Uncharted Paths: The Use of Traditional, Complementary and Alternative Medicine (TCAM) among Sub-Saharan Africans living in the Greater Toronto Area (GTA) by Prince Michael Amegbor A thesis submitted to the Department of Geography and Planning In conformity with the requirements for the degree of Doctor of Philosophy Queen’s University Kingston, Ontario, Canada (July, 2019) Copyright ©Prince Michael Amegbor, 2019 Abstract The appeal of traditional, complementary, and alternative medicine (TACM) is growing among persons living in developed countries. Personal beliefs and traditional values about health and healthcare are deemed significant motivations for the use of TCAM. While existing studies have focused on diverse population groups, including persons of European and Asian descent, TCAM use and behaviour among persons of sub-Saharan African (SSA) descent living in Canada and other developed countries remains unknown. Existing studies on TCAM and healthcare-seeking behaviour of racial or ethnic minorities suggests possible alienation due to sociocultural health beliefs and practices. These studies fail to investigate the role of context in the identity construction and sociocultural belonging and how this ultimately affects the choice of healing practices. Anthias' (2002, 2008, 2012a) asserts that immigrants and their descendants have complex relationships with different locales – country of residence (or naturalised countries) and country of origin. This complex relationship entails social, cultural, symbolic and material ties between homelands and destinations. This research seeks to examine TCAM use among persons of SSA origin living in the GTA and to understand how ethnocultural identity informs the use of TCAM remedies using Anthias’ translocational positionality as a theoretical framework. The study uses a sequential mixed-method approach to garner data on sociodemographic characteristics, transnational relationships, health status and health care-seeking behaviours of persons of SSA origin living in the Greater Toronto Area. Lifetime prevalence of TCAM use among respondents of SSA descent is ~57.14% and 12-month prevalence of TCAM use is ~23.81%. About 48.72% of the respondents indicated the TCAM used are of their ethnocultural ii origin. A sizeable proportion of respondents had unmet TCAM need (~20.88%) and engaged in transnational healthcare-seeking behaviour or medical return (~39.56%). The findings of the interview show the meaning associated with ethnocultural identity and the broader contextual factors that influence the utilisation of ethnocultural identity in health promotion or healthcare-seeking. The findings of the interviews challenge the alienation assumption and show the ability of participants to transcend and transition between ethnocultural identities in different contexts. iii Dedication For my parents (Sarah Acquaye, Mr. Samuel Baidoo and Mr. Roland Amegbor) for their innumerous support in all endeavours of my life, including my academic journey. I also dedicate this thesis to the loving memory of my maternal grandfather (Opanyin Kobina Kwei) for being my inspiration in life and the faith he had in me. iv Acknowledgements I wish to express my sincere gratitude to the respondents and interviewees of this research for their time and interest in participating in this study. This thesis would not be possible without your willingness to share your experiences and motivations with me. I would also like to thank the leaders and members of the various community-based groups and organisations I contacted during my research: the Nigerian Canadian Association, Igbo union, Yoruba union, Sierra Leonean Canadian Federation, Ghanaian-Canadian Association of Ontario, Seneca Village Community Centre, Scarborough Centre for Healthy Communities, Senior Adult Services. My profound appreciation to my supervisor and mentor, Professor Mark Warren Rosenberg, for his continuous support of my Ph.D. study and related research. His guidance helped me in all the time of research and writing of this thesis. I could not have imagined having a better advisor and mentor for my Ph.D. study. I would also like to thank the rest of my thesis committee members: Professor Audrey Kobayashi, Professor Heather Castleden and Professor Beverly Mulling (the committee Chair) for their support and encouragement. Their doors were always open to me whenever I ran into difficulties and needed guidance. My sincere thanks also go to Professor Joyce Davidson for her for the role she played in my coming to Queen’s University; her interest and support together with that of my supervisor (Prof. Mark W. Rosenberg) made me apply to the Queen’s PhD program. Although I never had the opportunity to meet and interact with you, I want you to know I will forever remain grateful. I would also use this opportunity to thank Professor (Emeritus) Jan Hesselberg (University of Oslo) and Prof. Alex B. Asiedu (University of Ghana) for the role and support they gave in my academic journey. My journey as a doctoral student was memorable due to the help of the staff in the Department of Geography and v Planning: Angela Balesdent, John Bond, Kathy Hoover, Joan Knox, Sharon Mohammed and Jo- Anne Tinlin. My appreciation goes to my cohort especially, John Haffner and his partner Laura Pascoe, Paul Sylvestre and his partner Sarah, Sandra McCubbin and her partner Rachel, Kyle Plumb and his partner Evelyn for the community they provided to my family and me during our stay in Kingston. I would also like to thank all professors in the department who in one way or the other contributed to my academic experience at Queen’s: Professor Alice Hovorka, Professor Laura Cameron, Professor Leela Viswanathan, Professor Anne Godlewska, Professor Paul Treitz (the Head of Department during my first year as a doctoral student), Professor Warren Mabee (the Head of Department), Professor Neal Scott, Professor Patricia Collins and Professor Patricia Streich. Last but not least, I would like to thank my wife Janet Marley and lovely daughter Audrey, for their support and love as well as accommodating my coming home late. Without your love, support and encouragement, this journey would have been a solitary one. Thank you, Janet and Audrey. vi Table of Contents Abstract ......................................................................................................................................................... ii Dedication .................................................................................................................................................... iv Acknowledgements ....................................................................................................................................... v List of Figures .............................................................................................................................................. xi List of Tables .............................................................................................................................................. xii List of Abbreviations ................................................................................................................................. xiii Chapter 1 Introduction .................................................................................................................................. 1 1.1 Background ......................................................................................................................................... 1 1.2 Problem rationale ................................................................................................................................ 3 1.3 Research Aims and Objectives ........................................................................................................... 6 1.4 Thesis outline ...................................................................................................................................... 8 Chapter 2 Literature Review ....................................................................................................................... 11 2.1 Introduction ....................................................................................................................................... 11 2.2 Defining : Traditional, complementary and alternative medicine (TCAM) ..................................... 11 2.3 TCAM: Canadian & global dimensions ............................................................................................ 14 2.4 Motivations for using TCAM ........................................................................................................... 18 2.5 Political economy of TCAM - a private market-based healthcare .................................................... 19 2.6 Ethnicity & TCAM ........................................................................................................................... 26 2.6.1 Challenges to access to healthcare among ethnic minority groups ............................................ 28 2.6.1.1 Lack of cultural empathy or cultural sensitivity ................................................................. 28 2.6.1.2 Language barriers ................................................................................................................ 29 2.6.1.3 Structural racism/discrimination ......................................................................................... 30 2.6.1.4 Socioeconomic factors .......................................................................................................