Social Representations of Immigrant Patients: Physicians’ Discourse

Abstract

With the global increase of migration and the effects of the economic crisis, health systems around the world are facing new challenges. In this context, we investigated the social representations of health provision to immigrant patients, held by physicians. We conducted 40 interviews with Greek physicians working in the public health system, the private health system, the health system in jails, and nongovernmental organizations. Using principles from thematic analysis, results show a social representation of immigrant patients as a burden to the health system. This social representation is constructed by themes focusing on immigrant patients as a group with mental health issues and on the construction of the health system as unable to provide health to noncitizens. Results are discussed in relation to current issues of social exclusion and the need to protect the human right of health.

Keywords

access to health care Greece immigrants inequality social representations thematic analysis

Introduction

Migration has been steadily increasing globally and since 2014 Greece has been a heavily targeted country for refugees from many nations. This poses a great challenge for health systems in terms of being able to ensure that human rights of this diverse population are met and respected (World Health Organization [WHO], 2020). Accessible and equitable health provision to immigrant patients is one of the major issues which health systems must meet to sustain the right to health for all (WHO, 2001). This is especially important since certain health outcomes for some immigrant groups deteriorate after they move to their destination country, usually due to poor living conditions and barriers they meet in their effort to access health provision (Castañeda et al., 2014; Farré, 2016; Kwak, 2016; Mathew & Nambiar, 2020; WHO, 2020). These barriers can also increase risk for immigrants and refugees to contract diseases including the COVID-19, especially due to the living conditions which can interfere with the ability to follow public health guidelines (Kluge et al., 2020). This is especially important as the pandemic is compounding problems in the already fragile Greek health system which is in the edge of collapse (Giannopoulou & Tsobanoglou, 2020). The Greek health care is characterized by the coexistence of a national health system (NHS) and a private health care system. The NHS suffers from inherent organizational, structural, and operational problems that worsened during the long-lasting period of the financial crisis that resulted in significant reductions in Greek public health expenditure (Giannopoulou & Tsobanoglou, 2020), a very weak primary health care in terms of access and continuity in care which led to two thirds of the patients attending hospital departments for health issues that could be handled by primary health care level. In addition, the financial crisis caused an increased need for public health services utilization especially for socially vulnerable groups (Prati et al., 2016; Sharif et al., 2020; Tsai et al., 2018) which are further exacerbated by the COVID-19 pandemic. According to Graetz et al. (2017), utilization of health services between immigrants and nonimmigrants forms different patterns and therefore a comprehensive comparison is very challenging. Important factors that hinder access to health provision for immigrants include language and cultural differences (Combes & Abu-Zaineh, 2018; Shrestha-Ranjit et al., 2020), lack of information about the host country’s health system (Grassino et al., 2009), cost of health care depending on the health care system (private, public) (Kitsaras & Baka, 2013), organizational issues of hospitals such as lack of multicultural training of physicians (Dutciuc et al., 2014; Grassino et al., 2009), and issues of interpersonal communication between physicians and immigrants (Michaelsen et al., 2004).

In Greece, research in health provision to immigrant patients suggests the need for multicultural training for physicians (Karamitri et al., 2013), the restructuring of the primary care system (Manomenidis, 2009), and the need for empowerment of immigrants (Galanis et al., 2013). In addition, immigrant patients report difficulties in communication with Greek physicians, low degree of knowledge of public health services in Greece (Galanis et al., 2013), and an overall low degree of satisfaction with the health care system in Greece (Boutziona et al., 2020; Vozikis & Siganou, 2015).

Apart from the commonly acknowledged cultural and organizational barriers identified, the notion of citizenship seems to play a key role in processes of inclusion and exclusion with regard to access to human rights (Andreouli & Dashtipour, 2014; Dell’Olio, 2017; Favell, 2016; Figgou, 2016), as citizenship has been identified as a determinant for health access (Asad & Clair, 2018). Discrimination and social integration policies (Kemppainen et al., 2018) as well as the fear of discrimination and prosecution due to their illegal status discourage immigrants from seeking health services (Hamed et al., 2020). The nature of these barriers seems to be a multifaceted challenge, as they stem from a variety of political, organizational, economic, and sociopsychological issues.

In this context, the role of the physicians’ beliefs or attitudes toward immigrants as factors that may hinder or strengthen immigrant access to health provision has been less explored. Physicians’ social representations hold a significant role in the area of inclusion and exclusion in health. Howarth et al. (2014) supported that social representations as systems of knowledge play a significant role in the defense of cultural identities and ultimately in the conceptualization of the processes of exclusion and inclusion such as the access and provision of health to immigrants. Indeed, social psychology has a long tradition of research in the social representations of health and their effect in maintaining or combating inequalities (Murray, 2000).

Social representations first proposed by Moscovici (1961) are consensual understandings of phenomena that circulate in a given culture and influence the ways social objects and groups are perceived (Joffe, 2003). Hence, social representations theory is a conceptual framework that enables an understanding of how people in groups transform and communicate their social reality. In this content, research on social representation theory has dealt with issues ranging from social representations of psychoanalysis (Moscovici, 1976, 1984a, 1984b) to social representations of health (Flick et al., 2002, 2003; Jodelet, 1991; Murray & Flick, 2002).

The WHO (2001) stresses the need for the development of health systems that allow greater integration and dialogue between physicians and immigrant patients. An important step in that direction is understanding the process of conceptualization of health provision that is mediated by social representations of health and immigration. This is especially important as concepts of health have an important influence on health practices (Flick et al., 2002).

Study Design

The present study focused on the qualitative exploration of physicians’ social representations on immigrant patients. As health practices are influenced by subjective definitions and concepts of health (Flick et al., 2002), the present study explores the ways that physicians’ more general social representations of immigration and health influence the more specific social representations of health provision to immigrant patients. Particularly, the analysis is focused on the ways physicians construct immigrants as patients within the Greek health system. Given that the study is a qualitative explorative study, the data were collected by the means of semi-structured interviews. The interviews consisted of two parts. The first part focused on questions concerning notions and concepts of health as well as current challenges of the health system in Greece. The second part consisted of more focused questions on immigration, work-related examples of health provision, as well as narrations (Murray, 2000) regarding the provision of health to immigrant patients.

Participants

Participants consisted of 40 physicians working in a variety of health settings in Greece. These health settings included the Greek public health system, private hospitals, nongovernmental organizations (NGOs) and the health system in jail in the three biggest cities in Greece (Athens, Thessaloniki, and Larissa). Twenty-nine of the physicians were male and 11 were female and had the following specialties: surgery, internal medicine, cardiology, hematology, pathology, orthopedics, and endocrinology. The mean age was 38 years. Sixteen of the physicians worked in public hospitals, 13 in private clinics, seven in NGOs, and four in high-security prisons (Table 1).

Table 1.

Occupational Context of Participants.

Occupational context	Total
Public	16
Private	13
Nongovernmental organizations	7
Prison	4
Total	40

Procedure

Participants were recruited using the snowball technique (Robinson, 2014; Waters, 2015). Physicians were initially asked to arrange individual meetings for interviews; however, due to difficulties related to time constraints, the majority of the physicians were interviewed during their shifts in their place of work. All of the participants were informed regarding the purpose of the study and that none of their personal information would be recorded. Participants were provided with an information sheet and a consent form and consented before the interviews started. The research was approved by the Aristotle University ethics committee. The interviews were tape recorded after requesting permission and ensuring anonymity would be preserved. All interviews were transcribed from the researcher. The duration of the interviews ranged from 20 to 50 minutes.

Method

Data were analyzed using thematic analysis to organize the data and produce the main themes and subthemes (Braun & Clarke, 2006). During the initial analytic stage, the six-phase proceeds of thematic context analysis as proposed by Braun and Clarke (2006) were used to organize data into meaningful themes. Initial codes were located from the data, which were then collated into overarching themes after re-focusing the analysis at a broader level of themes. This involved sorting codes into potential themes by carefully going through the codes repeatedly and considering how different codes combine to create an overarching theme (Braun & Clarke, 2006). Validity of the themes was supported by using triangulation with the three authors who reviewed and refined the themes until there was a common agreement. Social representations theory and thematic content analysis were used to integrate the theoretical dimensions of social representation theory to the structured methodological approach of thematic analysis (Batel & Castro, 2018; Jovchelovitch, 2019) to investigate the communicative action of physicians regarding health provision to immigrant patients as presented in the results.

Results

Results presented in this article focus on the themes of obstruction of health care use by immigrants and especially on the identified social representation of immigrants patients as a burden. During the interviews, participants described a diminished quality of health provision to immigrant patients that is mostly attributed to the immigrants themselves as physicians created health distinctions based on national identity with immigrants constructed as others who do not have the right to access this nationalized health. In this aspect, the immigrant patients are represented as a problem posed to the Greek health system. More specifically, this main social representation of immigrants as a burden is constructed by the following themes:

Immigrants patients as a group with mental health issues

Lack of immigrants’ assimilation as the main problem in health provision

Immigrant patients as an unnecessary cost to an already weakened health system

Immigrant Patients as a Group With Mental Health Issues

This theme focused on the representation of immigrant patients as a group of individuals with mental health and behavioral issues. This line of discourse serves to categorize immigrant patients as a group of “others” whose mental and behavioral issues make communication and health provision difficult for the physicians.

Excerpt 1

Physician: With immigrants, listen, their level is not very satisfactory. They are more aggressive and they have no right to be since they do not have health insurance.

Interviewer (Int): What do you mean when you say “their level”?

Physician: Mental health level

Int: And are they demanding?

Physician: I think to a greater extent than Greeks. They are demanding with spite as if you are responsible for them being sick. They are also cautious and scared since they believe that they might be treated in a racist way

According to Billig (1996), people formulate evaluations and use them to construct categorical distinctions in social groups. In a similar way, the physician forms a clear categorical distinction between “we” and “them” to differentiate between Greek and immigrant patients. The “otherness” of the immigrant patients is constructed with extreme case formulations (representing immigrant patients as inferior to Greeks having a lower mental health level and thus problematic in receiving health provision). This way the physician creates a national in group identity based on a Greek ethnic background versus the immigrant out group which is constructed as a problematic group of patients. This creates a health distinction based on national identity leading to a nationalization of health which rhetorically is used by the physician to attribute health provision problems to immigrants themselves as they are not entitled to health provision at all given that they are not Greek nationals. Nationalism in this sense is used as an all-encompassing, essentializing category that enables or disables even basic human rights such as health provision.

In a similar way, the physician in the following excerpt uses the categorical distinction of “we” versus “them” to differentiate the immigrant patients as a group with mental health issues.

Excerpt 2

Int: How would you describe immigrants as patients?

Physician: To begin with, they don’t respect the health system that provides them health. They don’t respect the physicians. They should be less condescending toward the way the Greek health system operates.

Int: Why do you think they behave this way?

Physician: Maybe due to the hardship they went through? Maybe because they go through so much in their lives and that got to their nerves? Maybe they are in a bad mental state? All of the above contribute to them not being able to communicate with a healthy human being. I do believe they are mentally unhealthy individuals.

The physician discursively constructs immigrants’ lack of mental health by drawing from stereotypes that construct immigrants as incompetent, untrustworthy (Lee & Fiske, 2006) with issues of abnormal behavior (Figgou et al., 2011). In doing so, he constructs immigrant patients as a high-risk subordinate social group with diminished human rights that should be content on receiving any health provision at all regardless of quality and be more condescending toward physicians. In this context, their lack of respect to physicians is attributed not to problems within the health system but to the immigrants themselves by constructing immigrant patients as a group having undefined mental issues that are a result of the hardship of immigration. This serves as a rhetorical defense to physicians as problems of communication are attributed directly to the immigrant patients themselves and not to the problematic aspects of the health system that fails to deliver health to any patient in need.

In the following theme, immigrants are also represented as a problem; however, this is attributed to their lack of assimilation to the Greek society and way of life. Physicians discursively construct the level of assimilation as a tool for the creation of a hierarchy of exclusion for patients whose health provision depends on their level of assimilation to the culture of the host country.

Lack of Assimilation of Immigrants as the Main Problem in Health Provision

Excerpt 3

Physician: Immigrants should not integrate to Greece because they create problems to the health and occupational system of Greece. You can see what is going on in the media, there is chaos in the country. There are immigrants that came to Greece legally, they have integrated in the society, they have their legal permits, their families, their jobs, but unfortunately the biggest percentage are immigrants who supposedly have come for a better life without actually doing something for it

Int: Don’t you think that by saying that we stigmatize a group of people that come from another country?

Physician: But a person is not stigmatized by his country of origin. He is stigmatized by the way he behaves when he enters my country. I don’t have a problem if someone is from Africa or Albania, but I do have a problem with him when instead of not behaving like an honest Greek citizen from the moment he enters Greece, he behaves like an Albanian who came here, without a permit, doesn’t have a health card and wants to be treated like a Greek who has worked hard and pays for his health insurance every month.

The physician in this excerpt uses group categorization to make a clear distinction between Greek and immigrant patients. These categories are constructed on the base of ethnic identity and citizenship and serve to represent immigrants and Greek patients as two groups with different rights to health provision. According to Tajfel (2017), perceiving one’s self and others as members of socially distinct groups can in itself lead to prejudice against other social groups. A contradictory assumption is implicit in the physician’s account of health provision to immigrant patients. While she supports that she does not stigmatize people on the basis of their country of origin, she also supports that immigrants should not integrate to Greece as they create problems unless they assimilate and behave “like an honest Greek citizen.” In this context, what constitutes Greekness is very specific as it involves abandoning the cultural identity of the immigrant and assimilating to get access to health provision. Health in this sense is represented as a right directly connected with citizenship and to the role of the nation state as the provider of health, as the relationship between citizenship and health is connected with the structure of the state.

The physician also constructs a negative representation of immigrants by drawing from media representations. Media discourses have constructed a negative “other” representation (Figgou, 2016) regarding immigrants. The physician uses this representation to construct assimilation as the only choice for immigrants to coexist with Greeks, with assimilation being a category defining criterion.

In the following excerpt, the physician draws from issues of integration to attribute problems of health provision of immigrants to the Greek state and to the commodification of health.

Excerpt 4

Int: What do you think about health provision to immigrant patients?

Physician: I will answer with the phrase “when faced with illness and death we are all equal.” Immigrants are depicted as a burden to the health system and face difficulties with health provision but they should be treated equally. This is because a person who is not occupied with an issue of disease has a much clearer mind to deal with his life and integrate into society. When you have a serious health issue the last thing you care about is the news or to get informed and thus to resist to what happens around you which has a direct impact on you.

Int: Yes, because when you’re sick, you’re in a position of weakness right?

Physician: When you are sick the system will stomp on you. Especially in the cases of immigrants. But even with Greeks in the case of the commercialization of health. I know that there are private polyclinics that work solely for profit and not for health. There are colleagues in private clinics and practices who will exploit your health problem to produce profit. These are issues that should be solved by the state, the national health system has to change policies.

The physician in this extract acknowledges the depiction of immigrant patients as a burden to the health system to denounce practices of prejudice to the public health system as well as practices that are informed by the privatization of health. To support his claims, he constructs illness as a condition that makes people helpless and unable to fight for their rights. Health in this sense is constructed as a universal human right and as such, a prerequisite of active citizenship that enables social participation and integration for immigrants (Figgou, 2016).

In this context, immigrant patients are constructed as a minority group that lack power over their health and hence are victimized by both the public health system that is characterized by prejudice toward them as well as the private health system whose sole purpose according to the physician is to maximize profit by exploiting patients. A solution proposed by the physician is for the national public health system to change to an extent that every patient is treated equally. The physician draws from the notion of health as a human right with the national health system constructed as a protector of the patients’ right to health with the state responsible for patients’ rights and their protection from the private sector’s profiteering.

In the third and final theme, the economic crisis is discursively constructed as a mediating factor for the exclusion of the immigrant patients from health services.

Immigrant Patients as an Unnecessary Cost to an Already Weakened Health System

Excerpt 5

Int: So you think that immigrants should not have access to health?

Physician: No they shouldn’t. On the other side you are a physician so you can’t let someone die. But immigrants are an economic burden to the health system.

Int: Doesn’t this affect quality of health provision? I mean if someone thinks that immigrant patients are a burden to the health system, won’t that affect his or her quality of health provision?

Physician: Sure, it is something you could have in the back of your mind and think that health provision is something you are compelled to do, but a lot of things do not depend upon me. There are people in executive positions such as managers who make these decisions so they might decide that a certain surgery is too expensive and so opt for other ways to avoid the surgery.

In this excerpt, the physician clearly supports that immigrants should not receive health provision. In the participant’s discourse, health is represented as an expensive product that immigrants do not have the right to access. For the physician to defend her line of argument, she externally attributes the decision to exclude immigrants from health services that are expensive such as surgeries. Health provision in this sense is given a national identity which in turn is earned through citizenship. As such, health is earned and costly and needs to be protected from immigrants who do not have the same right to it as Greek nationals. Billig (2001) supported that the construct of prejudice can be understood as an irrational categorical generalization in the sense that it overlooks a common human nature. In this context, immigrants are stereotypically represented as “others” and as such a threat to the expensive product of health that belongs only to those with a Greek citizenship.

Excerpt 6

Int: Could you tell me your opinion regarding the inclusion of immigrant patients in the country?

Physician: They are creating a huge problem, because the country is so small and with so many economic issues that our health system cannot withstand their inclusion

Int: Do you believe if immigrants leave this country the health system will improve?

Physician: It will improve a lot, but since they were allowed in the country, I am against denying them treatment. The main issue was not to allow them entry in the country in the first place. From the moment they are in, there is not much you can do.

Int: What would you suggest in order for the functionality of the health system to be improved?

Physician: For a better management

Int: You mean regarding immigrants?

Physician: Yes, the illegal ones should either become legalized or sent away

The physician draws from the representation of Greece as a space with specific physical boundaries that have limited capacity. This representation has been mentioned in previous studies where it was used as an argument of exclusion of immigrants (Figgou & Sourvinou, 2013). The physician uses this representation to construct immigrants as a social group responsible for a demographic imbalance of patients in Greece that threatens the functionality of the Greek system. These constructions are used as a rhetoric technique to argue against the provision of health to immigrant patients by constructing a separate category of “illegal” patients that use the Greek system without being entitled to, due to lack of citizenship. Indeed, the notion of citizenship has been used as a defining criterion for entitlement into services and rights (Condor, 2011; Figgou, 2018). This negotiation of citizenship by the physician is used as an argumentative resource against the use of the health system by the immigrant patients and is further supported by the participant’s reference to the economic turbulence in Greece that has depleted the recourses of the health system and thus cannot support health provision to noncitizens. Health in this context is not a universal human right but an expensive service to be provided only to those who paid for it, that is Greek citizens that pay health taxes.

Discussion

This study focused on presenting the social representation of immigrant patients in the context of health provision. Immigrant patients were constructed as a burden for the provision of health, using a categorical construction of “otherness” with assimilation and citizenship being category defining criterions. This construction of otherness as a mean of exclusion for immigrants has been noted in previous studies ranging from health care service use (Torres, 2006) to stereotypical accounts of criminality (Figgou et al., 2011) to social exclusion (Kadianaki & Andreouli, 2017).

Physicians seem to construct health provision to immigrants from a dilemmatic social representation of health. Indeed, Billig (1996) supported that health discourse should be viewed as dilemmatic and ideological. This dilemmatic social representation of health is used to draw from constructions of status of illegality and lack of assimilation to negate the equal right to health access. These arguments serve to promote and support their discourse of health as a product that stems from a national deposit to be used only by Greek citizens or people who economically contributed to it through taxes and insurance payments. Within this context, equity in health is constructed as unrealistic and is given an ethnic identity. Thus, health provision is argued to be a service that has to be earned through citizenship and assimilation. It is interesting that the representation of immigrants as a burden to the health system is used in a line of arguments that serve to justify and to a certain extent “legalize” the differentiation and in some cases even the denial of health provision to immigrant patients. This way, this social representation and its themes function as a way to attribute problems in health provision to immigrants rather than the Greek health system and the physicians working within it. In line with previous studies (Figgou et al., 2011; Hamed et al., 2020), participants attribute a sense of illegality and abnormality regarding immigrants’ behavior even when this refers to one of the most basic human rights such as the access to health (WHO, 2000). Participants also argued against health provision to immigrant patients, by dehumanizing them and constructing them as a mentally unstable group. This theme is used to strengthen the physicians’ arguments toward a rationalization of a system of exclusion for patients who belong to different social groups that have not assimilated to the host culture, a practice also supported in previous research (Kerbage et al., 2020; Son, 2013) The vast majority of participants in this research expressed prejudiced opinions regarding immigrant patients and constructed health as a nationalized product that needs to be earned. An alternative view was provided by some physicians working in NGOs, who acknowledged the systemic injustices of the health system to immigrant patients and offered an alternative representation of health. This alternative representation constructed health as a universal human right which should be ascribed to the nation state which should serve as its protector.

The above results demonstrate the dispersion of prejudiced ideologies within the health system that inhibit the access to health for immigrants and legalize a diminished quality of health provision toward immigrants. This is in line with findings of previous studies that examined health provision with regard to immigration in other countries (Ahlberg et al., 2019; Hamed et al., 2020; Shrestha-Ranjit et al., 2020) and supported that health provision is influenced by social and political determinants (Broom et al., 2020). This is especially important as the dispersion of prejudice in health systems creates and nurtures inequalities leading into further marginalization of immigrant groups. Given the current economic, social, and political challenges in Europe as well as the refugee crisis and the COVID-19 pandemic, the protection of socially vulnerable groups especially regarding health is an urgent human right matter that needs to be addressed by enhancing communicative action. Important steps in this direction are the restructuring of public health systems to offer health to anyone in need, implementing new health strategies that take into account refugee and immigrant health needs, as well as adopting a conceptualization of health as a fundamental human right for everyone.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Vasileios Chatzimpyros

Author Biographies

Vasileios Chatzimpyros is a lecturer ot the psychology department of CITY college international Faculty of the University of Sheffield. His research interests focus on minorities and intergration challenges with regards to physical and mental health.

Aphrodite Baka is an assistant professor of social psychology at school of psychology, Aristotle University of Thessaloniki. Her research interests lie in the field of minorities, intergroup conflict and collective identities, the social construction of ideas and on applications of social psychology.

Maria Dikaiou is a emeritus professor of social psychology at school of psychology, Aristotle University of Thessaloniki.

References

Ahlberg

B. M.

Bradby

Hamed

Thapar-Bjorkert

(2019). Invisibility of racism in the global neoliberal era: Implications for researching racism in healthcare. Frontiers in Sociology, 4, Article 61. https://doi.org/10.3389/fsoc.2019.00061

Andreouli

Dashtipour

(2014). British citizenship and the “other”: An analysis of the earned citizenship discourse. Journal of Community & Applied Social Psychology, 24(2), 100–110. https://doi.org/10.1002/casp.2154

Asad

A. L.

Clair

(2018). Racialized legal status as a social determinant of health. Social Science & Medicine, 199, 19–28. https://doi.org/10.1016/j.socscimed.2017.03.010

Batel

Castro

(2018). Reopening the dialogue between the theory of social representations and discursive psychology for examining the construction and transformation of meaning in discourse and communication. British Journal of Social Psychology, 57(4), 732–753. https://doi.org/10.1111/bjso.12259

Billig

(1996). Arguing and thinking: A rhetorical approach to social psychology. Cambridge University Press.

Billig

(2001) Discursive, rhetorical and ideological Messages. S.T. In Wetherell

Magarett

Yates

S. J.

(Eds.), Discourse Theory and Practice: A Reader (pp. 210–221). Sage Publications.

Boutziona

Papanikolaou

Sokolakis

Mytilekas

K. V.

Apostolidis

(2020). Healthcare access, quality, and satisfaction among Albanian immigrants using the emergency department in Northern Greece. Journal of Immigrant and Minority Health, 22(3), 512–525. https://doi.org/10.1007/s10903-020-00983-x

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Broom

Parker

Raymond

Kirby

Lewis

Kokanović

Adams

Souza

Woodland

Wyld

Lwin

Koh

E. S.

Lwin

(2020). The (co) production of difference in the care of patients with cancer from migrant backgrounds. Qualitative Health Research, 30(11), 1619–1631. https://doi.org/10.1177/1049732320930699

10.

Castañeda

Nemeh

Chatzimpyros

(2014). Health status of Mexican-immigrant women in the US (Fact sheet). Health Initiative of the Americas, University of California Berkeley, School of Public Health. https://hiaucb.files.wordpress.com/2014/03/2014-womens-health-eng-final-updated.pdf

11.

Combes

J. B.

Abu-Zaineh

(2018). Health differentials between citizens and immigrants in Europe: A heterogeneous convergence. Health Policy, 123(2), 235–243. https://doi.org/10.1016/j.healthpol.2018.12.005

12.

Condor

(2011). Towards a social psychology of citizenship? Introduction to the Special Issue. Journal of Community & Applied Social Psychology, 21, 193–201. https://doi.org/10.1002/casp.1089

13.

Dell’Olio

(2017). The Europeanization of citizenship: Between the ideology of nationality, immigration and European identity. Routledge.

14.

Dutciuc

T. D.

Gorman

Tanjasiri

S. P.

Brown

(2014). Qualitative Interviews of Romanian Key Informants Guiding a Preliminary Health Needs Assessment of Romanian Immigrants in Southern California. Californian Journal of Health Promotion, 12(1), 52–60. https://doi.org/10.32398/cjhp.v12i1.1555

15.

Farré

(2016). New evidence on the healthy immigrant effect. Journal of Population Economics, 29(2), 365–394. https://doi.org/10.1007/s00148-015-0578-4

16.

Favell

(2016). Philosophies of integration: Immigration and the idea of citizenship in France and Britain. Springer.

17.

Figgou

(2016). Constructions of “illegal” immigration and entitlement to citizenship: Debating an immigration law in Greece. Journal of Community & Applied Social Psychology, 26(2), 150–163. https://doi.org/10.1002/casp.2242

18.

Figgou

(2018). Multiculturalism, immigrants’ integration, and citizenship: Their ambiguous relations in educators’ discourse in Greece. Qualitative Psychology, 5(1), 117–134. https://doi.org/10.1037/qup0000080

19.

Figgou

Sourvinou

M. N.

(2013). Immigration and Citizenship in Greece: Young people’s focus group discussions on the new Immigration Law. Scientific Annals-School of Psychology AUTh, 10, 419–445.

20.

Figgou

Sapountzis

Bozatzis

Gardikiotis

Pantazis

(2011). Constructing the stereotype of immigrants’ criminality: Accounts of fear and risk in talk about immigration to Greece. Journal of Community & Applied Social Psychology, 21(2), 164–177. https://doi.org/10.1002/casp.1073

21.

Flick

Fischer

Neuber

Schwartz

F. W.

Walter

(2003). Health in the context of growing old: Social representations of health. Journal of Health Psychology, 8(5), 539–556. https://doi.org/10.1177/13591053030085006

22.

Flick

Fischer

Schwartz

F. W.

Walter

(2002). Social representations of health held by health professionals: The case of general practitioners and home-care nurses. Social Science Information, 41(4), 581–602. https://doi.org/10.1177/13591053030085006

23.

Galanis

Sourtzi

Bellali

Theodorou

Karamitri

Siskou

Charalambous

Kaitelidou

(2013). Public health services knowledge and utilization among immigrants in Greece: A cross-sectional study. BMC Health Services Research, 13(1), Article 350. https://doi.org/10.1186/1472-6963-13-350

24.

Giannopoulou

Tsobanoglou

G. O.

(2020). COVID-19 pandemic: Challenges and opportunities for the Greek health care system. Irish Journal of Psychological Medicine, 37(3), 226–230. https://doi.org/10.1017/ipm.2020.35

25.

Graetz

Rechel

Groot

Norredam

Pavlova

(2017). Utilization of health care services by migrants in Europe—A systematic literature review. British Medical Bulletin, 121(1), 5–18. https://doi.org/10.1093/bmb/ldw057

26.

Grassino

Ε. C.

Guidi

Monzani

Pietro

D. P.

Bona

. (2009). Access to pediatric emergency departments in Italy: A comparison between immigrant and Italian patients. Italian Journal of Pediatrics, 35, Article 3. https://doi.org/10.1186/1824-7288-35-3

27.

Hamed

Thapar-Björkert

Bradby

Ahlberg

B. M.

(2020). Racism in European health care: Structural violence and beyond. Qualitative Health Research, 30(11), 1662–1673. https://doi.org/10.1177/1049732320931430

28.

Howarth

Andreouli

Kessi

(2014). Social representations and the politics of participation. In Nesbitt-Larking

Kinnvall

Capelos

Dekker

(Eds.), The Palgrave handbook of global political psychology (pp. 19–38). Palgrave Macmillan. https://doi.org/10.1007/978-1-137-29118-9_2

29.

Jodelet

(1991). Madness and social representations: Living with the mad in one French community (Vol. 5). University of California Press.

30.

Joffe

(2003). Risk: From perception to social representation. British Journal of Social Psychology, 42(1), 55–73. https://doi.org/10.1348/014466603763276126

31.

Jovchelovitch

(2019). Discourse and representation: A comment on Batel and Castro “Reopening the dialogue between the theory of social representations and discursive psychology.” British Journal of Social Psychology, 58(2), 415–422. https://doi.org/10.1111/bjso.12296

32.

Kadianaki

Andreouli

(2017). Essentialism in social representations of citizenship: An analysis of Greeks’ and migrants’ discourse. Political Psychology, 38(5), 833–848. https://doi.org/10.1111/pops.12271

33.

Karamitri

Bellali

Galanis

Kaitelidou

(2013). The accessibility of vulnerable groups to health services in Greece: A Delphi study on the perceptions of health professionals. The International Journal of Health Planning and Management, 28(1), 35–47. https://doi.org/10.1002/hpm.2111

34.

Kemppainen

Skogberg

Kuusio

Koponen

(2018). Immigrants’ use of health care in their country of origin: The role of social integration, discrimination and the parallel use of health care systems. Scandinavian Journal of Caring Sciences, 3 2(2), 698–706. https://doi.org/10.1111/scs.12499

35.

Kerbage

Marranconi

Chamoun

Brunet

Richa

Zaman

(2020). Mental health services for Syrian refugees in Lebanon: Perceptions and experiences of professionals and refugees. Qualitative Health Research, 30(6), 849–864. https://doi.org/10.1177/1049732319895241

36.

Kitsaras

Baka

(2013). Immigrants’ discourse about the factors that hinder their access to health services in Greece. Scientific Annals-school of Psychology AUTh, 10, 474–498.

37.

Kluge

H. H. P.

Jakab

Bartovic

D’Anna

Severoni

(2020). Refugee and migrant health in the COVID-19 response. The Lancet, 395(10232), 1237–1239. https://doi.org/10.1016/S0140-6736(20)30791-1

38.

Kwak

(2016). An evaluation of the healthy immigrant effect with adolescents in Canada: Examinations of gender and length of residence. Social Science & Medicine, 157, 87–95. https://doi.org/10.1016/j.socscimed.2016.03.017

39.

Lee

T. L.

Fiske

S. T.

(2006). Not an outgroup, not yet an ingroup: Immigrants in the stereotype content model. International Journal of Intercultural Relations, 30(6), 751–768. https://doi.org/10.1016/j.ijintrel.2006.06.005

40.

Manomenidis

(2009). The Attitudes of Nurses towards Patients with Cultural Diversity. Nosileftiki, 48(4), 439–446.

41.

Mathew

Nambiar

(2020). Understanding the experiences of health care–seeking migrants in Delhi: Trajectories and challenges. Qualitative Health Research, 30(11), 1710–1722. https://doi.org/10.1177/1049732320921374

42.

Michaelsen

J. J.

Krasnik

Nielsen

A. S.

Norredam

Torres

A. M.

(2004). Health professionals’ knowledge, attitudes, and experiences in relation to immigrant patients: A questionnaire study at a Danish hospital. Scandinavian journal of public health, 32(4), 287–295. https://doi.org/10.1080/14034940310022223

43.

Moscovici

(1961). Psychoanalysis. Its image and its public. Presses Universitaires de France.

44.

Moscovici

(1984a). The myth of the lonely paradigm: A rejoinder. Social Research, 51(4), 939–968. https://doi.org/10.2307/40970972

45.

Moscovici

(1984b). The phenomenon of social representations. In Farr

R. M.

Moscovici

(Eds.), Social representations (pp. 3–70). Cambridge University Press.

46.

Murray

(2000). Levels of narrative analysis in health psychology. Journal of Health Psychology, 5(3), 337–347. https://doi.org/10.1177/135910530000500305

47.

Murray

Flick

(2002). Social representations of health and illness: Qualitative methods and related theories—An introduction. Social Science Information, 41(4), 555–558. https://doi.org/10.1177/0539018402041004003

48.

Prati

Crisp

R. J.

Pratto

Rubini

(2016). Encouraging majority support for immigrant access to health services: Multiple categorization and social identity complexity as antecedents of health equality. Group Processes & Intergroup Relations, 19(4), 426–438. https://doi.org/10.1177/1368430216629814

49.

Robinson

O. C.

(2014). Sampling in interview-based qualitative research: A theoretical and practical guide. Qualitative Research in Psychology, 11(1), 25–41. https://doi.org/10.1080/14780887.2013.801543

50.

Sharif

M. Z.

Samari

Alcalá

H. E.

(2020). Variations in access to care after the affordable care act among different immigrant groups. Journal of Community Health, 45(1), 30–40. https://doi.org/10.1007/s10900-019-00708-8

51.

Shrestha-Ranjit

Payne

Koziol-McLain

Crezee

Manias

(2020). Availability, accessibility, acceptability, and quality of interpreting services to refugee women in New Zealand. Qualitative Health Research, 30(11), 1697–1709. https://doi.org/10.1177/1049732320924360

52.

Son

(2013). Assimilation and health service utilization of Korean immigrant women. Qualitative Health Research, 23(11), 1528–1540. https://doi.org/10.1177/1049732313507142

53.

Tajfel

(2017). The formation of national attitudes: A social-psychological perspective. In Sherif

Sherif

C. W.

(Eds.), Interdisciplinary relationships in the social sciences (pp. 137–176). Routledge.

54.

Torres

(2006). Elderly immigrants in Sweden: “Otherness” under construction. Journal of Ethnic and Migration Studies, 32(8), 1341–1358. https://doi.org/10.1080/13691830600928730

55.

Tsai

T. I.

Lee

S. Y. D.

W. R.

(2018). Impact of a Problem-Based Learning (PBL) health literacy program on immigrant women’s health literacy, health empowerment, navigation efficacy, and health care utilization. Journal of Health Communication, 23(4), 340–349. https://doi.org/10.1080/10810730.2018.1445798

56.

Vozikis

Siganou

(2015). Immigrants’ satisfaction from the national health system in Greece: In the quest of the contributing factors. Health, 7(11), 1430–1440. https://doi.org/10.4236/health.2015.711157

57.

Waters

(2015). Snowball sampling: A cautionary tale involving a study of older drug users. International Journal of Social Research Methodology, 18(4), 367–380. https://doi.org/10.1080/13645579.2014.953316

58.

World Health Organization. (2000). The world health report 2000: health systems: improving performance. World Health Organization. https://www.who.int/whr/2000/en/

59.

World Health Organization. (2001). Mental health: New understanding, new hope. https://www.who.int/whr/2001/en/whr01_en.pdf?ua=1

60.

World Health Organization. (2020). Preparedness, prevention and control of coronavirus disease (COVID-19) for refugees and migrants in non-camp settings. https://www.who.int/publications/i/item/preparedness-prevention-and-control-of-coronavirus-disease-(covid-19)-for-refugees-and-migrants-in-non-camp-settings