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Examining community capacity to support Karen refugee women's mental health and well-being in the context… Clark, Nancy 2015

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EXAMINING COMMUNITY CAPACITY TO SUPPORT KAREN REFUGEE WOMEN’SMENTAL HEALTH AND WELL-BEING IN THE CONTEXT OF RESETTLEMENT INCANADAbyNancy ClarkB.S.N., The University of British Columbia, 1993M.S.N., The University of British Columbia, 2005A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF PHILOSOPHYinThe Faculty of Graduate and Postdoctoral Studies(Nursing)THE UNIVERSITY OF BRITISH COLUMBIA(Vancouver)April 2015© Nancy Clark, 2015iiABSTRACTFrom 2005 to 2009, Karen refugee women and their families living along theThailand Burma border were the largest group to be resettled in South WesternBritish Columbia. Research suggests that communities located at the metropolitanperiphery lack capacity to provide equitable, inclusive and accessible services forminority populations. Moreover, there exist growing inequities in health and healthcare for refugee women. As a result of historical oppression, many Karen womenarrived in Canada with lower literacy, lower education and exposure to trauma andviolence; however, little is known about Karen women’s needs for resettlement. Thepurpose of this study was to examine community capacity in the context of Karenwomen’s resettlement, i.e. to understand the social and structural processes thatimpacted their mental health and well-being, the factors that intersected to supporttheir resettlement process, and the ways the receiving community responded totheir resettlement needs.Ethnographic data was collected over a seventeen-month period, includingparticipant observation and, in-depth individual and focus group interviews withKaren women, settlement workers, health care and social service providers (N=38).Drawing on postcolonial feminist theory and tenets of intersectionality and culturalsafety, findings suggest that non-government organizations promoted successfulresettlement and mitigated the effects of trauma by supporting Karen women’shealth literacy. However, settlement reforms underpinned by neoliberal governancestructures resulted in gendering and mainstreaming of settlement services,negatively impacting the Karen women and families’ ability to access health careiiiservices and social supports. The overall lack of knowledge about their needs,integrated support for translators and formal social support systems challengednurses, allied health care providers and settlement workers in their attempts toprovide equitable health care and social resources. These structural aspects ofcommunity capacity created contexts of increased vulnerability and dependency forKaren women. Capacity-building strategies fostering advocacy, collaborativepartnerships, reciprocal support, and flexibility across service sectors (non-government organizations and primary and public health) facilitated communitycapacity to support the mental health and well-being of Karen women duringresettlement. Recommendations are proposed for integrated systems of care thatpromote social justice and that are culturally safe and trauma- and violence-informed.ivPREFACEEthics approval for this study was received from the University of BritishColumbia, Behavioral Research Ethics Board. This study was originally approved inMay 2012; the last annual renewal was received in January 2014 (Approval numberH12-00702). The Fraser Health Research Ethics Board FHREB under the FraserHealth Authority also granted ethical approval for this study in July 2012. The lastannual renewal was received in July 2013 (Approval number 2012-039).This dissertation is the original, unpublished, independent work by theauthor, Nancy Clark.vTABLE OF CONTENTSABSTRACT ................................................................................................................................................. iiPREFACE ................................................................................................................................................... ivTABLE OF CONTENTS ........................................................................................................................... vLIST OF TABLES ...................................................................................................................................... xLIST OF FIGURES.................................................................................................................................... xiLIST OF ACRONYMS.............................................................................................................................xiiACKNOWLEDGEMENTS ..................................................................................................................... xv1. SITUATING THE STUDY ......................................................................................................... 11.1 Introduction...................................................................................................................... 11.2 Locating the Problem .................................................................................................... 61.3 Research Purpose and Objectives ......................................................................... 121.4 Organization of the Dissertation............................................................................ 132. BACKGROUND AND LITERATURE REVIEW................................................................ 172.1 Introduction................................................................................................................... 172.2 Globalization, Transnationalism and the Construction of RefugeeIdentity ............................................................................................................................ 192.3 An Overview of the Discourses and the Sociopolitical HistoricalContext of Canadian Immigration ......................................................................... 302.4 The Evolution of Karen Refugee Resettlement in BC..................................... 492.5 Primary Health Services and Settlement Support for Refugees inCanada.............................................................................................................................. 522.5.1 Overview of settlement services in BC .................................................... 542.5.2 Nongovernment organizations and settlement.................................... 552.5.3 Overview of structures of settlement and GAR outcomes inBC............................................................................................................................ 622.6 Health and Health Care Access for Refugee Women...................................... 772.7 Examining Language and Literacy Barriers of Refugee Women............... 882.7.1 Lack of integrated official language policy ............................................. 972.8 Refugee Women’s Mental Health and Well-being.........................................1032.9 Refugee Women and Social Support ..................................................................1092.9.1 Intimate partner violence relating to immigrant andrefugee women................................................................................................114vi2.9.2 The role of social support and mental health......................................1172.10 Community and Community Capacity...............................................................1202.10.1 Social capital and community capacity...............................................1292.11 Mental Health Policy and Community Capacity.............................................1352.11.1 Examining the role of trauma and identity .......................................1412.11.2 Trauma and idioms of distress...............................................................1462.11.3 Trauma: pre- and post-migration .........................................................1512.12 Reflections of the Literature and Summary of Key Points.........................1563. METHODOLOGY AND METHODS ..................................................................................1603.1 Introduction.................................................................................................................1603.2 Theoretical and Methodological Approaches .................................................1603.2.1 Critical theoretical perspectives...............................................................1603.2.1.1 Postcolonial feminist theory.....................................................1643.2.1.2 Intersectionality ............................................................................1693.2.1.3 Cultural safety ................................................................................1723.2.2 Critical ethnography .....................................................................................1763.2.3 The standpoint method of inquiry...........................................................1793.3 Research Objectives and Methods ......................................................................1803.3.1 Negotiating entrance into community ...................................................1813.3.2 Sampling strategy, recruitment and rationale ....................................1823.3.3 Research setting .............................................................................................1863.3.4 Sample size .......................................................................................................1873.3.5 Participant characteristics..........................................................................1893.3.5.1 Karen women .................................................................................1893.3.5.2 Community health and social service providers...............1913.3.6 Data collection methods and procedures .............................................1943.3.6.1 Focus groups...................................................................................1953.3.6.2 In-depth interviews......................................................................1993.3.6.3 Participant observation in the field .......................................2013.3.6.4 Fieldnotes.........................................................................................2033.3.6.5 Policy lens ........................................................................................2053.3.7 Data analysis process....................................................................................2063.3.7.1 Organizing, reading and memoing .........................................2063.3.7.2 Describing, classifying and interpreting data intocodes and themes..........................................................................2073.3.7.3 Interpreting and making meaning of the data ...................2083.4 Ensuring Scientific Quality.....................................................................................2103.4.1 Positioning myself in this research .........................................................210vii3.4.2 Validity ...............................................................................................................2123.4.2.1 Threats to descriptive validity.................................................2143.4.2.2 Threats to theoretical validity..................................................2143.4.2.3 Threats to interpretive validity ...............................................2183.5 Ethical Considerations.............................................................................................2233.5.1 Reciprocity and remuneration..................................................................2273.6 Study Limitations.......................................................................................................2284. KAREN WOMEN’S EXPERIENCES OF RESETTLEMENT .......................................2304.1 A Context of Stress and Worry .............................................................................2304.1.1 Resettlement and mental health—“A lot of stress andworry”.................................................................................................................2314.1.2 Dependency—“You don’t need to wait for me”..................................2384.1.3 Re-visioning agency—“Standing on other people’s feet isnot the same as walking by yourself” .....................................................2444.1.4 Fitting into the mold—“It seems like they don’t have thetime” ....................................................................................................................2464.1.5 Seeking safety and the potential for traumatization—“Somebody step in and help her!”............................................................2534.1.6 Gender, identity and resettlement—“It’s invisible…” ......................2614.1.7 Education, language and gender—“It’s a big thing for me togo to school…” .................................................................................................2664.2 Summary.......................................................................................................................2705. EXAMINING COMMUNITY CAPACITY: HEALTH CARE AND SOCIALSERVICE PROVIDER PERSPECTIVES ON SUPPORTINGRESETTLEMENT AND THE MENTAL HEALTH AND WELL-BEING OFKAREN WOMEN ...................................................................................................................2745.1 Culture, Healthcare Provision and Karen Women’s Resettlement.........2745.1.1 Mental health, culture and health literacy—“Why are youbringing me here today? I feel well…”....................................................2745.1.2 Volunteerism and resettlement—“Flying by the seat of ourpants” ..................................................................................................................2855.1.3 Challenges to community capacity—“The funding dictates” ........2915.1.4 Increased need for social support—“They leave you highand dry”..............................................................................................................2995.1.5 Accompaniment—“If we don’t help who will?”..................................3025.1.6 Structural violence—“Let me talk to someone who speaksEnglish; I don’t have time for this!” .........................................................308viii5.1.7 Building community capacity—“You have to work from adifferent model”..............................................................................................3205.2 Summary.......................................................................................................................3256. DISCUSSION AND SUMMARY OF KEY RESEARCH FINDINGS ............................3286.1 Introduction.................................................................................................................3286.4 Language, Health Literacy and Gender in the Context ofResettlement ...............................................................................................................3536.5 A Move Toward Addressing Structural Inequities: What WorkedWell?3567. RECOMMENDATIONS FOR POLICY AND PRACTICE AND CONCLUDINGCOMMENTS............................................................................................................................3657.1 Culturally Safe, Trauma- and Violence-Informed Policy andPractices ........................................................................................................................3657.1.1 Recommendation for restructuring health care andsettlement services........................................................................................3697.1.2 Recommendations for promoting health literacy andintegration of language resources ...........................................................3737.2 Recommendations for Future Research ...........................................................3767.3 Methodological Reflections....................................................................................3787.4 Conclusion ....................................................................................................................380REFERENCES .......................................................................................................................................382APPENDICES........................................................................................................................................407Appendix A.  Recruitment Poster for Karen women ............................................................408Appendix B.  Poster for Health Care and Social Service Providers .................................409Appendix C.  Recruitment/Information Letter.......................................................................410Appendix D.  Socio-Demographic Form for Research Participants................................414Appendix E.  Focus Group Interview Guide for Karen Women........................................416Appendix F.  Focus Group Interview Guide for Health Care and Social ServiceProviders .........................................................................................................................417Appendix G.  Consent Form for Health Care and Social Service Providers .................418Appendix H.  Karen Women Individual Interview Guide ...................................................421ixAppendix I.  Consent Form for Karen Women to Participate in Individual andFocus Group Interviews.............................................................................................423Appendix J. Selected Fieldnotes.......................................................................................427Appendix K.  Translator Confidentiality Agreement Form................................................436Appendix L. Script of Oral Consent to Conduct Participant Observations...................438Appendix M: Consent to Participate in Field Observations...............................................440Appendix N.  Consent for Karen Women’s Family Members to Participate inIndividual and Focus Group Interviews ..............................................................444Appendix O.  Interview Guide for Karen Family members ................................................448Appendix P.  Consent for Policy Makers to Participate in IndividualInterviews .......................................................................................................................449Appendix Q.  Interview Guide for Policy Members...............................................................453xLIST OF TABLESTable 1. Total Participants .............................................................................................................188Table 2. Karen Women’s Demographic Data (n = 12) .........................................................190Table 3. Health Care and Social Service Provider Data (n = 26)......................................193xiLIST OF FIGURESFigure 1. Framework of the Critical Theoretical Approaches ..........................................176xiiLIST OF ACRONYMSAboriginal Health Center ...............................................................................................................AHCAcquired Immune Deficiency Syndrome ................................................................................AIDSAffiliation of Multicultural Societies and Services Agencies of BC........................... AMSSAAmerican Psychological Association ........................................................................................ APABoston Centre for Refugee Health and Human Rights...............................................BCRHHRBridge Community Health Clinic.............................................................................................. BCHCBritish Columbia................................................................................................................................... BCCanadian Nurses Association .......................................................................................................CNACanadian Psychiatric Association............................................................................................... CPACensus Metropolitan Area ........................................................................................................... CMACitizenship and Immigration Canada..........................................................................................CICEarly Childhood Educator...............................................................................................................ECEEarly Years Refugee Program ....................................................................................................EYRPEdinburgh Postnatal Depression Scale...................................................................................EPDSEnglish Language Skills Assessment ....................................................................................... ELSAGender Based Analysis....................................................................................................................GBAGovernment Assisted Refugee .....................................................................................................GARGreater Vancouver Regional District......................................................................................GVRDHealth and Social Services Center ............................................................................................ HSSCHealthcare Interpretation Network............................................................................................HINHuman Immunodeficiency Virus .................................................................................................HIVImmigrant Services Association....................................................................................................ISAImmigrant, Refugee, Ethno-cultural or other Racialized person ................................. IRERImmigrant Services Society of BC...................................................................................... ISS of BCxiiiImmigration and Refugee Protection Act ............................................................................. IRPAImmigration Refugee Board ......................................................................................................... IRBInstitute for Research on Public Policy ...................................................................................IRPPInterim Federal Health Program................................................................................................IFHPInternally Displaced Person .......................................................................................................... IDPIntimate Partner Violence ...............................................................................................................IPVMental Health Commission of Canada ................................................................................. MHCCMohawk Valley Resource Center for Refugees.................................................................. MVRCNew Public Management ..............................................................................................................NPMNon-Government Organization .................................................................................................. NGONurse Practitioner ...............................................................................................................................NPPost Traumatic Stress Disorder ................................................................................................PTSDPost-partum Depression ................................................................................................................ PPDPrimary Health Care ........................................................................................................................ PHCPrivately Sponsored Refugee ........................................................................................................PSRPublic Health Nurse ........................................................................................................................ PHNRefugee Assistance Program ........................................................................................................ RAPRyerson University Resettlement Project ............................................................................... RRPSeptember 11, 2001 (World Trade Center/Pentagon terrorism attacks)................ 9/11Southeast Asia .....................................................................................................................................SEATuberculosis ..........................................................................................................................................TBUnited Kingdom....................................................................................................................................UKUnited Nations ..................................................................................................................................... UNUnited Nations High Commissioner for Refugees ......................................................... UNHCRUnited States of America.................................................................................................... US or USAxivVulnerable Immigrant Populations Program........................................................................VIPPWorld Health Organization .........................................................................................................WHOWorld War Two ..............................................................................................................................WWIIxvACKNOWLEDGEMENTSThere are many people I would like to thank for supporting me in pursuingthis academic endeavor. First, I would like to acknowledge and thank the Karenwomen and families who contributed their time and shared their stories with me. Ialso would like to extend my heartfelt thanks to the NGO that kept the door openand allowed me to do this study; thank you Bill and Jane. In particular I extend mydeepest appreciation to Sharon, who has been an integral part of my learningthroughout this journey. I am grateful for the kindness extended by Tamira, Saw Joand Herman, who took time out of their schedules to support this research. I am alsoin gratitude to the Karen women who provided translation for this study: Candy,Zipporah, Hser Chri and Hser Gay; without your assistance this study would nothave been possible.I am sincerely grateful to my supervisory committee, Drs. Annette Browneand Sheryl Reimer-Kirkham and my research supervisor, Dr. Victoria Smye, whoprovided ongoing support and encouragement. I also extend my gratitude andthanks to Vicky Bach who provided ongoing support during the early phases of thisstudy. Thank you to my friends, colleagues, and family who stood beside me, wholistened and regularly checked in with me to make sure I was still moving forward. Iam also grateful to the support from Lynn, John and Sue who provide their expertiseand support. Thank you, Augie and Harvey for your support and lastly, to myhusband Chris who stood by me and inspired me to continue, I am truly grateful.11. SITUATING THE STUDY1.1 IntroductionThe process of migration and context of resettlement are importantdeterminants for the mental health and overall well-being of refugee women inCanada. By the end of 2010, women and girls at risk represented 49% of refugeesworldwide including asylum seekers, stateless women and internally displacedpersons (IDP)1 (United Nation High Commissioner for Refugees [UNHCR], 2010b).Since 2007 the percentage of refugee women at risk2 has risen from 6.8% to 11.15%in 2011 (UNHCR, 2013). Resettlement is recognized as a key protection tool forrefugee women and girls at risk to ensure protection and well-being, but only if theirgendered specific needs are recognized and addressed (UNHCR, 2013).Decades of state sponsored violence in Burma has resulted in wide humandisplacement of Karen ethnic minorities within Southeast Asia and abroad. Inresponse to the growing refugee crisis, recognition of gender violence, Karenrefugees from this region were identified by the United Nation High Commission forRefugees (UNHCR) and Citizenship Immigration Canada (CIC) as refugees in need of1 Refugees are individuals who are considered to need protection under the United Nations HighCommission for Refugees (UNHCR). Stateless persons are not considered under international law tobe nationals of a particular state (UNHCR, 2010b). Internally displaced persons (IDP) are “individualsthat have been forced to leave their homes in order to avoid armed conflict, violence and violation oftheir human rights but who have not crossed an international border” (UNHCR, 2010b, p. 35).Asylum seekers are refugees whose refugee status has not yet been determined but who also requireprotection for humanitarian reasons (UNHCR, 2010b). The UNHCR has the responsibility foridentification and referral of refugees for resettlement world-wide. I discuss the implications of theseidentity formations in Chapter Two.2 The UNHCR (2013) defines a refugee woman thus: “a refugee woman who faces threats to hersafety and well-being that is unresolvable in her current location may be deemed to be a woman-at-risk requiring resettlement” (p. 5).2rapid and large scale resettlement. Between the years 2005-2009 the province ofBritish Columbia (BC) received 4,026 government assisted refugees (GARs)3. Thelargest group of 786 represented Karen refugees from Burma [Myanmar], and 33%of this original group were destined outside of metro Vancouver, making them thelargest refugee group in south west region of British Columbia (BC) (ISS of BC,2010). In 2002, Canadian immigration policies changed to reflect the growingdemand for refugee resettlement, which resulted in the Immigration and RefugeeProtection Act (IRPA). The IRPA represents a historical landmark in Canadianhistory because it resulted in the removal of barriers that historically limited theadmission of immigrant groups into Canada, including those with complex chronicmedical and psychological conditions and limited language and literacy ability andeducation. The IRPA has set the stage for a protection policy framework which couldhave direct implications related to the settlement and health care sectors designedto support and mitigate challenges faced by newly arrived refugee groups. In thiscontext Karen women and families were recognized as a high-risk group since manycame with long histories of colonial oppression, including limited access toeducation, and protracted camp situations (CIC, 2006; 2008).3 GARs refer to government assisted refugees who also fall under the category of conventionrefugees. As discussed by Chambers and Ganesan (2005) “under the Immigration and RefugeeProtection Act (IRPA) there are two main pathways through which refugees can become accepted asrefugees in Canada: (1) the Refugee and Humanitarian Resettlement program, for people applyingoutside of Canada as “convention refugees”, and (2) the In-Canada Refugee Protection Process, forpersons applying from within Canada [such as] ‘asylum seekers‘”(p.293). In this dissertation I use theshort term GARs respectfully recognizing that I would not normally reference people in this way, i.e.,this is for the purpose of brevity and conceptual understanding of categorization of refugee groupsand their entrance into Canada.3A review of research studies suggests that refugee women’s mental healthand well-being is related to broad intersecting factors associated with gender roles,social support, literacy and education and domestic violence (Mahler & Pessar,2006; Mason & Hyman, 2008; Merry, Gagnon, Kalim, Bouris, 2011; Simich, 2009;Simich, Beiser, Mawani, 2003; Zanchetta, Kaszap, Mohamed, Racine et al., 2012).Refugee women’s gendered experiences of migration and resettlement arequalitatively different than men’s, and socially determined by access to economic,health and other social resources in the receiving country (Beiser, 2009; CIC, 2006;2008; Deacon & Sullivan, 2009; Guruge & Collins, 2008; Kirmayer et al., 2011;Oxman-Martinez & Hanley, 2011). Post migration, studies show that refugee mentalhealth is socially determined by access to adequate housing, unequal jobopportunities and pay, poverty, racial discrimination, and lack of linguistic supportdespite resettling in developed countries with better economic and socialopportunities (Baya, Simich, & Bukhari, 2008; Beiser, 2005; 2009; CIC, 2008; Deacon& Sullivan, 2009; Porter & Haslam, 2005; Newbold, 2009; Morris, Popper, Rodwell,Brodine & Brouwer, 2009). In particular refugee women that are older, single andwho are heads of households are identified as experiencing greater risk for healthinequities during resettlement4 (Citizenship and Immigration Canada (CIC), 2006;4 Health inequities are defined as inequities that are “socially produced; systematic in theirdistribution across a population; and unfair” (Health Inequities in British Columbia (HIBC):Discussion Paper, p. 17). Drawing on the definition from the World Health Organization, in thedocument ‘Health Inequities in British Columbia,’ health inequities are systemic differences resultingfrom differences among socioeconomic groups. Health disparities or inequalities are defined bydifferences in health status among individuals due to a genetic predisposition or behavior. Inequitiescan be further defined by ‘upstream’ systemic differences that ‘structure’ and shape “the differentialvulnerability of people to health-affecting conditions and are powerful determinants of health”42008; Marchbank et al., 2014). Studies have also shown that refugee women are atgreater risk for postpartum depression (PPD)5 (Ardiles, Dennis & Ross, 2008;Collins, Zimmerman & Howard, 2011; Kirmayer et al., 2011; Pottie, Greenway,Feightner, Welch et al., 2011). Structural barriers related to lack of adequate serviceprovision, vis-à-vis language interpreters are one of the major barriers for healthcare access for refugee women and this has resulted in discriminatory healthpractices that socially exclude many refugee women from access to culturally safe6health care provision (Johnstone & Kanitsaki, 2007; Merry et al., 2011, Mortensen,2010 ). Access to employment and language skill differ between refugee men andwomen (Akhavan, Bildt, Franzén & Wamala, 2004; Khoo, 2010). In particular,government assisted refugee (GAR) women experience significantly greaterchallenges in resettlement in comparison with other migrant groups, due to lowliteracy levels in their original language (CIC, 2006; 2008). English language fluency(HIBC, 2008, p. 8). Downstream is often referred to the behavioral aspects of health (individual)where the individual is perceived to have some measure of control.5 According to the American Psychological Association (APA) (2013) postpartum depression (PPD) isa “serious mental health problem characterized by a prolonged period of emotional disturbance,occurring at a time of major life change and increased responsibilities in the care of a newborninfant” (p.2).6 Cultural safety is a concept that originated from nursing scholars in New Zealand. It is an approachto healthcare practice that addresses health inequities that have resulted from a processes ofcolonization. In response to addressing issues of cultural difference various frameworks andpractices have been adopted by health care and social service providers in Canada. Theseframeworks include cultural sensitivity, cultural competence and to more critical approaches such ascultural safety. In this research I adopt a critical cultural approach which extends the culture focusbeyond the individual and individual difference to a focus on power imbalances within socialrelationships that produce inequitable access to health and social services through discriminatorypractices (Browne, Varcoe, Smye, Reimer-Kirkham et al., 2009). Gustafson (2008) argues, “culturalidentities emerge from a dynamic interplay between micro-level relations … and macro-levelrelations reflected in organizational policies and practices” (p. 40). I discuss theoretical underpin-nings of cultural safety as an important approach for examining Karen women’s resettlement andaccess to healthcare in Canada in Chapters Two, Three and Four.5and unemployment are also significant predictors of depression amongst refugeewomen during resettlement placing less educated women and elderly refugees atgreater risk for social isolation and psychological distress (Beiser, 2009; CIC, 2008;Chung & Bemack, 2002; Deacon & Sullivan, 2009; Hyndman & Walton-Roberts,1999; Zanchetta et al., 2012). Even in contexts where refugees receive English asSecond Language training in Canada, there is evidence to suggest that these trainingprograms are insufficient to meet the demands of language skill required foremployment, moreover language skill training is structured to facilitate the labouremployability of men (Beiser, 2009, Hyndman & Walton-Roberts, 1998; Kirmayer etal., 2011; Sherrell, 2003). In addition, emerging research suggests that literacy andhealth literacy of minority women determines women’s access to social resourcesand health (Kickbusch, 2001; Peerson & Saunders, 2009; Simich, 2009; Rouhani,2011; Zanchetta et al., 2012). Although critical scholars have drawn attention tobroader systemic inequities experienced by immigrant and refugee women(Anderson, 2000; Anderson, Tang & Blue, 1999; Drennan & Joseph, 2005; Bannerji,2000; Collins, Yogendra, Shakya, Guruge & Santos, 2008; Fung & Wong, 2007;Mawani, 2008; O’Mahoney & Donnelly, 2010), very little is known about Karenrefugee women’s experiences of migration and resettlement in Canada. The purposeof this research was to conduct an in-depth study of Karen women’s perspectives onwhat they found had supported their resettlement process, including their access tohealth care services and social supports during their resettlement in Canada.Moreover, evidence shows that even five years after resettlement, manyGARs in BC continue to lack accessible health care services and social service6supports necessary for successful integration (Marchbank, Sherrell, Friesen,Hyndman, 2014; Rouhani, 2011). The second aim of this research was therefore togain an in-depth understanding of the social and structural factors that facilitatedand/or challenged the receiving community’s ability to promote Karen women’smental health and well-being in the context of their resettlement.1.2 Locating the ProblemThe research problem that this study aims to address can be framed in twointerrelated themes. First, equality and issues of distributive justice vis-à-visdistribution of services or resources does not address issues of equity and complexneeds of refugee women. In addition, an ethos of liberal individualism and a climateof neoliberal economy have perpetuated marginalization of immigrant and refugeegroups that come to Canada with limited skills for successful resettlement throughmainstreaming of services and restrictive mandates to settlement policy (Creese,1998; Geronimo, 2000; Marchbank, et al., 2014; Sadiq, 2004). Canadianmulticulturalism, underpinned by values of liberal individualism and egalitarianism,assumes that all members of society have equal access to health care, social servicesand support, independent of social constraints (Anderson & Reimer-Kirkham,1998). Although various options and strategies across Canada have beenimplemented to promote the mental health and well-being of refugee women duringresettlement, including the development of community-based program initiativesthat reduce cultural and linguistic barriers to care, establishment of immigrantrefugee health clinics, delivery of health programming in refugee communities and7the use of outreach workers or cultural brokers’7, trends in settlement reflectneoliberal8 governance structures in which a market economy remains the maindriver for the restructuring of health and social policy (Geronimo, 2000). Thedistribution of equitable, inclusive and accessible services and support variesbetween and within Canadian provinces. In BC, municipalities located at theperiphery of metropolitan cities have been shown to have minimal capacity forequity-oriented services and supports for newly arrived refugee groups (Edgington& Hutton, 2000; Geronimo, 2000; Sadiq, 2004; Sherrell, 2003). Research related toequity oriented mental health and primary health care services has shown thatrelationally based governance structures in which non-dominant groups have avoice in developing policy, integration of social determinants of health9 through7 Miklavcic & LeBlanc (2014) trace the genealogy of the term cultural broker from its anthropologicalorigins to describe “a process of cultural contact in various contexts of domination, including trade,colonialism, nation-state building, and modernization” (p.117). In contemporary understandingcultural brokering in health care may vary and includes various levels of expertise that requiremediation between different knowledges and perspectives. For example, “Categories of individualswho may act as culture brokers include health practitioners, nurses, social workers who function ascultural brokers by virtue of their bilingual/bicultural identity or direct knowledge of a specificcommunity…”(p.117).8 Smith (2005) defines neoliberalism as an ideological discourse based on “economic theories thatstress the paramount significance of a free market for general prosperity; government is viewed ascostly and inefficient; concepts of citizenship stress individual responsibility for economic well-beingand so on” (p. 217).9 In this research mental health is recognized as a construct that may have different culturalmeanings amongst and within different cultures and ethnic groups. The World Health Organization(WHO) (2014) defines mental health and well-being broadly as “a state of well-being in which theindividual realizes his or her own abilities, can cope with the normal stresses of life, can workproductively and fruitfully, and is able to make a contribution to his or her community” (para 3). TheWHO further defines social determinants of mental health to include multiple social, psychologicaland biological factors including poverty, low levels of education, rapid social change, genderdiscrimination, social exclusion, risk of violence, physical ill health and human rights violations asassociated with poorer mental health.8inter-sectoral collaboration, advocacy and long term funding partnerships areneeded in order promote health equity of vulnerable groups (Creese, 1998; Lavoie,Browne, Varcoe, Wong et al., 2014; Mental Health Commission of Canada (MHCC,2009); Geronimo, 2000).Moreover, growing inequities are perpetuated by discursive practices –which construct stereotypes and position refugee groups as a threat to public safety.Scholars have drawn attention to how racialization10 serves to portray the ways inwhich dominant culture constructs race and conceptualizes issues of migration, in apreoccupation with national security (Bradimore & Bauder 2011; Kirmayer, 2007;Tomasso, 2012). In turn, dominant discourses are embedded in broader social andgeo-political processes that shape policy related to minority health.Secondly, dominant Western discourses have constructed refugees astraumatized victims, dependent and vulnerable (Marlow, 2010; Pupavac, 2008;Malkki, 1995). Although many refugee women experience trauma pre migration,studies suggest that 80% of refugees do not go on to experience psychologicalconditions such as post traumatic stress disorder (PTSD) (Pottie, Greenaway,Feightner, Welch et al., 2011). Rather evidence suggests that over time refugee10 Racialization in this research is used to mean “a relationship based on power—the power to define,contain and neutralize and other. Other is not a neutral category, but is understood as inferior, andthe process of Othering is a process whereby the inferior position is sustained” (Berman & Jiwani,2008, p. 138). A particular form of othering is racialization. According to Tomasso (2012),“racialization is a process whereby race is constructed and negotiated according to systems of powerin specific temporal contexts and places.”(p.332). I employ the terms racializing or racialization asdoes Tamasso, as a non static term and where connotations of race are not based on a phenotype butwhere “notions of whiteness and discourses of racialization are fluid, and always changing over timeand in relation to others.” (Tomasso, 2012, p.332). It can be argued that that outcome of racializationproduces multiple forms of marginalization and othering through various economic, gendered andpolitical discourse.9groups experience systemic forms of Othering11 based on race, gender and classdifferences which determine poorer health outcomes (Beiser, 2005; 2009;Kirmayer, Narasiah, Munoz, et al., 2011). These findings open up space from whichto re-examine the complexity of trauma beyond individual and pre migratory events(Lester, 2013, Marlowe, 2010).Reducing refugee women’s barriers to accessing health, social services andsupports to cultural differences mask the systemic inequities that are embedded inhistories of colonialism12 and ongoing dominant cultural practices that fail tointegrate social determinants of refugee women’s mental health. For exampleculturalism13 often evoked in multicultural societies is used to address issues of11 Grove and Zwi (2006) conceptualize Othering as a process of differentiation that “defines andsecures one’s own identity by distancing and stigmatizing an (other). Its purpose is to reinforcenotions of our own “normality”, and to set up the difference of others as a point of deviance.”(p.1933). The outcomes of this process lead to marginalization, disempowerment and socialexclusion (Grove & Zwi, 2006). However, Canales’ (2000) foundational work on othering suggeststhat othering can be both inclusive and exclusive processes whereby exclusionary othering utilizesthe power within relationships for domination and subordination. Conversely, inclusionary otheringattempts to utilize power within relationships for transformation and coalition building (Canales,2000). Othering therefore occurs within multiple levels and social contexts, both within interperson-al relations (micro) contexts as well as broader (macro) levels such as institutional health and socialpolicy.12 Colonialism is a term used to define a “specific form of cultural exploitation that developed withthe expansion of Europe over the last 400 years” (Ashcroft, Griffiths, & Tiffin, 2000, p.40). HoweverAschcroft et al. go on to note that “European colonialism in the post-Renaissance world became asufficiently specialized and historically specific form of imperial expansion…as a distinctive kind ofideology” (p.40). Post-colonialism originally described the post-colonial state referring to post-independence period (Aschroft et al., 2000). The term post-colonial is now widely used in diverseways to not only study European conquests but also to study the impact of European imperialism andas such is concerned with “the process and effects of, and reactions to, European colonialism from thesixteenth century up to and including the neo-colonialism of the present day” (Aschroft et al., 2000,p.169).13 Browne, Varcoe, Smye, Reimer-Kirkham et al. (2009) define culturalism as a process in whichpeople are viewed through constructions of culture “defined narrowly as shared values, beliefs andpractices, and often conflated with ethnicity” (p.10). In a similar vein I argue that the construction of10diversity and refugee women’s lack of access to mental health care services. Theseexplanations obscure the impact of structural factors on refugee women’s health.However, studies show that while beliefs and values about cultural practices maydetermine different explanatory models about illness and health, health carepractices are also structured by “culture” (Fernando, 2010; Fung & Wong, 2007;Kirmayer & Minas, 2000; Kirmayer, Lemelsen & Barad, 2007). The lack of access tohealth and social services for refugee women has been linked to systemic violenceembedded in institutional structures and practices that undermine and sociallyexclude refugee women, which results in unequal opportunities (Oxman-Martinez &Hanley, 2011).Nurses are at the forefront of delivering public health and primary healthcare services in the context of local communities in which refugee groups areresettled. However broader structural sociopolitical, historical and economic factorshave increasingly constrained the distribution of equitable health and socialresources, challenging nursing’s ability to uphold its broader mandate of socialjustice. Nursing scholars have drawn attention to the need to examine variousdimensions of social identity (race, gender and class) of migrant women withinbroader ecological contexts (Collins, Yogendra, Shakya, Guruge & Santos, 2008;Guruge & Khanlou, 2004; Guruge & Collins, 2008) and advocate for a comprehensiveframework that is responsive to the holistic and gendered aspects of refugeewomen’s mental health and well-being during resettlement. However, a holisticrefugees as traumatized victims stems from dominant cultural frameworks that work to narrowlydefine trauma as only embodied by refugee groups.11response requires an analysis of broader structural processes that are rooted indifferential power relations experienced by refugee women and specific historicalcontexts including the social and structural aspects of community that shapewomen’s mental health and well-being. This research contributes to advancement ofnursing knowledge of refugee care in that it draws attention to historical,sociopolitical and economic contexts that structure refugee identities and thefactors that shape gender in the context of resettlement. Examining Karen women’sexperiences of resettlement and the intersecting factors can inform nursing practiceand policy in Canada and promote social justice.It is predicted that immigration will increase by 58% in BC; particularly insuburban communities that have not traditionally experienced rapid influx ofdiverse groups who come with linguistic barriers and complex health andsettlement needs (Edgington & Hutton, 2000). GARs will increase to 8,000 within 36communities across Canada, including 13 communities in the Province of Quebec,(Sherrell, Friesen, Hyndman & Shrestha 2011). This trend suggests that there will beincreased demand for primary health and mental health services to promoteequitable responsibility in receiving communities to accommodate the needs ofdiverse refugee women and families, who arrive with high needs, and increasingdemand for settlement and health resources. Because of an increased emphasis onsocial determinants of health and primary care, the Canadian Nurses Association(2010) has advocated for an urgent call to pursue research and practice thatpromotes the aims of the social mandate in nursing, underpinned by a social justiceagenda.121.3 Research Purpose and ObjectivesThe purpose of this research is to examine community capacity to supportKaren refugee women’s mental health and well-being in the context of resettlementin British Columbia, and to understand the social and structural processes thatimpact the mental health and well-being of Karen women, the factors thatintersected to support their resettlement process and the ways the community wasable to respond to their resettlement needs.The specific research objectives of this study were to:1. Explicate, from the perspective of Karen women, those aspects of suburbancommunity and mental health and social services and supports thatfacilitated and/or challenged their resettlement process.2. Explain, from the perspective of health and service providers, the social andstructural factors that facilitated and/or challenged community capacity tosupport the resettlement and mental health and well-being of Karen refugeewomen in a suburban context, including their access to mental healthservices and supports.3. Use the findings of the study to make recommendations regarding the socialand structural aspects of community capacity to inform related health andsocial policy and practice on what promotes mental health and well-being ofKaren refugee women.131.4 Organization of the DissertationHaving introduced the background to the research problem and specificobjectives of this study in chapter one, I now turn to the outline of this dissertation.This outline is premised on an empirical body of evidence that suggests refugeewomen’s mental health and well-being is shaped by multiple social intersectingfactors during resettlement.In chapter two I situate the study against a backdrop of internationalpolitical, social and historical policies and processes that shape refugee migrationand identity. I then discuss the historical and social context that necessitated themass resettlement of Karen women and families to BC. In particular I discuss what isknown about community capacity in relation to settlement and health ofgovernment assisted refugee women in BC. I discuss community capacity as animportant construct to understanding social and structural aspects of community.Drawing on constructs of social capital and critical public health I foreground thesocial and structural factors necessary for promoting mental health and well-beingof vulnerable groups including Karen women. In the remainder of chapter two, Idiscuss how racializing discourses reinforce and construct refugee groups as Otherwhich adds to exclusionary health and social practices. I draw attention to broaderdefinitions of culture beyond individual values, beliefs and practices and link thiswith the construct of structural violence; dominant cultural practices and policieswithin societal institutions may unwittingly cause harms and potential re-traumatize refugee women and families that come to Canada seeking protection. I14follow this discussion with a cultural critique of dominant constructions of traumaand the related empirical evidence.In chapter three I discuss the theoretical underpinnings of critical theoreticalperspectives and link them with postcolonial feminist theory, tenets ofintersectionality and cultural safety. I discuss the integration of these approaches asfitting with feminist scholarship that seeks to promote research in nursing with theoverall aims of social justice. I also draw on tenets of intersectionality to discusspotential axes of inequities that are related to refugee women. I discuss theepistemological and ontological underpinnings of cultural safety as congruent withpostcolonial feminist theory and intersectionality in foregrounding subjugatedvoices that have been historically marginalized.  I then discuss cultural safety as aviable lens for examining unequal power relations between Karen women andhealth and social service providers as well as broader macro institutional contexts.Following this I discuss how I employed critical ethnography and Smith’s (2005)standpoint method of inquiry to understand from the subjective positions of Karenwomen what they found supported their resettlement. Fitting with aims of socialjustice work I then discuss the inherent tensions in conducting research withemancipatory aims and the key elements I used to guard against validity threats. Iend this chapter with a discussion of ethical considerations for conducting researchwith Karen women and the limitations of this research.In chapter four I foreground Karen women’s voices and present findingsfrom the standpoint of Karen women related to what they perceived as supportiveto their resettlement. In this chapter I draw attention to how policies and practices15constrained Karen women’s agency, reinforced women’s dependency and createdsituations for increased vulnerability and safety risk. I also discuss how genderintersected with language and access to education produced advantage anddisadvantage between Karen men and women.In chapter five I provide a more in-depth contextual analysis of the process ofresettlement of Karen women and families from the perspectives of health care andsocial service providers. This analysis provides another analytic lens with which toexplore structures and social processes of community capacity. In particular, Ihighlight how settlement reforms increased barriers to health access and worked toshape inefficient health and settlement practices. I then discuss how coalitions ofcommunity capacity building often provided by faith based volunteer groups,worked to identify service gaps, promote health literacy and build collaborativepartnerships to support the mental health and well-being of Karen women.In the sixth chapter I provide the overall tenor and key themes that emergedfrom the data. I further discuss the forms of structural violence and the effects ofKaren women’s identity in relation to vulnerability and dependency. I drawattention to how systemic forms of discrimination vis-à-vis lack of professionallanguage interpreters, and immigration policies related to higher English languageattainment worked to socially exclude Karen women and deny them full citizenship.I also discuss how funding arrangements underpinned by neoliberal ideologies ofefficiency and time intersect with notions of multiculturalism at the expense ofaddressing structural factors that impacted the health and well-being of Karenwomen. I close this chapter with an overview of what worked to support Karen16women’s mental health and well-being, including aspects of social capital thatpromote mental health and well-being of Karen women. Health literacy intersectedwith education and gender to increase literacy and access to health and socialservices.I dedicate the final chapter to highlighting the need to expand the definitionof social justice in order to decrease structural inequities and enhance settlementand primary health care provision for Karen women, other minority women andfamilies. I argue that promoting community capacity must integrate culturally safe,and trauma- and violence- informed responses in order to promote social justiceand decrease health and healthcare inequities. This includes increased advocacy byNGOs as well as nurses practicing across and within primary healthcare and publichealth services. I conclude with recommendations for future research and somemethodological reflections.172. BACKGROUND AND LITERATURE REVIEW2.1 IntroductionThe overall purpose of this literature review is to present an overview of theexisting literature pertaining to community capacity and the social and structuralfactors that shape refugee women’s mental health and well-being in theresettlement context. In conducting the literature review I searched the followingdata bases: Medline (OvidSP), CINAHL (Ebsco), PsychINFO (Ebsco), Women’sStudies International (Ebsco), Cochrane Database of Systematic Reviews, Databaseof Abstract of Reviews of Effects (DARE) and Web of Science. Initial academic searchterms included: women, gender, inequity and/or disparity, mental health andrefugee and/or displaced. A second review was done in order to focus on studiesthat specifically examined community capacity in relation to refugee women andresettlement, using the following key words: community capacity, social capital,refugee women, and resettlement. Much of the research literature examining themental health and well-being of refugee women is limited. Therefore, I have alsoincluded articles on immigrant women. Where possible I reviewed what is knownabout refugee women in relation to resettlement and mental health specifically. Ialso searched bibliographic references for all the evidence-based articles that Ireviewed.I reviewed both academic and web-based resources pertaining to settlementand health care policies and practices in Canada and BC. This included a review ofGovernmental web sites including Citizenship Immigration Canada (CIC) and web18based resources pertaining to settlement in BC such as Welcome BC and ISS of BC.The majority of studies reviewed fell within the years 1999-2011.I begin the story of Karen refugee migration in the context of the broaderprocesses that shape migration and resettlement of refugees, in particular I drawattention to the social context of resettlement, and the factors that shape identity,mental health and well-being by shifting the gaze to structures, i.e. institutionalpolicies of immigration and what actually happens in practice. In this review Iexamined policies and practices and the structures to foreground gaps in serviceprovision and potential factors that promote greater service integration and supportfor refugee women in Canada.To situate this study in a wider historical, socioeconomic and politicalcontext, I felt it was important to first describe the historical and political climate inwhich refugee groups have been categorized; this categorization has implicationsfor global resettlement policy and distribution of health care resources oncerefugees are resettled by nation states. I briefly discuss the categorization of refugeediscursive practices against the backdrop of humanitarian policies which fail tocapture the diversity of refugee experiences but also a systemic failure in ensuringsafety and protection of groups deemed vulnerable by sociopolitical and historicalprocesses. Following this I review outcome studies on various refugee groups,settlement and health practices in BC, as well as international reviews on the effectsof migration and refugee women’s health. I conclude this chapter with summary andkey reflections of the literature including gaps in evidence and what this study19contributes to the discipline of nursing policy and practice in relation to refugeewomen’s mental health and well-being.2.2 Globalization, Transnationalism and the Construction ofRefugee IdentityThe categorization of refugee is not a neutral process and is historicallyinfluenced by wider political, global bureaucratic and social processes (Malkki,1995; Pupavac, 2006; Zetter, 2007). In mapping out the genealogy of the birth of the“refugee,” Malkki (1995) argues that although there may be justification forcategorization, there is no proto-refugee of which the modern refugee is a directdescendant. Moreover, the category of refugee does not represent a homogenousgrouping or single representation of forced migration patterns of any group.Hyndman and Walton-Roberts (1999) observe that theconcepts of “immigrant” and “refugee” are defined by juridical andpolitical apparati of national governments, premised upon theterritoriality of nations… a refugee is defined as one who is outsidethe borders of her nation-state due to violence or persecution, anddisplaced from what has become the centered norm of citizenship orplacement within her country, in contrast an immigrant is seen toreplace one nationalist identity with another (p. 6).Prior to World War II (WWII), mass migration of refugees in the west wasrooted in religious exile where protestant groups fled to neighboring Europeancountries. The categorization of people who are oppressed and hunted firstappeared “in the 17th century [when] Louis XIV cancelled the Edict of Nantes,thereby giving the Catholic majority of France carte blanche to turn on theProtestant minority whose rights the Treaty had guaranteed” (Beiser, 2009, p. 540).20This revocation of the Edict of Nantes stopped the protection of the religious rightsof French Protestants also called Huguenots. Beiser (2009) further explains thatthose Protestants who escaped persecution later “became known as ‘refugees’ inHolland, Germany, England and later, North America” (p.540). However, it was notuntil after World War II that a new dimension to the concept of refugee resulted in asocially shared responsibility and legal imperative (Beiser, 2009). Malkki (1995)discusses the category of the refugee as “built on a whole history of differences, notonly of race, class and world region, and historical era but of different people’s verydifferent entanglements with the state and international bureaucracies thatcharacterize the national14 order of things” (p. 513). Post WWII techniques formanaging mass displacement of people first became standardized and thenglobalized (Beiser, 2009; Malkki, 1995; Zetter, 2007).Globalization and the process of human displacement led to the developmentof refugee camps as a legal domain and generalizable technology of power (Malkki,1995). Technologies of power were linked with earlier forms of confinement such asquarantine and concentration camps in which the refugee was marked andcontrolled by the military through spatial concentration and ordering of peoplethroughout Europe (Malkki, 1995). International refugee law and related legaldefinitions resulted in the Universal Declaration of Human Rights in 1948 and the14 By national order of things, Malkki (1995) is referring to the fact that refugees “do not constitute anaturally self-delimiting domain of anthropological knowledge” (p. 496). Rather, the label of refugeeis embedded within bureaucratic and international humanitarian realm. Thus the term ‘refugee’ has“analytic usefulness not as a label for a special, generalizable ‘kind’ or ‘type’ of person or situation,but only as a broad legal or descriptive rubric that includes within it a world of different socioeco-nomic statuses, personal histories, and psychological or spiritual situations” (Malkki, 1995, p. 496).21subsequent 1951 United Nation High Commissioner for Refugees (UNHCR). TheUNHCR (2010a) Convention and Protocol Relating To The Status of Refugees, definesrefugee under the Geneva Convention 1951 as someone who “is unable or unwillingto return to their country of origin owing to a well-founded fear of being persecutedfor reasons of race, religion, nationality, membership of a particular social group, orpolitical opinion” (p. 3).Pupavac’s (2006) historical analysis of humanitarianism suggests thatdespite the formation of the UNHCR as being the formal advocate for the globalrefugee crisis, human rights are increasingly interpreted within a widerinternational stage, where increasingly refugee concerns are mitigated through theinternational community, e.g., nation states and their approved Non-GovernmentOrganizations (NGOs) (Pupavac, 2008). The Geneva Convention, as cited in theUNHCR, represents international law pertaining to the human rights of refugees andtheir need for protection. However, as Malkki (1995) explains, “the widely citeddefinition of what constitutes a refugee was only intended to address the Europeanrefugee situation (covering events occurring before January 1, 1951) and notrefugees as a universal phenomenon” (p. 501). Similarly, Pupavac (2008) critiquesthe sanctity of the 1951 Refugee Convention by stating that the main drivers of theConvention were European dissidents after WWII and where national Europeaninterests welcomed migrant labour and Western preference for European refugees.In a recent inaugural address to the UNHCR, Friesen (2013) noted there arecurrently “45 million displaced persons worldwide and the number of places forUNHCR submissions sits at 86,000 representing approximately 1/8 actual need” (p.221). Although countries with strong economies are more capable of absorbing andsupporting refugees, only 2 million refugees were received by developed nations(19%) with more than 38% of refugees residing in Asia and the Pacific region incomparison to 8.5 million (80%) refugees received by developing countries(UNHCR, 2010). This suggests that global policies, including those such as theUNHCR, have less influence over nation states’ interests in resettling refugees.Pupavac’s (2006) central argument rests on the fact that refugees are no longergreeted as members of a political community in another country. This has led toexclusion of refugees and construction of refugees as lacking capacity to determinetheir own interests. The issue, as Pupavac (2008) discusses, is that “refugees as acategory needing protection do not enjoy the protection of citizenship or the rightsthat flow from political membership” (p. 3).Likewise, Zetter (2007) has argued that the labeling of refugee is a highlypoliticized reproduction of institutional fractioning embedded in a wider politicaldiscourse of resistance to migrants and refugees which has significant material andpolitical consequences for refugees in the context of displacement and resettlement(Tomasso 2011; Zetter, 2007). Zetter (2007) discusses thatin the past political discourse on refugees focused on rights andentitlements. Now, the analysis of labeling as public policy practicesshow how this discourse is preoccupied by notions of identity andbelonging embedded in debates about citizenship and the Other in anera of global migration (p. 190).Similarly, Kirmayer (2008) further argues thatthe creation of nation states has mapped the world in terms ofcitizenship, giving everyone a place where they legally belong. This23creates the possibility of being pushed aside by the state into anambiguous place where individuals do not belong to the land onwhich they stand (p. 18).In the context of resettlement, global processes are decentered from nationalterritories (Hyndman & Walton-Roberts, 1999). Grove and Zwi (2006) add that theprocess of asylum and resettlement do not necessarily guarantee membership or asense of belonging. In response to the current mass flow of migration and refugeecrisis, bureaucratic labels are made to differentiate categories of eligibility andentitlements in the state’s interests. Thus, labels do not exist in a vacuum, rather asZetter (2007) notes “they are the tangible representation of policies and programs,in which labels are not only formed but transformed and differentiate categories ofeligibility and entitlements … instrumental practices and interests of the state” (p.180). Bauder (2013) further argues that “nation states exercise significant controlover the international mobility of people through laws, policies and policingpractices” (p. 57) and shape identities through the maintenance of materialdifferences, that afford some migrants citizenship, access to resources andprotection and expose others to economic exploitation and political marginalization.For example, the refugee label has resulted in distinguishing between the deservingrefugee such as those who are government assisted to enter into Western countrieswhile “asylum seekers” must prove their need for asylum and refugee status as perthe Geneva Convention.Zetter maintains that “labels such as asylum seeker transform identity intosomething which conforms to the politicized image of the label – destitute,24dependent, above all an alien because they have no right to belong” (p. 186 ). He alsoargues that globalized processes and patterns of forced migration in thecontemporary era were shaped by refugee crisis, regionally contained in the globalsouth during the 1970s and 1980s, “as a proxy for wider geostrategic and post-colonial conflict” (Zetter, 2007, p. 175). Malkki (1995) observes thatthe period of rapid decolonization in the 1960’s saw a watershedperiod in the modern phenomena of refugees and refugee settlementpractices … [and the emergence of refugees as a Third Worldproblem] (p. 503).However Malkki also contests that “if we accept that poverty, political oppression,and the mass displacement of people are all global or world-systemic phenomenathen it becomes difficult to localize [refugees to the] Third world” (p. 503).Moreover, contemporary forced migration may be the result of more subtleforms of persecution which, “reflect a less categorical interpretation of the label …minority groups [including women] are persecuted through insidious forms ofsocial, political, and economic exclusion, often without explicit violence and overprotracted periods” (Zetter, 2007, p. 177). For example, Zetter has drawn attentionto conditions of injustice where prolonged socioeconomic exclusion of ethnicminorities has created sufficient reason for refugees and asylum seekers to fleeagainst the backdrop of economic globalization.Another thematic tendency regarding refugee identity is the contemporary“prominence of psychological interpretations of displacement” (Malkki, 1995,p. 509). Marlowe (2010) has argued that25while having this [refugee] status affords a number of rights fromcountries signatory to the 1951 UN convention, the concept of“refugeehood” within resettlement contexts can become a masterstatus that defines a person above and beyond any other form ofidentity (p. 184).Pupavac’s (2006) historical analysis of refugees in the ‘sick role” sheds lighton the west’s tendency to construct refugees as traumatized victims. Pupavacobserves that in the 1980’s reports from Cambodian, Vietnamese, and LatinAmerican refugees and holocaust survivors began to stimulate American interests inpsychological conditions such as post traumatic stress disorder (PTSD). As shewrites, “contemporary concern for refugee health involves a changed perception ofrefugee identity from refugee as political exile to refugee as patient, casting refugeesin the sick role”(p.20). Informed by Parson’s theory of permissive empathy, Pupavacargues that the refugee as patient presents a double-edged sword: on the one handconstructing refugees as victims depoliticizes their need for migration and self-determination, and on the other, refugees become the object of professionalmanagement with no greater rights. In addition, Pupavac suggests that states governrefugee access to social resources and support in resettlement as a form ofinstitutional control embedded in discourses of pathology:Even non-health refugee programmes may represent a form oftherapeutic governance. Employment training programmes or otherintegration programmes such as youth or gender empowermentclasses are often not so much practically oriented towards direct jobrelated skills but life skills, essentially emotional managementdirected towards their self-esteem, interpersonal relations andattitudes (2006, p. 20).26This form of governmentality15 in the guise of permissive empathy obscurespower relations between refugees and professionals and creates a relationship ofdependency which undermines individual autonomy (Pupavac, 2006). In a similarvein, Malkki (1995) points out that discourse of development has colonized refugeeissues, and that other intellectual or political connections have been erased.Drawing on Malkki (1995), Sampson and Gifford (2010) suggest that essentialistunderstandings of refugee identity run the risk of perpetuating the marginalizationof refugees as outside of their  “natural place” and viewing displacement aspathological.This does not negate the fact that many refugees experience significantdistress and, as Malkki argues,we cannot assume psychological disorder or mental illness apriori…nor can we know the actual sources of a person’s suffering.15According to Gordon (1991) the French philosopher Michel Foucault coined the term governmen-tality to mean the “…a form of activity aiming to shape, guide or affect the conduct of some person orpersons” (p.2). Government in a broad sense concerned “the relations between self and self, privateinterpersonal relations involving some form of control or guidance, relations within socialinstitutions and communities and, finally, relations concerned with the exercise of politicalsovereignty” (Gordon, 1991, p.3). For Foucault, the term governmentality was historically situated inthree things including 1) “the ensemble formed by institutions…that allow the exercise of veryspecific…complex form of power, which has as its target populations, as its principal form ofknowledge political economy, and as its essential technical means apparatuses of security; 2) thetendency which, over a long period and throughout the West, has steadily led towards…all otherforms (sovereignty, discipline, etc.) of this type of power which may be termed government, on theone hand, in the formation of a whole series of specific governmental apparatuses…;3) The process,or rather the result of the process, through which the state of justice of the Middle Ages, transformedinto the administrative state during the fifteenth and sixteenth centuries, gradually becomes‘governmentalized’.(p.102-103). Originating in theological foundations, Holmes and Gastaldo (2002)discuss a particular aspect of governmentality, pastoral power. Pastoral power is mediated by caringprofessions, including nursing, which simultaneously manage, control and survey populations as wellas provide therapeutic governance. In a similar vein Pupavac (2006) argues that emotionalmanagement of refugees is governed by disciplinary techniques that reinforce normalcy anddependency.27This does not mean …that health professionals have nothing to say ordo about refugees and [effects] of displacement…many refugees havesurvived violence… [However] we mustn’t assume that refugee statusin and of itself constitutes a recognizable, generalizable psychologicalcondition (1995, p. 510).In the current context of globalization and changing patterns of humandisplacement, refugee identity is shaped by cultural constructions that coalescearound health and human rights (Pupavac, 2006). For example Pupavac argues thatthe construction of refugees as traumatized may dramatize their sufferingand underscore the validity for their claims for asylum, but castingrefugees in the sick role problematizes the capacity of refugees todetermine their own interests and tens to legitimize the externalmanagement of refugees (2006, p. 24).External management can be framed within a sociocultural context where“the universality of human rights demands careful attention to the social contexts ofpotential application and the hidden agendas of powers that may use the claims ofculture to justify their oppression” (Kirmayer, 2008, p. 3). Culture in this way isviewed not as narrowly defined by ones values and beliefs but as a complexconstruct embedded in relations of power (Dirks, Eley & Ortner, 1994). A staticcategorical approach to refugee identity leaves out and/or ignores broader culturalvalues that serve hegemonic political and economic interests of the state (Kirmayer,2008). In a similar way, contemporary understandings of trauma are understoodnot only as they are linked with the predicament of refugee migration but also, asKirmayer argues, “violence is embedded in the structures of most receiving societies28[and] indeed the mental health outcomes of migration depend on the quality ofreception by the host society” (Kirmayer, 2007, p. 377).From another perspective the substantive changes in refugee migration havebeen attributed to a growing gap between the Geneva Convention definition ofrefugee and contemporary understandings of those seeking refuge. Contestingterritorial boundaries, Sampson and Gifford (2010) have argued that globalizedcontexts have opened up new dialogues regarding people, place and identity. Theseauthors suggest that “non-essentialist understandings of identity and connection toplace have challenged the commonly held assumption that once a refugee always arefugee” (p. 117). Sampson and Gifford further argue that identity is framed in aworld that continues to distribute rights and social membership along territorialboundaries and thereforethe relationship between people who become refugees and place is aposition somewhere in between: one that recognizes the strong senseof connection to places left behind and their associated traumas whileat the same time recognizing the possibility of constructive (re)-building of connections to place within a context of resettlement(2010, p. 117).Similarly, Sherrell (2003) observes, contemporary understandings of refugeeidentity have abandoned essentialist and gender blind constructions of refugee infavour of a more fluid and dynamic understanding of refugee identity. In this regard,transnationalism is a useful analytic concept that recognizes the multiple identitiesand cross border connections refugees have. In short, transnationalism16 is about16 Hyndman and Walton-Roberts (1999) explicate the definition of transnationalism as “constitutingdistinct social, cultural, political and economic spaces, which do not adhere to straightforwardcategories of nation, class, ethnicity and gender” (p. 4). These authors argue that transnationalism29identities with multiple places (Hyndman & Walton-Roberts, 1999). Hyndman andWalton-Roberts (1999) make salient the notion of belonging for refugees who arrivein Canada under extenuating circumstances and where “people whose sense ofidentity is defined by collective histories of nation, culture, as well as shared visceralgeographies of displacement and violent loss, do not simply forget or abandon theseconnections upon arrival in a new country” (p.25).Sherrell (2003) outlines several ways in which transnationalism impactsrefugee resettlement. These include activities such as economic remittances,ongoing political involvement with sending nation and ongoing social relationsacross territorial boundaries of resettled states. Sherrell observes that it is onlyrecently that scholars have paid attention to gender17 and gendered relations as acentral axis of analysis related to refugee men and women in resettlement. Sherrellargues thatit is impossible to consider the process of resettlement withoutconsidering the ways in which gendered relations shape it … [rather]settlement entails the negotiation of identities, roles and relationsbetween women and men, some of which may be in conflict withgender ideology in the country of origin … consequently, relations andextends from diaspora where transnationalism does not presuppose a territory defined by geo-political lines. Similarly, Faist (2010) suggest that while both transnationalism and diaspora areprominent lenses through which to view the aftermath of international migration and the shifting ofstate borders across populations, “diaspora has been often used to denote religious or nationalgroups living outside an (imagined) homeland, whereas transnationalism is often used both morenarrowly—to refer to migrants’ durable ties across countries—and, more widely, to capture not onlycommunities, but all sorts of social formations, such as transnationally active networks, groups andorganizations” (p. 9). Both transnationalism and diaspora however, “refer to phenomena that occurwithin the limited social and geographical spaces of a particular set of regions or states” (Faist, 2010,p. 9).17 In this research gender is defined as “ a process that operates on multiple spatial and social scales(e.g., the body, the family, the state) across transnational terrains” (Pessar & Mahler, 2003, p. 815).30identities in both the countries of origin and resettlement influenceidentities formed during resettlement (2003, p. 9).Refugee migration has led to increased debate about nationalism,construction of identity and human rights. Globalization and colonialism are salientto the constructions of refugee identities and point out the need to examineuniversal human rights across national boundaries and territories. However, theintersections of gender and migration have not adequately been explored in theplight of refugee women. Discursive practices also shape refugee identities andconsequently impact national resettlement policies in Canada. In the following Ibriefly outline how current discourses constructed refugees in the context ofCanadian immigration.2.3 An Overview of the Discourses and the SociopoliticalHistorical Context of Canadian ImmigrationBefore embarking on an examination of Karen women’s resettlement inCanada, and the contexts that led to their resettlement it is important to discuss thebroader sociopolitical and historical context of Canadian immigration as thisprovides a background for how health and social policies are structured within theframework of multiculturalism. Multiculturalism has been described as animportant part of Canada’s identity (Strong-Boag, Grace, Eisenberg & Anderson,1998; Tomasso, 2012). Multiculturalism is underpinned by a pluralist ideologywhich reflects a model of citizenship that values diversity and cultural differencewhile at the same time espouses respect for justice under a collective Canadian31citizenry which seeks common interests based on general human rights (Brascoupé& Waters, 2009).However, critical scholars have come to question Canada’s explicit ideologyof multiculturalism as a model of citizenship which valorizes diversity andsimultaneously espouses a collective Canadian identity. Prior to Canada’s adoptionof an explicit ideology of multiculturalism, Anderson and Reimer-Kirkham (1998)have argued that the period of colonization “was critical in constructing theIndigenous peoples of Canada as savage, other, and inferior, and it had disastrouseffects on health, beginning with early pandemic infectious disease (such assmallpox and typhus brought by European explores and settlers) and continuing totoday’s higher morbidity and mortality” (p. 245). Alterity (otherness) is thesocial condition that frames people or groups as other, and the moralstance that allows us to recognize, respect and value diversity as apositive resource for individuals and society without shying awayfrom the ways in which culture and difference are used to stereotypeand oppress people or divert attention from various forms ofstructural violence18 (Kirmayer, 2012, p. 159).Eisenberg (1998) has observed political ideologies vis-à-vis Canadianmulticulturalism have not upheld the obligation to rights of Aboriginal people:18 Structural violence is a complex term that can be taken to mean a violence that is exertedsystematically and indirectly by a particular society (Farmer, 2004). Galtung (1969) definesstructural violence as a corollary to social injustice. This form of violence is built into social andpolitical economic systems where resources are unevenly distributed, as when income distributionsare heavily skewed, literacy/education unevenly distributed and, medical services exist in somedistricts and for some groups only; above all the power to decide over the distribution of resources isunevenly distributed. The situation is aggravated further if the persons low in income are also low ineducation, low in health, and low in power, as is frequently the case because these rank dimensionstend to be heavily correlated.32While the cultural values reflected in the representative system haveexcluded many cultural minority groups in Canada, the treatment ofAboriginal peoples is unique, partly because of the many treatiessigned between Aboriginal peoples and the Government of Canadathat state or imply that Aboriginal societies will co-exist with non-Aboriginal society and be protected from the latter’s influence. Inspite of the explicit understandings reflected in the treaties, theCanadian government has vigorously pursued policies to assimilateAboriginal peoples against their will (1998, p. 48).These historical processes have implications for the ways in which variousminority groups are positioned in Canada. From a historical perspective, Satzewichand Liodakis (2010) add that Canada’s immigration policy was developed out ofobstacles amongst colonial relations with First Nations people, and in light of thefact that “European authorities felt that their [Aboriginal] culture did not translatewell when economic priorities shifted to the requirements of commercialagriculture and capitalist industry” (p. 47). Processes of assimilation havereinforced the construction of Canada as a white eurocentric nation (Abu-Laban,1998; Anderson & Reimer-Kirkham, 1998; Tomasso, 2012).Between the years 1896 and 1905, large numbers of immigrants weresettling19 in Canada from the United Kingdom, Europe and the United States,primarily to promote industrial growth and building of nationhood (Satzewich &Liodakis, 2010). However, the Immigrant Act of 1910 prohibited entry of foreigners19 The terms ‘settler and settlement’ cannot be divorced from their historical meaning in theCanadian context. In order to talk about resettlement there is a need to address its origins ofEuropean and Euro-American colonialism. The process of settlement of newcomer groups isunderstood “not in old terms in which the settler is conceived as an empowered agent remaking theland into something new, but in the new terms in which the existing society is conceived as analready settled entity and the newcomer is figured as someone who has to adjust to that society inorder to become settled” (Kataoka & Magnusson, 2007, p. 4).33who were not deemed to have mental fitness for settlement (Satzewich & Liodakis).As Beiser (2005) discusses, the “sick immigrant paradigm”20 reflected the valuesand beliefs of Canadian society, in which immigrants were viewed as carriers ofdisease or as people who were afflicted with mental health problems. Based onthese beliefs, Canada expelled approximately 10,000 immigrants annually betweenthe years 1900 and 1940, and in addition some 1,000 immigrants were expelledspecifically for psychiatric reasons alone (Beiser). Pre WWII, Chinese immigrantswere encouraged to come to Canada since contractors were looking for cheap laborto build Canada’s transcontinental railroad (Satzewich & Liodakis). For example, inBC, out of concern for competition in the labour market, government tried to resolvelabour conflicts by enforcing the “Chinese head tax” in which Chinese male andfemale workers and family members had to pay the government when they arrivedin Canada (Satzewich & Liodakis).In 1952 the Immigration Act continued to prohibit people from entry intoCanada based on nationality, ethnic group, and poverty as well as educational,health or other conditions (Satzewich & Liodakis, 2010). However, immigrants who20 Beiser (2005) discusses three general paradigms related to immigrant and refugee health. The“sick immigrant paradigm proposes that it is the least healthy and well-adjusted people who chooseto emigrate from their home countries of origin” (S31). The healthy immigrant paradigm suggeststhat in general, immigrant health slowly worsens over time to match Canadian born populations, thisis also referred to as “healthy immigrant effect” (Beiser). Beiser proposes that neither of theseparadigms address the complexity of factors that shape mental health and overall health in the postmigration/resettlement context. This is in part due to the great heterogeneity within migrant groupsand the contextual factors that shape mental health during resettlement. Beiser proposes a thirdparadigm called the convergence model in which “exposure to the physical, social, cultural andenvironmental influences in a destination country sets in motion a process in which migrant patternsof morbidity and mortality shift so that they come to resemble the (usually worse) health norms ofthe resettlement country” (S33).34brought in resources, skills and education were ranked according to a point systemin the 1960s (Anderson & Reimer-Kirkham, 1998). This point system continues aspart of Canadian immigration policy today (Reitz, 2011). Reitz’ examination ofcontemporary Canadian views on pro-immigration suggest that two majordiscourses are prevalent. Those who are pro-immigration view immigrants as aneconomic benefit while “opponents of immigration argue that economic benefits areexaggerated and that immigrants depress wage levels, undercutting native bornworkers … and over-reliance on welfare [are] a significant burden for the country”(p. 5). Anderson and Reimer-Kirkham have observed that while overtly racistpolicies were replaced in the 1960s, the more recent point systems are classist.However, as I discuss in the following sections, public discourse continues to Otherimmigrants and refugees through discursive social practices.According to Satzewich and Liodakis (2010), multiculturalism policy isunderpinned by four central issues that include: i) a demographic reality; ii) part ofa pluralist ideology; iii) a form of struggle among groups for access to economic andpolitical resources; and iv) a set of government policies and programs.Reitz (2011) discusses that “ the issues of racial difference and visible minoritiesbecame prominent in the 1980’s, since the elimination of discriminatory selectioncriteria in 1962 led to a shift from predominantly European to about 80% non-European immigrants by the 1990s” (p. 8). As a pluralist ideology, multiculturalismreduces issues of difference to racial and ethnic differences without attention to therole of power in shaping systemic inequities between racialized groups. However,Anderson and Reimer-Kirkham (1998) have discussed that the Multiculturalism Act35passed in 1988 in order to not only recognize differences among ethnic, racial andcultural composition of Canada’s diverse groups but to ensure “equal access andparticipation for all Canadians in the economic, social and cultural and political life”(p. 248-249). However, as critical race scholar Bannerji (2000) points out, “multi-ethnic, multinational state, with its history of racialized class formation and politicalideology, discovering multiculturalism as a way of both hiding and enshriningpower relations, provided a naturalized political language even to the others of theCanadian society” (p. 31). Similarly, Tomasso (2012) explains that “liberalmulticulturalism puts forth a discourse of colour-blindness that constructs racism asaberrational…or as a symptom of individual pathology…and, lastly, multiculturalismcontributes to…powerful cultural mythologies about equality of opportunity andaccess to power” (p. 334).Thus many scholars have come to question what Anderson and Reimer-Kirkham (1998) call a disjuncture between discourse of the state and actualpractice. For example, since the institution of formal multiculturalism by theCanadian government, many immigrants and refugees have poorer economicoutcomes in comparison to other immigrants (Beiser, 2009; Hyndman & Walton-Roberts, 1999; Kirmayer et al., 2011; Newbold, 2009; Reitz, 2011). Migrant womenin particular have been shown to experience increased risk to their overall health asa result of their lack of access to health and social services and linguistic support(Anderson, Reimer-Kirkham, Waxler-Morrison, Herbert & Murphy, (2005);Kirmayer, & Minas, 2000; Anderson, Tang, & Blue, 1999). Drawing on research withimmigrant women Anderson and Reimer-Kirkham argue that women’s gendered36responsibilities of child care and lack of labour market protection, unequal pay andlanguage ability intersect with institutional systems in a way that perpetuates theirmarginalization in Canadian society. These realities not only bring forward issues ofcitizenship, individual rights and collective belonging, but also shift the gaze towardstructural processes that reinforce inequities. Moreover racialization of immigrant,refugee and other groups occurs when culture is narrowly defined by ethnici-ty/race. Tomasso (2012) argues thatthe underlying concepts of official multiculturalism are not complexenough to permit an understanding of people’s nuanced identities….The conflation of race and culture reinforces hegemonic whiteness byperpetually relegating racialized people, including Aboriginals andCanadian born citizens, to subjectivities ulterior to “Canadian” (2012,p. 333).Nursing scholars have called for a reorientation of the meaning of culturewithin liberal multicultural nations that espouse egalitarian values of fairness andjustice on the one hand but on the other are blind to the social and structuralprocesses that create context of marginality and vulnerability (Browne, Varcoe,Smye, Reimer-Kirkham, Lynam & Wong, 2009; Anderson & Reimer-Kirkham, 1998).It is argued that when culture21 is conflated with ethnicity/race it obscures the21 In Culture/Power/History (1994), Stuart Hall discusses different ways of conceptualizing culture.The first is to conceptualize culture as “descriptions through which societies make sense of andreflect their common experiences” (p. 522.). In this context culture is regarded as “the summits ofcivilization—that ideal of perfection to which, in earlier usage, all aspired” (p. 522). Similarly,Kirmayer and Minas (2000) argue that “the concept of culture, which is a grand abstraction, has itsorigins in a metaphoric contrast between the cultivated and the wild” (p. 439). The second form ofunderstanding culture stems from the field of anthropology and more contemporary understandingsof culture. Culture “is not a practice; nor is it simply the descriptive sum of the “mores and folkways”of societies—as it tended to become in certain kinds of anthropology. It is threaded through all socialpractices, and is the sum of their interrelationship” (Hall, 1994, p. 523). And, as Hall further adds, acultural analysis is "the attempt to discover the nature of the organization which is the complex of37conditions which create cultural risk (Papps & Ramsden, 1996). Unsafety andcultural risk are produced when acts endanger the well-being of persons and wherepersonal identities are demeaned and/or disempowered (Nursing Council of NewZealand, as cited in Papps and Ramsden, 1996). Contemporary understandings ofculture are not linked with ethnic identities, rather they shift the gaze toward powerstructures and social practices which promote or constrain patterns of valuing ordevaluing by constituting some members of society as Other, inferior andpotentially dangerous ( Smye, Rameka & Willis, 2006). This politicized view movesbeyond tolerance for difference, and locates culture “within broader macroeconomicand political structures and discourses that shape how [institutions and] health caresystems are organized “ (Anderson, Tang & Blue, 1999, p.2). Broadening the notionof culture in this way allows for an examination of structural causes of inequities.Drawing on the work of nursing scholars in New Zealand, cultural safetychallenges assumptions about cultural identity as a set of fixed set of beliefsascribed to particular people, and moves the discourse of culture as a fluid sociallyconstructed category. Included in contemporary understandings is the claim that“culture” is a process, not a thing. Postcolonial scholar Stewart Hall (1994) definesculture as:these relationships” (p. 523). Culture therefore is not a matter of group membership, individualtraits, values and beliefs, and fixed set of characteristics, but rather “culture involves flexible ongoingprocesses of transmitting and using knowledge that depends on dynamics both within ethnoculturalcommunities and at the interfaces between institutions of the larger society, like the health caresystem” (Kirmayer, 2012, p.155).This view of culture lends itself to non-essentialist understandingsin which culture is not reduced to a form of culturalism that often conflates race/ethnicity withculture and produces stereotypes (Browne et al., 2009).38both the meanings and values which arise amongst distinctive socialgroups and classes, on the basis of their given historical conditionsand relationships, through which they ”handle” and respond to theconditions of existence; and as the lived traditions and practicesthrough which those “understandings” are expressed and in whichthey are embodied (1994, p. 527).Anderson and Reimer-Kirkham (1998) have argued “the present discoursesof multiculturalism, ethnicity, visible minority…overlook the social relationsinherent in the production of these categories, mask the processes that determinepeople’s experience and create stereotypes” (p. 255). For example, the conflation ofculture and ethnic identity has reinforced discourses of national threat,securitization and refugee pathology. Tomasso (2012) writes that “the presentCanadian sociopolitical landscape, which serves to delineate the ways in whichdominant culture constructs race and conceptualizes issues of migration, is apreoccupation with national security” (p. 334).Some scholars reflect that since the terrorist attack of 9/11, many states havebecome increasingly restrictive about protecting refugees, and that concerns aboutnational security have been used to justify restrictive policies and practices onimmigration (Baker, 2007; Bradimore & Bauder, 2011; Kirmayer, 2007;Piwowarczyk & Keane 2007; Tomasso, 2012). For example, the restrictions on whocan claim asylum are increasingly played out in judicial hearings within Canada’sImmigration Refugee Board (IRB). Refugees seeking asylum are increasinglyvulnerable to psychological adversity as they must prove their claim to warrantrefugee status (Kirmayer).39In this context, Kirmayer (2007) explains that personal stories vary and donot fit neatly with some larger account or master narrative. Moreover, providing abackground biography of trauma may unwittingly retraumatize claimants who “mayhave tried to forget…to survive socially, may have been prohibited from speaking(and hence recollecting) certain details or events; or [the claimant] may havedeveloped alternative stories and, perhaps, to develop one version that willmaximize his or her chances of acceptance into a safe haven” (Kirmayer, p. 368). Inaddition, the “disbelief when faced with the refugee’s story serves defensive orprotective functions. It keeps individuals from encountering a destabilizingotherness that would call their assumptive world into question” (p. 376). Experts intrauma note that PTSD does not necessarily follow a clear beginning and end(Lester, 2013; Young, 1990). Constructions of narratives of PTSD and stereotypesabsorbed by the media have real world effects on the lives of refugees. Thus “thestories we find credible depend on a backdrop of narratives in constant circulationcontrolled by interests that are not neutral and would have us imagine our world ina certain way” (Kirmayer, 2007, p. 378). Refugee mental health and well-being isframed by what Oxman-Martinez and Hanley (2011) term systemic violence, whichis implicated in public policy, government practice, and the educational, social, andhealth system, as well as the justice system. Symptoms of violence manifest “in anincreased level of vulnerability, depression, mental distress, and are oftenassociated with feelings of social exclusion and isolation” (p. 230).The effects of 9/11 and public discourse in Canada on terrorism have hadongoing cultural effects on many immigrant and refugee communities. Baker (2007)40examined the effects of globalization and the aftermath of 9/11, and the socialhealth of a small immigrant community of Muslims in a relatively homogenousregion in Eastern Canada. Findings showed that both Asian and Middle Easternimmigrants experienced a shift from cultural safety to discourses of cultural riskpost 9/11. Cultural safety was linked with immigrants’ sense of integration andfeelings of belonging with the communities in which they lived. Cultural risk wasrelated to Muslim immigrants heightened visibility post 9/11 and their experienceof increased distress due to a process of racialization and parochialism (Baker,2007). For example, Baker explains that African and Arab immigrants wereperceived differently and made visible based on their presumed religious faith post9/11. Baker notes that “Muslim immigrants from Africa believed that themainstream community had responded to them as members of a visible minoritybefore the terrorist attacks, because of their skin colour rather than their religion”(p.301). In contrast, Christian immigrants from Arab countries experiencedincreased visibility post 9/11 in the sense that mainstream communities attributedtheir ethnicity with a presumed religious, Muslim identity (Baker, 2007).Baker’s findings also showed that the greatest source of cultural risk wasassociated with racialization of Muslims as terrorists as many felt that they wereunder public surveillance, including increased police surveillance in prayer roomspost 9/11 (Baker, 2007). Overall, Baker’s findings suggest that the collective socialhealth was noted to deteriorate due to sudden increased visibility of Muslim faithand its conflation with terrorism. As Baker notes, “they became a cultural category41within the community, and the categorization process placed them in a situation ofcultural risk” (p. 303).Congruent with Baker’s findings, the study Piwowarczyk and Keane (2007)examined N=63 participants’ (asylum seekers as well as refugees) perceptions ofpersonal safety, fear of war and self-reported health status, before and after 9/11, atthe International Mental Health Program of the Boston Centre for Refugee Healthand Human Rights( BCRHHR); after 9/11 refugees and asylum seekers were morefearful of deportation, arrest, detention, imprisonment, discrimination, physicalviolence and destruction of property. Factors such as religious background, dressand English language ability were also identified as contributing to participants’fears with the effects of 9/11. Of note is that of the 63 participants, 46 (73%) werefemale, with 14% of women being widowed or having a missing spouse, and 41%married. Although the participant sample varied in country of origin, many were ofthe Muslim faith (44%), approximately 56% of the sample spoke English fairly ornot at all and almost 78% of the study samples were torture survivors(Piwowarczyk & Keane). Although asylum seekers were noted to have concernsover personal safety prior to 9/11, findings from Piwowarcyk and Keane showedthat all participants described increased deterioration of emotional and physicalhealth post 9/11 (Piwowarcyk & Keane). Prayer and reliance on social support frominformal and formal networks, as well as increased substance use, were viewed asmethods of coping with events of 9/11. The most salient consequence of 9/11 wasthat refugees and asylum seekers felt that they had lost their sense of safety, whichPiwowarczyk and Keane argue “was particularly poignant as they had come to the42USA fleeing persecution in search of protection and safety” (p. 572). Piwowarczykand Keane close by arguing that it is important to consider the role of community inthe context of societies that are more community oriented and where community-based solutions to trauma are often fragmented during migration and settlementcontexts.Changes to Canada’s immigration policy have also been influenced by globalmigration trends as a result of increased political tensions between democracy,“freedom” and totalitarian regimes. In the years 1975-1980 almost 2 million peoplefled Southeast Asia. Sixty thousand Cambodians, Laotians and Vietnamese refugees,commonly referred to as “boat people”, were admitted into Canada between 1979and 1981 (Beiser, 1999).22 Following this, in 1999, 599 refugees fled from the Fujianprovince of China and arrived off the coast of Vancouver. Between 1987 and 1986,152 Sri Lankan Tamils reached the shores of Nova Scotia, followed by the arrival ofSikh refugees (Bradimore & Bauder, 2011). More recently, between 2009 and 2010,the arrival of Tamil refugees on Canada’s west coast has been described asprompting even tighter controls over the admittance of refugees into Canada(Bradimore & Bauder).In 2002 the Immigration and Refugee Protection Act (IRPA) replaced theformer Immigration Act of Canada, 1976. After several amendments, Bill C-31, (nowBill C-11), is known as the Immigration and Refugee Protection Act (IRPA) and was22 Beiser (1999) points out that most of the refugees that fled Southeast Asia left by land routesrather than by sea but are referenced as “boat people”. Labels and terms such as “boat people”, or“illegal boat migrants” denotes a lexicon that Bradimore and Bauder argue dehumanizes migrantsand distorts public discourse about refugees arriving by boat.43formalized in 2002 (Canadian Healthcare Association, 2012). The IRPA is currentlythe legislation framework that allows for Citizenship and Immigration Canada (CIC)(under the Minister of Citizenship and Immigration) to admit refugees. The IRPAbecame an historical landmark in Canadian immigration because it allowed largescale resettlement of refugees who would have previously been denied access basedon lack of skill, education and resources. Moreover, this allowed for refugees,particularly those categorized as government-assisted, to enter Canada withcomplex medical conditions including communicable diseases such as TB, whowould have been previously denied entrance. These changes can be interpreted asappealing to global humanitarian dispersal policies. However, the rise of globalterrorism has compounded Canadian sociopolitical and historical debate aboutrefugees. These discourses place many refugees in different positions of marginalityand vulnerability in Canadian society.Refugees represent approximately 11% of Canada’s total newcomers(Kenney, 2013-2014). In 2012 Canada admitted 23,056 refugees and families. Ofthese, 5,412 were GARs, 4,212 were privately sponsored refugees (PSRs) and 8,578were refugees landed in Canada (AMSSA, 2013). 3,747 of the GARs were women.This represents 3.05% of all refugees (including privately sponsored, at 12.8%,protected persons, at 4.85% and dependents abroad, at 18.22%) (CIC, 2008).Approximately 7,300-7,500 GARs arrive in Canada annually (by plane), destined forthirty-six communities across Canada, with between eight and nine hundred (10-12%) arriving in BC (Sherrell et al., 2011). According to Sherrell et al. the city ofVancouver receives the largest concentrated number of GARs in Canada. Sherrell44(2003) observes that post WWII, Canadian immigration was predominantly anurban phenomenon and adds that “in the 1990s, three-quarters of all newcomers toCanada settled within three census metropolitan areas (CMAs): Toronto, Montrealand Vancouver” (p.4). However, current government interests in regionalizationhave shifted away from economic migrants, toward GARs resettling into smallermid-size communities (Sherrell).It is evident that Canada has a unique history of immigration and refugeeresettlement that predates 9/11. In particular, a small number of migrants arrivingby boat have been constructed as illegal, a burden on Canadian society and a threatto public safety and made highly visible through media, unlike the invisibility ofrefugees categorized as GARs.Bradimore and Bauder (2011) conducted a discourse analysis of Canadianmedia’s portrayal of the seventy-six Tamil refugees who arrived off the coast ofVictoria BC in 2009. This analysis consisted of N=37 articles and headlines fromthree major newspapers (National Post, Vancouver Sun and Toronto Star). Findingssuggest that fears of global terrorism underpinned by historical and global controlover mass migration of people have reinforced a discourse of security managementand restriction of who constitutes a “real” refugee, moving the discussion away fromhuman rights to one of security and risk management (Bradimore & Bauder).Bradimore and Bauder argue that a paradigm of securitization reinforces acultural politics of risk and . . . attached these risks to the migrant body . . .[therefore] as global risk become personified in the immigrant, the stateattempts to manage the risk by increased security and management ofhuman development (2011, p. 14).45Grove and Zwi (2006) similarly argue that concern over a risk to publicsafety “inverts health concerns such that the receiving population is seen to beunder threat rather than attending to the health needs of the displaced” (p. 1937).The safety and well-being of all people remains a public concern in Canada;however, an over-emphasis on risk and security management has continued to notonly reinforce stigma and racialization of minority groups but also shape Canadianpolitics and practice. For example, after the release of the Tamil refugees, a new BillC-1123 was enacted to prevent and protect Canada from refugees arriving by boat(Bradimore & Bauder, 2011), despite protests from advocacy groups. Bradimoreand Bauder argue thatthe spectacle which surrounded the Tamil boat arrival had created thenecessary discursive environment and sense of urgency to push Bill-C11 through parliament…[this] fostered a sense of anxiety around amultitude of issues…like terrorism, and national security [and] as inprevious cases a small group of “boat people” became a symboliccatalyst for political action and legislative reform (2011, p. 34).Tomasso (2012) conducted a more recent discourse analysis on the Canadianpublic’s views about the arrival of 492 women, children and men from Sri Lanka offthe coast of Vancouver Island in 2010. Despite changes to immigration policy vis-à-vis IRPA, at that time fifty-four children were under the care of approximately23 In 2002 the Immigration and Refugee Protection Act (IRPA) replaced the former Immigration Actof Canada, 1976. After several amendments Bill C-31, (now Bill C-11), is known as the Immigrationand Refugee Protection Act (IRPA) and was formalized in 2002 (Canadian Healthcare Association,2012). The IRPA is currently the legislation framework that allows for Citizenship and ImmigrationCanada (CIC) (under the Minister of Citizenship and Immigration) to admit refugees. The IRPAbecame an historical landmark in Canadian immigration because it allowed large scale resettlementof refugees who would have previously been denied access based on high barriers to integration intoCanadian society.46twenty-five mothers, held at the Burnaby Detention Centre. Tomasso’s findingsshowed a convergence of discourses of racialization, national security,multiculturalism and neoliberalism as powerful cultural narratives reflectingCanadian public opinion of Tamil refugees. Consistent with the findings ofBradimore and Bauder (2011) Sri Lankan refugees were viewed as terrorists and asa threat to Canadians. However Tomasso argues the Canadian government foundonly one person linked with Tamil Tigers. In addition, Tomasso draws attention tothe comments posted reflecting the Canadian public’s resistance to Sri Lankanmigrants who do not speak English, for example, twenty-eight readers described acollective belonging as “we” who speak “our language” (Tomasso, p. 340).Tamasso (2012) argues that these discourses reflect a particular brand ofCanadian nationalism overshadowed by Canada’s white settler national imagery. Inaddition, Tamil refugees were perceived as fraudulent queue jumpers. Tomassowrites that “these types of commentaries blend a discourse of Canadian benevolenceand civility with neoliberal notions of what it means to be a productive member ofsociety. Believing in fairness and waiting one’s turn are ontologized as Canadian”(p.341). Reflecting the perspective of multiculturalism, many Canadians respondedto Tamil refugees depicting them as objects needing to be “tolerated.” Drawing onBrown (2006) Tomasso further argues thatthose who tolerate choose to do so, and this power of choice paves theway to superiority through benevolence. Tolerance language alsomakes use of works like “sensitivity” and “respect” to negotiatepolitical solutions to issues of diversity, which … is a dangerouspractice of depoliticization that reduces issues of social justice tosensitivity training (2012, p. 342).47Anderson and Reimer-Kirkham (1998) remind us that “there is a real risk ofoversimplifying the concept of culture, with the concomitant cultural stereotypesthat this produces.” Culture, vis-à-vis ethnic identity, “is only one aspect of thecomplex nexus in which people’s experiences are located. When “difference” isreduced to the culture of the individual or the ethnicity, the structural factors thatshape inequity may be overlooked, and “Western culture” taken as the norm againstwhich others are judged, goes unquestioned and unscrutinized” (p.256).Moreover Tomasso (2012) observes that racialized and objectified images ofrefugees depict forms of Orientalism that have historical and political rootsintertwined in academic, political and mainstream discourses (Said, 1998). Saidargues that Orientalism is defined by and maintained through configurations ofpower,24 and closely tied to socioeconomic and political institutions whereby“Orientalism is not an airy European fantasy about the Orient, but a created body oftheory and practice in which, for many generations, there has been a considerablematerial investment” (p. 6). Drawing on Gramsci’s notion of hegemony, Said furtherargues that Orientalism depends on a “flexible positional superiority, which puts theWesterner in a whole series of possible relationships with the Orient without everlosing him the relative upper hand” (p. 6). In this way the “ontological identity”24 Drawing on Gramsci, Said points to direct and indirect forms of domination. Indirect forms ofdomination, Said notes as “culture … operating within civil society, where the influence of ideas, ofinstitutions, and of other persons works not through domination but by what Gramsci calls consent.[Thus] certain cultural forms predominate over others, just as certain ideas are more influential thanothers; the form of this cultural leadership is what Gramsci has identified as hegemony” (p. 7). Saidargues that hegemony gives power and/or sustains Orientalist discursive practice.48created through “racialized imagery” suggests that any future incoming boats are“ipso facto ‘illegal’ and Chinese/Asian” (Bradimore & Bauder, 2011, p. 11).Globalization, terrorism and mass movements of people have challengedCanada’s multiculturalist ideologies that are also intertwined with geopolitical andeconomic markets (capitalism). Historical colonial processes of settlement,compounded by 9/11, shape societal constructions of refugees as a national securitythreat and permeate immigration discourse Canada. The process of categorizationand conflation of refugee identity with terrorism has had negative social as well asmental health consequences. This fractioning and categorization of “refugee” hasnot only shaped policy responses to the ways in which refugees gain entrance, butalso access to resources and support once inside Canada’s borders. Fractioning ofrefugee identity through various categorizing processes raises concern overCanada’s appeal to humanitarian resettlement policy and reinforces the idea thatthe “label ‘refugee’ is no longer a basic convention [human] right, but a highlyprivileged prize which few deserve and most claim illegally” (Zetter, 2007, p. 184).And, as Tomasso (2012) writes,since 2001, we have seen individual rights trampled, and theintensification of violent state interventions directed at specificcommunities, such as increased detentions and deportations. Theseforms of sanctioned state violence are racialized in that those targetedand predominantly the “Them” constructed by mainstream discourse(p. 335).A brief overview of immigration in the Canadian contexts suggests that manyrefugee groups are racialized and marginalized against the backdrop of globalizedand national discourses that have shifted the focus on human rights to one of49national threat and risk management. It is within these broader sociopolitical andhistorical contexts that Karen women and families were resettled in Canada. I nowturn to a brief discussion of the factors that shaped Karen migration, and theirresettlement in BC, Canada.2.4 The Evolution of Karen Refugee Resettlement in BCIn response to the global refugee crisis, Canada is one of 147 nations to havesigned the UN convention on refugees, and offers both temporary protection and theoption of permanent resettlement (Beiser, 2009). As a result of the IRPA, betweenthe years 2005-2009 the top source countries of resettlement25 in BC were Burma(Myanmar),26 Afghanistan, Iran, Iraq and Somalia. The Karen, pronounced (Kah-Ren) people are considered descendants of the Mongols and are represented bysome 20 ethnically diverse sub groups that are living within Burma (InternationalOrganization for Migration (IOM), 2006). Karen communities are indigenous tomountainous and plains regions of southeast Burma and western Thailand anddiffer in language, geography and name (Neiman, Soh & Sutan, 2008). According to25 Resettlement refers to the larger global processes of migration that are structured through globalpolicies between the UNHCR and nations who are signatories of the United Nations (UN). The UNHCR(2010) defines resettlement as a process which provides “protection to refugees when their lives,liberty, safety, health or other fundamental human rights are at risk in their country of asylum” (p.18).26 According to Norsworthy and Khuankaew (2004) the renaming of Burma to Myanmar occurred asa result of the military junta’s refusal to “to allow legally elected democratic government party, theNational League for Democracy, led by Nobel Peace Prize laureate Aung San Suu Kyi, to take officefollowing elections in 1990” (p. 261). It is also recognized that some ethnic minority groups withinBurma’s borders prefer sovereignty over their states, recognizing that even Burma was the namegiven to the territory by British colonizers (Norsworthy & Khuankaew, 2004). In recognition ofBurma’s colonial past and ongoing state violence toward minority ethnic groups, I use both Burmaand Myanmar throughout this dissertation.50Neiman et al., during WWII the Karen aligned with the British and the Burmese withthe Japanese. Although resistance movements against the Burmese have beenongoing since the time of Burma’s independence, the military regime continues todeprive its indigenous people of natural resources and traditional ways of life thatsustained the Karen and other ethnic minority groups (Neiman et al., 2008;Norsworthy & Khuankaew, 2004).Despite Canada’s economic and trade sanctions with Burma, the currentleadership, the State Peace and Development Council (SPDC) (formerly known asState Law and Order Restoration Council (SLORC)) continues to govern Burmathrough military decree, obverting their power through state-wide sponsoredviolence which deprives its people of fundamental human rights (Norsworthy &Khuankaew, 2004). This has resulted in one of the largest internally displacedgroups of people and refugee population in Southeast Asia (CIC, 2007). Refugeesfrom Burma are the fifth source country of refugees worldwide, including 200,000refugees who are resettled to Bangladesh (UNHCR, 2010).As a result of ongoing threat of violence, forced relocation, and dependenceon humanitarian assistance Karen refugees are considered by the UNHCR asrefugees in most need of protection and in need of third country resettlement.Under the humanitarian assistance program vis-à-vis Canada’s recent changes toimmigration policy, Karen refugees were resettled as part of larger familial groupsthat arrived in Canada in 2005 with the most recent arrivals in 2009 (ISS of BC,2010). These groups were known to come from the Mae La Oon and Mae Ra MaLuang refugee camps in the remote regions of Northern Thailand (CIC, 2009). These51camps are considered the most difficult to reach, the most overcrowded and inthreat of serious public health risks to women and families (CIC, 2007, 2006).Marchbank, Sherrell, Friesen & Hyndman, (2014) discuss that “Karen refugees [are]a distinct group with particular protection needs” and therefore called upon theinternational community to assist in their resettlement (p.5).27 In addition to livingin protracted refugee camps it is also noted that literacy (reading and writing intheir traditional language) and education among both adults and children is verylow (Marchbank et al.). Most Karen speak two dialects, S’gaw or Pwo Karen, andsome speak Burmese and Thai languages.In the years 2005-2009, approximately 786 Karen GARs were destineddisproportionately across three different regions within Greater VancouverRegional District (GVRD). Two of these regions are considered larger metropolitancenters with longer-standing immigration and refugee services, includingspecialized immigrant and refugee health and settlement services. Approximately250 Karen women and families were relocated to a smaller a suburban communitylocated along the Fraser Valley in southwestern British Columbia (BC). This smallersuburban region covers approximately 10 square kilometers, with a population of100,000 people (Marchbank et al., 2014). Historically this receiving community waslargely a farming and trade community developed by European foreign settlers as27 Marchbank et al. (2014) note that “ [t]he Karen settlement initiative was an example of ‘groupprocessing’ whereby the Canadian Government designated specific refugee groups in protractedsituations and/or high protection needs” (p. 8). For example, Marchbank adds that “Somali andSudanese refugees from Kenyan camps were the focus of early group processing, followed by theKaren and Bhutanese who had been living in Nepal for almost two decades. All of these contexts aredefined by extended exile whereby access to health care, education, and employment were allrestricted” (p. 8).52well as Sikh, Chinese and First Nations people who contributed to the economic andsocial fabric of this region (Sommer, 1999). Throughout the late 1800s, faith-basedcommunities shaped the identity of this region and were represented by variousreligious denominations which continue to this day and have been described as “acommunity of faith, strength and purpose and spirit of community” (Sommer, p.180). The vast majority of Karen in BC are noted to be Baptist Christian while theminority are Buddhists and Seventh Day Adventists (ISS of BC, 2010). Howevermany Karen people also believe in animism (Oleson, Chute, O’Fallon and Sherwood,2012). These variations of religious practices reflect Burma’s history ofcolonization28 as well as indigenous belief systems. I discuss the significance ofreligion and associated faith based groups as an important aspect of Karenresettlement under the section titled “Overview of Structures of Settlement andOutcomes of GARs in BC”. I now turn to discuss the structures both national andreg