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Building bridges or negotiating tensions? Experiences from a project aimed at enabling migrant access to health and social care in Sweden

Agneta Abrahamsson BA PhD1* and Joyce Andersson MSc2 and Jane Springett BA MA PhD3

Senior Lecturer, Sector of Health and Social Science, Kristianstad University, Kristianstad, Sweden

Tutor, Swedish for Immigrants School, Kristianstad, Sweden

Professor of Health Promotion, Faculty of Health and Applied Social Sciences, Liverpool John Moores University, Liverpool, UK

*Corresponding Author:
Agneta Abrahamsson
Senior Lecturer, Sector of Health and Social Science
Kristianstad University, 29188 Kristianstad, Sweden
Tel: 00 46 4420 4050
email: [email protected]

Received: 27 November 2008
Accepted: 1 March 2009

 
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Abstract

to enable forced migrants to access health and social care that meets their needs. One solution is to use paraprofessionals – that is, trained individuals who are not professionals – to act as bridge-builders between minority communities and the health and social care sectors. This paper explores the development of a quality improvement project in Sweden. The project aimed to recruit and train forced migrants who had lived in Sweden for more than five years to act as bridge-builders. The aim was to use their unique experiences and knowledge in two ways – to work with service staff in developing newways of working, and to become culturally competent paraprofessionals working with their own communities. This paper focuses on how an understanding of the role evolved as the participants reflected on their experiences and undertook an inquiry process culminating in the development of three possible models of what the task of a bridge-builder should be in developing culturally appropriate health and social services that are responsive to the needs of forced migrants. The conclusion reflects on what was learned and how the experiences from this project may be useful for others who are struggling with the same kind of problem in Sweden and in other countries.

Keywords

bridge-builders, cultural competence, health and social care, individual/collective thinking, para-professional, refugees

Introduction

Forced migrants are people who are forced to flee their homes because of political unrest and violence (Grove and Zwi, 2006). Such groups are culturally diverse, and have complex social and health needs which emanate in part from the traumas that they have experienced. Moreover, perceptions and beliefs about illness and its treatment and what is appropriate differ widely from one culture to another, leading to many misunderstandings between healthcare professionals of the host country and migrants. However, healthcare personnel have hitherto received little help in dealing with such issues (Mares, 2002). They often find it difficult to decode the way those from different cultures express suffering, and the role that family members play in the clinical or social care encounter (Ahmadi, 2003; Al- Saffar, 2003; Ekblad, 2003).

One possible solution is to train health and social workers in cultural competency, thus ‘building capacity to provide effective health care taking into consideration people’s cultural beliefs, behaviours and needs’ (Papadopoulos, 2004, p. 109). Another solution is for health and social care organisations to recruit and train paraprofessionals, from among the minority communities, who have experience and understanding of the cultures in both their home country and the host countries. The paraprofessionals’ remit is to build bridges between migrant communities and the health and social care sectors. Various names have been given to such a role, including culture broker, bridge-builder, cultural mediator, lay health adviser and mental health advocate (Eng et al, 1997; Al-Krenawi and Graham, 2001; Rai-Atkins, 2002; Owen and English, 2005). These paraprofessionals may not necessarily represent their own particular cultural groups or communities, but must have knowledge of the values, beliefs and practices of other cultural groups and themselves be culturally competent. Emphasis is placed on the capacity to understand their own cultural identity and value systems, to act as a go-between, and to advocate on behalf of another individual or group (Jezewski and Sotnik, 2005). However, although organisations value their support, such paraprofessionals can often experience heavy workloads and have a high risk of burnout which results in high turnover. Training programmes and supervision are seen as a way to recognise the importance of their work and achieve their retention as paraprofessionals (Owen and English, 2005).

This paper explores the development of a quality improvement project initiated in Sweden which aimed to recruit paraprofessionals from a population of forced migrants who had lived in Sweden for more than five years. Their role was described as that of bridgebuilder. The intention was to draw on their insight and experience to develop new ways ofworkingwithin the services and, at the same time, to provide training to enable bridge-builders to work within their own communities and in health and social care services. The paper shows how the bridge-builders’ understanding of the role evolved as they reflected on their experiences using a structured approach, which in turn gave rise to three possible models of what the task of a bridge-builder should be.

Background

Swedish society is relatively homogeneous. There is an overall consensus within society,which is largely taken for granted, with regard to values and ways of behaving and high expectations of conformity to those prevailing norms. Equity, equality and solidarity or consensus form part of these core values (Lo¨fgren, 2003). Although there are differences of opinion between individuals about these norms, the collective values tend to focus on a middle ground of educated, white, middleclass people. Cultural norms about safety (trygghet) and equality (ja¨mlikhet) are institutionalised within the State and the health service (Saltman and Bergman, 2005). Non-Swedish people find it easier to conform and adopt the prevailing norms in order to fit in with society as a whole, rather than retain the cultural practices and traditions of their home countries alongside those of their new host country. Pressure to conform implies a move towards cultural assimilation that runs counter to the policy of multiculturalism. Although equality is the aspiration, the reality for those who are different is actually inequality.

An emphasis on equality also means a tendency towards uniformity or sameness (lagom), in which everyone is equalised to the level of the group (Welles- Nystro¨m, 1996), which paradoxically makes difference or diversity difficult to handle. Moreover, there is a strong emphasis on self-sufficiency and not seeking help (Town, 2002).

Sweden has no colonial history, and during the 19th and early 20th century it experienced large-scale immigration. Large-scale immigration is a new experience, but over 13% of the population are now defined as non- Swedish in origin (Statistics Sweden, 2008), and a significant proportion of the migrants in recent years have been forced refugees with specific health and social needs (Ekblad, 2004). This change is creating an invisible wall at the interface between the relatively uniform Swedish majority and the relatively new minority communities who are perceived as different or other (Weiss, 1995, p. 19). This ‘othering’ process, in which publicly funded health services are currently playing a part, has potentially profound implications for health inequality (Grove and Zwi, 2006).

The project discussed in this paper arose from the sense of frustration that health personnel in a primary care centre were experiencing when trying to deal effectively with forced migrants’ complex needs which they did not fully understand. A needs assessment facilitated by the local university explored the nature of the problem and its solution by involving local forced migrants directly in the process. This drew attention to the importance of giving a voice to local forced migrants with regard to capacity building, and their value as a resource to the health system in terms of their unique experiences and bicultural background. It also raised awareness of a more general need, beyond the primary care centre, in the wider health and social care system (Abrahamsson et al, 2005; Lind, 2007).

Building on this earlier project, a demonstration project was initiated, namely the bridge-builders’ project. This was a unique collaboration between local agencies who were involved in the delivery of health and social care, including local primary care centres, two local hospitals, the local authorities responsible for community health and social care, and the local social insurance office and job centre. The aim was to develop a working model of how to engage with the forced migrant community within the health and social sector in such a way as to produce more culturally sensitive and appropriate services. Experienced healthcare professionals who regularly encountered forced migrants in their work were recruited to facilitate contact between the project team and the communities. These frontline members of staff were to act as gate-openers, so that bridge-builders could gain experience of what it was like within the health service units (Abrahamsson, 2007). The project leader, who was appointed by the local authority, recruited eight potential bridge-builders to the project, consisting of five women and three men, aged 26–61 years. Five of these individuals came from the Baltic States (Nos 1–5), two came from Arabic countries (Nos 6–7), and one came from Northern Africa (No. 8). In order to protect their identities, it was agreed that no further information about them would be included in any report. The project was very small, and it was feared that some forced migrants might be identifiable.

The objective was to recruit individuals who had lived in Sweden for at least five years and who were familiar with their new home country’s societal structure, norms, values and traditions. Some individuals were judged as not meeting these criteria and were therefore excluded during the recruitment process because of their unwillingness to accept some fundamental values – for example, equal rights for women.

The bridge-builders were linked to eight units, each of which had a gate-opener, whose task was to prepare and anchor the initiative among their colleagues and to facilitate the bridge-builders’ access to the units to do their work. Bridge-builders would work full-time for one month familiarising themselves with the work of the unit and getting to know staff.

The project was underpinned by a set of core values. First, the bridge-builders themselves and their experiences and knowledge were considered to be central to the development of the new working model. Secondly, it was important to ensure that the people who took on the role of bridge-builders were seen not only as representatives of their respective communities, but also as individuals who could contribute to the development of society by becoming paraprofessionals. Indeed, since part of the funding came from the European Social Fund, pathways to employment in health and social care had by necessity to be part of the equation. This meant that the capacity of the participants to achieve this would be developed at the same time as exploring and co-creating the role itself. Thirdly, and perhaps most importantly, the tendency to treat the participants as different or other would be actively counteracted (Grove and Zwi, 2006) through a process that was based on participatory principles (Lind, 2007). The intention was to give voice to all parties involved, including the migrant community members themselves.

Capacity building and service development through dialogue and reflection

A cyclical process consisting of continuous sets of cycles of reflection and learning involving the key elements of ‘look’, ‘think’ and ‘act’ was adopted (Koch and Kralic, 2006). The cycles were used both to develop the participating bridge-builders to the level of paraprofessional and to co-construct the working model. Thus the two sets of cycles were interlinked in such a way that the new bridge-builders’ unique experiences would act as a platform from which to build capacity in the development of new ways of working that would better address forced migrants’ needs at the same time as they were being trained in their new role. In practice, both during the training programmes and in meetings between bridge-builders and gate-openers, there were many mini-cycles of reflection on action, learning and new action (Wadsworth, 2006) within these two main strands.

The notion of dialogue was central because ‘During conversations, people absorb new ways of seeing or thinking in the light of their experience, leading to new actions. With practice, these become the focus of discussion, further reflection and group self-understanding’ (Koch and Kralic, 2006, p. 30). In the training and development project, dialogical opportunities or, as McKie (2003) calls them, ‘rhetorical spaces’ were created for such learning to take place. This complemented the project’s training objectives, such as increased cultural awareness and competence and increased knowledge of public health, ethics and society. An example of such a process was the story dialogue method that started the first training session. A story dialogue session is a way to develop a theory by exploring the participants’ ways of seeing a problem (Labonte et al, 1999). Another dialogical space was created by a workshop at the end of the internship where a set of evaluation questions was developed by representatives from all primary stakeholders, including bridge-builders, gate-openers,managers, project leaders and researchers. Evaluation data to answer these questions were collected using an Internet-based questionnaire, primarily consisting of open-ended questions, which was sent to gate-openers, managers and front-line workers at the units where the bridge-builders had been doing their fieldwork. In addition, each bridge-builder was interviewed one week after the demonstration project had ended. An initial analysis of the interview and questionnaire data was performed by the first author. During a series of workshops with the bridge-builders, this analysis was further developed collectively.

Learning to become a bridge-builder through a co-creation process

Building on experience: the meaning of being a forced migrant

During the initial story dialogue session (Labonte et al, 1999) the newly recruited bridge-builders were asked to tell their personal stories of forced immigration. All of the stories were summarised and analysed collectively during the session. Both positive and negative aspects of being a forced migrant emerged. There were negative experiences of lost identity, disappointment and a sense of inferiority in relation to the indigenous population, particularly officials in the new country:

‘To be a refugee means to work on the recollection of difficult moments when one was involuntarily forced to leave his/her country and family. Life changes when one lacks the power to decide over one’s life, whether during the process of fleeing or when as a new Swede one is confronted by the Migration Office or the police. The expectations regarding the feeling of security turned out to be fake. We often encounter fear, suspicion and distance. One does not feel as a person, [but] rather as a case. Others don’t believe in us and we tend to be judged by others who lack sufficient knowledge. At the same time we think that others know and don’t question. It is very difficult to be oneself when one has lost one’s way, when both the rhythm of life and dreams have been shattered.’

The importance of one’s own identity became obvious after living in the new country for a longer period of time.

‘To be an immigrant and sometimes a Muslim means facing difficulties. However, it is important to stand up for who we are. One must struggle and be open even if pertaining to the Muslim religion. After all, there is no difference between us people of different religious affiliation. Prejudice exists not only among Swedish people but also among immigrants against Swedish people and their society. Individuals are often kind if not influenced by group pressure. We should not regard ourselves as victims. We have rights as well as obligations and duties, and we must show it to our kids. We have made a choice and we must therefore abide by it. If not, one can always pack up and move on.’

On the other hand, there were positive experiences of having had the opportunity to experience a new country with a different culture to the one that an individual was born into:

‘To be a refugee is not only something regarded negatively. The positive part of it is that one is able to speak many languages, understand others and gain experiences worth safeguarding. To leave one’s country means that we now face new life requirements that is not solely of surviving, adapting to your group and avoiding social criticisms.’

Collective analysis of the stories led to the development of a statement aboutwhat the group had learned. This was summarised as follows:

‘Better preconditions for integration may be about optimism and less uncertainty about the future. This is easier to achieve if, when you get to Sweden, you are seen as an individual with resources that are useful to society.’

Reflecting on theory in relation to previous experience

The training was planned as a dialectic process between theory and the bridge-builders’ experiences. The didactic content focused on theoretical studies that were seen as useful knowledge for a bridge-builder. Reading material in Swedish included the following:

• public health (e.g. determinants of health inequalities)

• psychology (e.g. issues of identity and psychological first aid)

• medical anthropology (e.g. to increase understanding of beliefs about health and of different health systems).

This reading was complemented by visits to different institutions. Bridge-builders’ experiences of their escape from conflict, and their life in Sweden, were used as material for reflection.

The theoretical starting point in the course was the concept of a sense of coherence (SOC) developed by Antonovsky (1987). This is defined as a stable generalised orientation with regard to perceiving and controlling the environment for meaningful and appropriate action. Three factors are essential for SOC, namely comprehensibility, manageability and meaningfulness. SOC helped the bridge-builders to make sense of their experiences:

‘I suddenly realised that I must take responsibility for my acts and prove that I have something to give to Swedish society. I drew a great lesson from our discussion on the salutogenic theory which shed light on the positive factors which exist around and which we often neglect. Now that I am living in Sweden I must be part of the society and make sure that I merge in one way or another, and avoid regarding myself as an immigrant [who is] hoping and waiting for the natives to treat me as such.’

The bridge-builders were surprised that their unique knowledge and experiences were being regarded as resources in the development of a working model for bridge-building. This was the first time that they had been recognised as resources in the society in which they now lived:

‘First I didn’t realise that we bridge-builders were going to develop a working model. Not before the period of fieldwork. It occurred to me that we were going to create something new, that this was what the project was about. I was so stuck to that other decides what to do and take responsibility, even though I am well educated, this picture of me was still there. This time, at last, I was expected to work independently. Before I fled from my country that was me. It resulted in that I found myself again without anyone giving you instructions and watching what you’re doing. Now things had changed. I’m not a case and a number any longer.’

In the follow-up workshop which took place after the one-month internship had ended, the bridge-builders highlighted how important it was, as refugees, to gain insight into having a choice. The nature of their own transition was reflected in their stories, and particularly the resulting acculturative stress. Acculturative stress results from disruptions to the processes of identity change that commonly occur as part of cultural adaptation. The process involves three stages. In the first stage, the old identity is rejected. In the second stage, the person gets caught up between the old and new identity. In the final stage, they develop a new identity (Berry, 1997). This process impacts on selfesteem, self-efficacy and health, and can result in either segregation or total rejection of the old culture (Bridges, 2003). Increased personal awareness and knowledge of transition processes in general were reflected on in dialogue. In the discussions and reflections on the process through the story dialogue process the aim was to reach a point where the bridge-builder could feel ‘at home’ in both cultures (Samarasinghe, 2007). They could then act as facilitators to others in this process.

Health beliefs in different cultures, and differences in the way in which health and welfare systems in general are organised, were reflected upon using both theory and experiences. The following extract, from the internship, illustrates how these different belief systems had consequences for diagnosis and treatment compliance. For example, after a visit to the physician a man said to one of the bridge-builders:

‘The physician looked in a big book. It scared me. Is he really a trained doctor skilled to do his job, since he can’t write a prescription without looking in a big book? At home the doctors don’t do so – they are skilled. They do know what to do without reading in big books.’

Another example stemmed from stigmatisation of mental health problems that were perceived as deviant, and which resulted in a reluctance to talk about such problems. One bridge-builder said:

‘A man with frequent headaches often visits the emergency unit seeking help in vain. It is only when he meets me that he explains in his own language that he suffers from psychological problems, something he could not inform the Swedish staff. I inform him where he could possibly get help. After a period of time I meet him again and he thanks me for the advice he got and the instructions he followed to get better.’

These examples illustrate some of the conflicts between staff and refugees that stemmed from refugees’ psychological barriers to using health services. The clinical bias of healthcare in their home countries had generated a general mistrust of staff (Ekblad, 2003). However, trust and distrust in a new country were not exclusively linked to healthcare, as the bridge-builders also told stories about life in Swedish society in general. These experiences, together with differences in health and social support in their home countries, emerged as critical to explaining why encounters in health and social services became problematic. Nonetheless, it was concluded that trust could more easily be built when a forced migrant came to a welfare organisation and encountered a bridge-builder – that is, a person who, as well as understanding his or her language, was more like him- or herself and could more easily ascertain his or her real needs because of their common background and experiences. Talking to someone who was perceived as able to acknowledge the individual was very important, and contrasted with the distanced and professional manner that Swedes usually displayed. From the internship, one bridgebuilder concluded that his experiences of refugees’ trust in their relationship with staff could be summed up as follows:

‘When you feel lonely and unfairly treated you don’t trust the help you are offered, since you don’t believe that you are understood. If you don’t trust the help, you reject it.’

An equal relationship when meeting psychosocial needs has been described as especially important for the mental health of refugees (McKinney, 2007). Cultural differences were often a source of conflict in encounters. A new country’s belief system does not always make sense to refugees. Within minority communities this creates a sense of insecurity, because individuals are often moving from a society which thinks primarily in terms of the collective into one that is more individualistic (Helwig, 2006). Ways of expressing unpleasant feelings both verbally and nonverbally, ways of relating to individuals in authority and relationships between men and women differ markedly. For example, the shaking of hands is very common in Swedish society, and if a man does not shake the hand of a woman this can create a sense of uneasiness among the host population. The bridgebuilders’ understanding of such situations, and the importance of differences in ways of thinking and the symbolic meanings of actions enabled them to facilitate encounters between forced migrants and staff. One bridge-builder described how such situations could be dealt with:

‘I’ve learned to use theory, and I can use Swedish words to explain what happens culturally. I also see people in a different way. I’m talking differently to people. This is useful when I map an encounter with an immigrant that has become problematic and I can explain why.’

Bridge-builders considered that it was crucial for them to develop a cultural self-awareness of their own background and identity in order to approach encounters between forced migrants and frontline workers successfully. In the follow-up workshop, one bridgebuilder said:

‘Since we [have] now got words to use to explain cultural differences and can understand what they are about we can be more open and can get other people to understand each other. As a bridge-builder you [have] got to be more culturally aware than everyday men and women.’

The above quote demonstrates the findings of Papadopoulos et al (2004) that bridge-builders contribute to cultural competency in organisations by bringing the cultural knowledge, awareness, sensitivity and competence that they have developed as part of their training.

The co-created working models

A key aim of this demonstration project was to develop a working model that would combine the bridge-builders’ own experiences and the theoretical content of the training programmes. In the end, three working models were developed by the bridgebuilders. The models reflected the three earlier foci identified by participants together in the project (gateopeners, frontline workers and bridge-builders). Each incorporated bridge-builder roles as a mediator in the care encounter (see Table 1), as an information provider (see Table 2) and as an enabler of integration (see Table 3). In each case they identified not only what actions the bridge-builder should take, but also how andwhy they should do so. Thus, in the context of encounters between forced migrants, healthcare and social service personnel, a bridge-builder would be working to increase understanding of cultural differences, creating mutual trust and feelings of safety. The bridge-builder would therefore facilitate problematic encounters in order to improve the quality of service delivery in health and social care. In the context of meetings between and the training of frontline workers in cultural competence, a bridge-builder would work to prevent fear and suspicion of immigrants by the majority community. Bridge-builders’ encounters with minority communities would aim to prevent fear and suspicion of the new home country’s culture, and to guide individuals through the complex process of assimilation and integration into Swedish society, and the inevitable reconstruction of self that this entails (Gastaldo et al, 2004).

The participants saw bridge-builders’ roles as having three potential foci, and they could focus on one or all of these. The first focus is on the interface between the health and social care system and the forced migrant as a facilitator of relationship. The second focus is on building cultural competency in organisations. The third focus is on enabling those from the forced migrant community to adapt to the new host society.

Negotiating the inherent ‘othering’ processes within both the Swedish and forced migrant communities

This paper has reported experiences of a quality improvement project aimed at developing a working model that is relevant to the context of the Swedish health and social care system. An understanding of the tasks that bridge-builders should undertake evolved as they reflected on their theoretical training, their ethnic and social backgrounds, and their experiences as forced migrants. The parallel process in this project of enhancing service provision and of training lay forced migrants to take on a paraprofessional role brought to the surface a number of tensions for the participants as their understanding evolved and they developed personally. These tensions arose partly from the specific tasks of the boundary role played by the bridgebuilders, as well as from their own processes of selfreconstruction as they adapted to their new role.

diversityhealthcare-care-encounter

Table 1: A bridge-builder as mediator in a care encounter.

diversityhealthcare-bridge-builder

Table 2:A bridge-builder as an information provider.

Their experiences as bridge-builders also encapsulated some of the tensions emanating from contradictions and paradoxes with regard to immigration that exist in Swedish society as a whole. Adopting a cyclical approach, based on reflection and learning, to the development of the bridge-builders and their role allowed the interplay between the personal and social aspects to be explored (Freire, 2002). This facilitated the incorporation of theoretical ideas and the bridgebuilders’ lived experience of ethnicity, class, gender, age and what had happened during the internship. However, this approach enabled only some of the bridge-builders to gain an understanding of their experiences and to set those experiences in a societal context. When it was originally developed, the project did not expect or plan for the wide variation in individuals’ educational backgrounds and learning styles. This would need to be addressed in any future similar project.

diversityhealthcare-facilitator-integration

Table 3:A bridge-builder as a facilitator of integration.

Overall, the learning process was not an easy one for any of those concerned, including the project leaders, as anumber of tensions became apparent.These tensions reflected those that exist in Swedish society as a whole, and originated from within both the majority and the minority communities. From the majority community, tensions arose from an implicit but continuously ongoing othering process (Grove and Zwi, 2006). This was evidenced by a general reluctance and unwillingness on the part of individuals to get involved with people who were dissimilar to them – in this case, forced migrants (Yonas et al, 2006). On an everyday level this reluctance is experienced by forced migrants as being avoided by others and being excluded from normal social relationships.

The failures of health and social services to deliver an adequate service to forced migrants can be seen as a form of institutionalised racism (Papadopoulos, 2004). The culture of the organisations involved is such that staff do not want to admit to a lack of knowledge about people who do not fit into their world view. Instead of engagement in a process of cultural learning, there is discrimination against people who are different. In this project, bridge-builders experienced this in one particular setting. The othering process was reinforced by everyday experiences of encounters with forced migrants who, frustrated by their failure to be understood or to understand, often became angry, emotional and confrontational. Such behaviours are not part of Swedish norms, and therefore further reinforce the predilection for othering. Institutionalised racism is also manifested when individuals who are in positions of power base their decisions on implicit traditions and routines that exclude those who are different (Agevall, 1994). This could explain why only a few of the eight bridge-builders actually obtained employment in health and social care organisations, which was the original aim of the project.

However, there are also othering processes in the forced migrant communities themselves, which are evidenced in two ways. First, because of an ongoing distrust of Swedish society based on refugees’ early experiences of exclusion, any bad experience is seen as affirming previous perceptions of marginalisation. This encourages a tendency to move closer to the security of a familiar culture and traditional values (Grove and Zwi, 2006). These offer a sense of belonging and security to newcomers who advocate segregation and put pressure on others to join a lifestyle that is based on traditional values. Thus Swedish society and Swedes are othered. Secondly, interwoven with issues of identity there is the othering of those who choose to be different. This is particularly the case with women. As a vulnerable group they are often seen as subordinated to men within collectivist and patriarchical communities (Thurston and Vissandje´e, 2005). In choosing to move towards assimilation and integration potential, they may experience rejection. The following quote from one of the female bridge-builders who failed to find a pathway to employment after the project illustrates the tension:

‘Other people in my group have noticed that I’ve changed, that I do things differently. I’m also thinking differently. Some people dislike that and others respect me more. I’ve moved away from them since I’m working, but now when I’m out of work it is difficult. ... They now have grist to their mill. They say the Swedish society does not want to acknowledge us and pay us for our work. We are not good full citizens.’

Although every effort was made by the project lead to prevent this from happening, this situation demonstrates a paradox that has been highlighted elsewhere by Williams and Labonte (2007) with regard to empowerment projects aimed at marginalised communities, namely that they can also create marginalisation within that community of those who have become more empowered. Women’s rights as individuals – a key feature of Swedish society – are seen as a threat to the family, especially where there is already a sense of insecurity emanating from being in a new and confusing world (Thurston and Vissandje´e, 2005). Families who were less traditional in their home country often move towards a more traditional lifestyle in the new country as a way to prevent crises and to gain security and stability for the family (Samarasinge, 2007). Moreover, the inability to find employment undermines men’s role as breadwinners, and suggests that solving this problem will enable the empowerment of women in such communities.

There were other ethical issues that also needed attention. For example, extra time and energy were required to address the issue of secrecy and how it is handled in different social practices based on collectivist or individualistic cultural orientations (Li and Vermillion, 2006). The identity of the bridge-builders was difficult to protect, as the population from which they were recruited was small and the city in which they were recruited was also small. For this reason, details of their gender, age and country of origin were not included in any reports.

The project was a pilot and was funded for only one year. However, the working models that were created as a result of the process should be seen as prototypes which need to be properly evaluated in different contexts. It would be particularly useful to test the model in other countries, with different histories of immigration, and to compare those participants’ experiences. The issues raised in this project are not unique to Sweden, but are a useful starting point in understanding variations in cultural norms and values and how they impact on issues of delivery of health and social care to refugees and other forced migrants.

The challenge for Swedish society is to move from seeing integration as a service that is provided to passive forced migrants, to seeing such individuals as resources who will help to build a multicultural society. In other countries, the challenges may well be different. In terms of the broader issues that exist in society, the bridge-builder project was just one small step on the road to unpicking misunderstandings between majority and minority communities at different levels in different circumstances. Ultimately, however, the structures within society that reinforce the othering process need to be addressed, as ‘commitment to redressing exclusion must be pervasive, persistent and intersectoral, and focus attention at all levels’ (Lynam and Cowley, 2007, p. 148).

Conclusion

Inherent in any boundary-worker role is the need to deal with being on the edge of two cultural systems while maintaining the link with one’s own culture (Braithwaite and Cockwill, 2007). Facilitating the transition of a potential bridge-builder to this role means helping them to acquire the competence to feel at home in both cultures while at the same time being able to negotiate the differences (Oppedal, 2006).During the development and implementation of this project, many hard lessons were learned. From those lessons the following recommendations are made with regard to what should be taken into account when planning projects like this one. Qualities such as openness to change, flexibility, and the ability to achieve some distance from and awareness of their own background in relation to the host country should play a key role in identifying and recruiting potential bridge-builders.

Project leaders themselves need both to keep an open mind and to be sufficiently self-reflective to handle the implicit and hidden othering processes in both majority and minority communities that are central to creating the frustration often experienced by all involved.

Time is needed for potential bridge-builders to become familiar with educational systems that are less didactic and which are based on taking responsibility for one’s own learning. In this project it became clear that it was necessary to allocate extra time for supervision and reflection, particularly about the difficult but nonetheless interesting and relevant issues of how the bridge-builders’ ethnicity mediated their experience in the broader context of their lives. The dialogical and reflexive processes inherent in Freirean approaches to education facilitate sensitive and appropriate exploration of these issues.

There are special ethical issues related to the consequences for individuals who participate in a project. These consequences are linked to ways of seeing the world from a collective and individual perspective, as well as the social structure of minority communities. Processes need to be in place to support those who may be at risk because they have entered a process of personal change that could potentially lead to alienation. Securing permanent posts to enhance economic independence would go a long way towards alleviating the problem.

It is important to acknowledge and explore differences as well as similarities. In homogenous societies such as that in Sweden, an open and reflective debate on these would enhance public understanding and contribute to learning and development.

Acknowledgements

We extend special thanks to all of the bridge-builders who participated in this experimental project, as well as to the individual gate-openers and service personnel whose thoughts, experiences, and desire to make it work contributed to the development of the project. The study was supported by Kristianstad University and Region Ska˚ne.

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