of attaining conventional objectivity, argued that this needs to be replaced by or transformed into “feminist objectivity,” which simply means “situated knowledge.” The main tenet of this kind of objectivity is, as Hesse-Biberr and Yaiser explained, “The nature of truth is that it is partial, situated, subjective, power imbued, and relational” (2004, 13). Harding’s “strong objectivity” examines not only the how, but also the why of a research project (Hesse-Biberr and Yaiser 2004). It is a process that obligates the researcher to disclose her/his subject positions, histories, influences, beliefs, and morals all along and at every step of the research process. Rather than taking a value neutral, detached and objective position, feminist researchers usually start from their own personal experiences (Reinharz 1992, 260) and critically situate themselves within the research process and production of knowledge. My research interest has been shaped both by my academic endeavour in a Canadian university and my personal experience as a South Asian immigrant woman from Bangladesh. The current research topic has been built on the research undertaken in my Master’s program in Women’s Studies which examined how the race, gender and class biases in Canadian immigration and related policies create negative implications and barriers for immigrant women to access state-funded services, including shelters for survivors of domestic violence and mental health care.  Despite the disagreement among feminists over the distinctive features of a feminist research, such research tends to share certain political and ethical concerns, particularly that of social change. There is a common ethical concern for “the morality of social investigation” (Ramazanoglu and Holland 2002, 3) and a commitment to political activism and social justice (Hesse-Biberr and Yaiser 2004). For Harding and Norberg, a good social research is a socially engaged one – ethically and politically accountable for its social consequences – a more 57  desirable way for feminists to produce knowledge that can promote the development of more democratic social relations (2005, 2010). Thus feminist researchers take responsibility for the practical and ethical implications of their decisions about knowledge production, and aim to produce knowledge that has potential to be used for effective social transformation. As a South Asian immigrant woman and as a feminist scholar, my research interest has been kindled not only by the existing gap in the literature of South Asian women’s use of Pap smear and mammogram, but also by an ethical and political commitment to social justice and more equitable and just healthcare policy and practice.  Patricia Hill Collins (1999) has argued that Black women’s and other marginalized groups’ status of “outsiders within” the white dominated academia and the mainstream sociology provide them with a unique standpoint for producing distinctive analyses and understandings of the intersection of race, class and gender in the lives of these people. Winddance Twine (2000) has also pointed out the merits of “racial matching” as a methodological tool in facilitating a better understanding of the social realities from the standpoint of the racially oppressed and addressing the absence of race analysis in mainstream white feminist discourse. My own location as a feminist of color in the white Western academia and my insider status within the South Asian community therefore, were likely to provide me with certain epistemological and methodological advantages to better understand these women’s perspectives and experiences and thus to produce reliable and convincing knowledge. As Reinharz insists, the “epistemology of insiderness” claims that being an “insider” enables a researcher to understand the experiences of a community in a way that would not be possible for an “outsider” (1992, 260).  As such, I had claimed in my research proposal that my ability to converse in a number of major South Asian languages (Bangla, Hindi, and Urdu) and familiarity with the cultural nuances and metaphors as an ‘insider’ to the community would be an asset for this project. In many cases this was proven true. As a South Asian woman I was able to attract interest, attention and trust of many women in my ethnic community. I was easily welcomed to many women’s houses and never encountered any discomfort in having conversations about women’s breast and cervical health and illnesses, and the cancer screening processes which are quite invasive into women’s interior body parts. As an immigrant woman I could share with many women my experience of financial and other struggles. My heterosexual, married background and experience of mothering 58  helped me to build rapport with many women. But I was unable to include in the study women of different sexual orientations. Only one of the participants was single and rest of the women were presently or previously involved in a heterosexual marital relationship.  However, I did not always feel like an insider to the community. Given my understandings of the socially constructed and fluid nature of identity, and of the mutability and artificiality of the insider/outsider dichotomy as suggested by Naples (2003), I knew that my insider status within the community would not be guaranteed at all the times. Naples (2003) provides ample examples of the multiple and fluid state of fieldwork identities for feminist ethnographers, and in depth accounts of how their insider/outsider identities are re/negotiated throughout the fieldwork period. I had realized that my status of an ‘insider’ or ‘outsider’ within South Asian community would be contingent on the social locations of the research participants and to the extent and degree they identify themselves as well as myself as bearing certain racial, ethnic, class and other dynamics of social identity. Considering my multiple social locations as a feminist researcher, middle aged, working class (given my yearly income), able-bodied, heterosexual woman, I might have been considered an ‘outsider’ to many women within the community. My multiple locations not only determined my insider/outsider position(s) in a certain context, but also shaped the power relations within the research process.  The biggest shock to my claim as an insider came from my inability to speak Punjabi, the language spoken by the majority of South Asians in my sample as well as in greater Vancouver. Although I thought my Hindi and Urdu speaking ability would give me easy access to women from India and Pakistan, I found that elderly women from Punjab, especially those with no formal schooling, could not speak Hindi at all. Two women from Punjab, Pakistan, who had never attended school, spoke only Punjabi (and no Urdu). I was surprised to find that four different languages (Hindko, Punjabi, Pushto and Urdu) were spoken within a small sample of seven Pakistani women. Relatively young and educated women could speak and/ or read and write Hindi or Urdu because these state languages are taught in schools in India and Pakistan. I felt a certain level of comfort and identification with the Pakistani women due our same religious affiliation. On the other hand, I learned a lot about Sikh culture when I visited a Sikh temple first time in my life for the sake of this research. I felt both strange and welcomed within the Sikh community. 59  In the case of the Bangladeshi community I was not able to reach women beyond my own educational level and/or social status. Although my economic status was lower compared to almost all the Bangladeshi participants I felt a middle class comfort within the community due to my academic status. But I failed to attract Bangladeshi women with lower educational or English skills among whom I was probably not viewed as trustworthy or an insider. Contrarily, I might have been perceived as too much of an insider (too close for comfort) by some community members who would rather feel safer with the distance between themselves and a non- Bangladeshi researcher. I sensed a lack of trust or discomfort among some South Asian women who had reservation about disclosing their yearly income.  One woman, who interpreted my conversation with her mother-in-law and her elderly neighbours, refused to ask them questions on my behalf about their socioeconomic status as she thought they would not understand or be able to answer my question. These women could not read or write in their own language, and I did not anticipate such problems before starting the field research.  In summary, certain advantages as well as disadvantages emerged from the fluid and contested nature of my insider/outsider status. Winddance Twine (2000) however, cautioned that racial matching, particularly singular emphasis on race, can result in homogenizing the experiences of a particular racial group and overlooking the intersectionality of people’s oppression due to their multiple locations or identities. As an ‘insider’ to the South Asian community, I might have also missed certain issues that would be more visible to ‘outsiders.’ Instead of claiming the knowledge produced through my research as universal, complete and ultimate truth about the experiences of South Asian immigrant women in Canada, I rather acknowledge that the product of my research is incomplete, partial and located within the relationships established through the insider/outsider boundaries during the research process. The challenges I faced in terms of interviewing and effectively communicating with the women, especially the language barriers and my feelings of being an outsider to the community clearly suggest that South Asians, like any other community, are diverse despite their commonalities of ethnic background.  Research Design and Procedure  Equity and justice in health care can be achieved through integrating the voices and perspectives of South Asian women as equally rightful citizens into relevant policymaking. With this 60  objective in mind, my research attempted to understand and incorporate the lived experiences and voices of South Asian women in greater Vancouver. Therefore, I designed a qualitative study in order to situate South Asian women’s health experiences in the contexts of their everyday lives shaped by their immigration, relocation and settlement processes.  Social constructionism, one of the philosophical or epistemological foundations of qualitative research, acknowledges and highlights the active engagement of researchers in creating knowledge within certain socio-cultural and historical contexts.  It also dismisses the idea of knowledge being apolitical or neutral. As such, it is a particularly compelling philosophical framework for critical feminist qualitative researchers (Morrow and Hankivsky 2007).  Quantitative methods, Ramazanoglu and Holland argued, “offer limited access to accounts of experiences, nuances of meaning, the nature of social relationships, and their shifts and contradictions” (2002, 155). Qualitative methods, on the other hand, are supposed to challenge and transform the status quo by providing insights of women’s lives from their own perspectives, and access to women’s own interpretations of gender relations and to women’s voices, especially through in-depth interviews and participatory action research (Hankivsky et al. 2005; Lawson 1995; Reinharz 1993). Guba and Lincoln (1998) observed that feminists and critical theorists predominantly use qualitative methodology with a goal to critique, transform and emancipate. Although policy makers most often tend to favour research findings of quantitative studies involving large samples, Mulvihill and her colleagues (2001) accurately noted that quantitative methods often fail to capture the unique and gendered experiences of marginalized women, and that there is a particular need for more qualitative research with respect to the differential or unique healthcare experiences of immigrant and refugee women from non-European cultures. In the health context, qualitative research provides rich and detailed descriptions about how people experience health and illness within the broader contexts of their lives (Morrow and Hankivsky 2007), and gives insights about the agency and voices of people seeking health care, particularly the less privileged groups (Segal and Vasilikie 2003). Therefore, while developing a methodological approach to answering my research questions I found feminist qualitative research informed by the social constructionist epistemology as a possible good fit and it was also consistent with my ontological and theoretical frameworks.   61  Data Sources In-depth interviews, audio-recorded and conducted in individual, couple and group contexts, constituted the main source of data. Two of the individual interviews were not audio taped and rather recorded in written notes due to technical difficulties in one case and reservation of the participant in another. Additionally, participants were asked to provide their personal and demographic information on a separate checklist. Information gathered through personal/demographic data sheets and field notes about the interview processes comprised valuable data for qualitative analysis. My field notes, written after finishing the interviews, provided situational or contextual information particularly about participants’ class or socioeconomic conditions, everyday life contexts, lifestyles and life constraints among others 4 . I tried to take notes, especially at the beginning of the interview, but found it distracting for staying focused on the conversation. As such, I did not take many notes during the interview unless necessary, and rather wrote my reflexive reports after coming home. The notes also included my reflections of the interviewing process and insights about the interview relationships, or any other noticeable events, cultural aspects, non-verbal communication and the context of interviews, and often even early analyses of the interviews. These additional sources enhanced the data quality and helped me better contextualize the women’s voices and experiences, and analyse those at a greater depth or breadth. They were also useful for reflexive reporting. In total, 31 women were interviewed in individual, couple and group interview  4  For example, a few interviews were done in the presence of children even though childcare was often paid. In one case, the father was babysitting in a room next to the living room where the interview was going on. But the children were very young and the older one often visited the mother while the younger one had to be nursed in the midst of the interview. This reflected the gendered role of mothering young children and lack of childcare skills on part of the father. The children had a professional babysitter but the service was not available on weekends, which was more appropriate for the interview. This is a social reality of many new immigrants with young children who lack the support of extended family members. In another case in an extended family scenario, the toddler granddaughter frequently sneaked into the living room even though the mother and grandfather were present inside the house. This indicated the affinity of the child to her grandmother and the important role she played in caring for her grandchild (who was not attending any daycare on a week day), and also the fact that it takes the whole family and often the community to take care of a single toddler. On a different occasion of a couple-interview, the young mother of two young children was helping with interpretation of my conversation with her mother- in-law and an elderly neighbour. The children had to stay in the living room with the TV on because their father was sleeping inside on a weekend morning after his graveyard shift. My own experience of raising young children in Canada in absence of extended family support helped me to be sensitive to the realities of the participants’ lives but I realized while transcribing that the presence of young children during the interview often severely impacted the audio quality.  62  settings. The total number of women under the individual, couple and group interviews are shown in Table 3.1. Table 3.1: Number and Types of Interviews Types of interviews Number of interviews Number of women Individual 12 12 Couple  3 6 Group  3 13 [6,4,3] Total  18 31  My initial research plan included individual in-depth interview as the only method of data collection. But as Mason (2002) points out, qualitative research is characteristically exploratory, fluid, data-driven and context-sensitive. Flexibility and sequential nature of research design are important features of qualitative research. As the research progressed, and as I increasingly depended on snowball technique for finding research participants, some women showed interest in being interviewed with a friend or neighbour. In addition to facilitating women’s preference, this option provided an advantage in addressing the language barriers in interviewing. A large number of the participants were from Punjab (India) and spoke only Punjabi. A couple of women from Pakistan also spoke only Punjabi. And often one of the women in a couple or group setting spoke good English and could help us (the other participant[s] and I) with the translation. 5  Furthermore, being outnumbered by the participants in the couple or group setting might have downplayed my power as an academic researcher and offered women a less intimidating and more comfortable atmosphere. Feminist interviewers have noticed that conversation in a group setting holds a potential of generating new, complex and rich details about women’s experiences because the data come from the participants’ interactions with each other (Morgan 1996). The group interview format “facilitates women building on each other’s ideas and augments the identification of patterns though their shared experience” (Callahan 1983, 38, cited in Reinharz  5  This was the case in two group and one couple interviews. In an individual interview situation, a family member (daughter) helped with the interpretation. In a couple interview a daughter-in-law mediated my conversation with her mother-in-law and her neighbour. And for the group interview with women receiving facilities from an immigrant women’s family support services agency, the South Asian support worker provided assistance with translation. 63  1992, 223). Such interactions and group dynamics may invoke discussions about particular aspects of women’s lives beyond researcher’s expectations or assumptions, leading to important insights and directions for a qualitative research and analysis. In fact, women’s conversations in couple and group settings provided opportunities for instant comparisons and analysis of the similarities and differences between women’s experiences and added richness and depth to the data. This also often helped to identify and address data gaps and take new directions or make necessary changes in the research design or sampling techniques in order to enrich the data. From methodological perspectives, the individual and group interview data seemed ontologically consistent due to their similar and complementary assumptions about the nature of social entities recognized through women’s subjective experience. From epistemological point of view, interviews in couple and group settings made it possible to include the voices of women disadvantaged by their limitation in English language and generally excluded from mainstream health research. Marshall and While (1994) pointed out that participants with significant English language difficulties have been traditionally excluded from research studies due to the language barriers.  The group interviews consisted of three to six women. When an immigrant women’s family support services agency was contacted for help with recruitment of research participants, the South Asian support worker informed that her clients requested that they be offered the option of a group interview. She proposed the idea of conducting a group interview with the women during one of their regular support group sessions, and also offered assistance with inter