Researching health and welfare in an era of superdiversity

Introduction

In this chapter we highlight some of the main shortcomings of existing approaches to researching health, welfare and healthcare access in diverse places. In particular we explore some of the risks of the adoption of ethno-national sampling techniques and of a siloed approach to understanding welfare and healthcare-seeking behaviours. We argue the need for methods which move away from groupism and which can examine processes undetway in highly complex settings. We then set out a number of different methods for exploring health and welfare in areas of superdiversity, including community research, respondent-driven sampling and maximum diversity sampling before outlining the mixed methods approach we adopted to examine welfare bricolage in superdiverse neighbourhoods. The remainder of the chapter describes in detail the methods implemented in a parallel sequential methodology and the ways in which data was analysed to maximise the usefulness of a comparative approach.

Understanding and researching diversity, healthcare and the welfare state

As we outline in Chapter 3 it was not until post-World War II migration to different areas of Europe that significant attention was focused on the health of migrant populations. Only when health was perceived as a potential risk to the non-migrant population were migrants given attention by researchers and healthcare services to diminish any ‘threat’. Furthermore, other welfare needs of migrants received no attention whatsoever. However, once it was evident that migrants were settling permanently and being joined by family in many European cities, attention turned to incidences of chronic disease and focused mainly on risk factors and outcomes for migrant populations. Problem areas, identified through a (biased) Western ethnocentric lens, were associated with migrant behaviours considered to be harmful. In addition, the health of migrants was associated with international travel and migrants were seen as carriers of certain tropical diseases.

In the UK, socio-economic inequalities in mortality and morbidity were connected to country of birth through the introduction of ethnic group categories, a move that acknowledged the permanence of migrant populations but implied high levels of intra-group homogeneity. Ethnic categories were intended to enable the identification of inequalities between ethnic groups (Nazroo, 2001) with the ‘White British’ category as a comparator. The number of ethnic categories used in the UK has varied over time (but rarely goes beyond 11) and were developed in the 1990s prior to the emergence of superdiversity. However, since this time they have changed relatively little. In any event, the scale and speed of change associated with the increasing diversity of populations means that any attempt to update categories is pointless. As such, they have rapidly become out of date and fail to reflect changing migration patterns (Aspinall, 2012).

The specificity of the UK ethnic categories also prevents comparison with other countries. Many EU countries, including Portugal, Sweden and Germany, explicitly prohibit the use of racial or ethnic categories, and instead focus on categorising migrants as ‘foreign-born’ and their descendants as children of foreign- born. In Portugal, categories only reflect country of origin or birth, while multiple ethnic or racial identities are made invisible; this approach contributes to erasing the vivid colonial history among Portuguese individuals who were born in the former colonies or those who lost their birth citizenship after the independence of those colonies (Padilla & Franca, 2020; Padilla & Ortiz, 2012). Hence the increasing diversity of populations is often invisible in administrative data.

While approaches to categorising diverse populations across our case study countries are different, they do share a common feature in that they label populations as homogeneous under ethno-national origins. Such homogenisation - which is reproduced by both official statistical sources as well as those undextaking research - reduces the potential to identify meaningful health outcomes within populations. Concerns have been expressed that such ethno-national categories not only ignore 'within group' heterogeneity but also make the assumption that cultural factors underpin certain kinds of migrant and minority health and wellbeing problems. In so doing, they pathologise culture as a causal factor without seeking to understand wider drivers of inequality or acknowledging the lack of evidence about the relationship between culture and health inequalities. Such categorisations also omit the influence of both stincture and context. With the advent of ‘hostile environments’ restricting migrants’ access to state healthcare provision, structure is a factor of increased importance for some categories of migrant which requires examination when seeking to understand unequal outcomes (Phillimore, Bradby & Brand, 2019). Structure is a relevant component of context, where policies can trickle down or reinforce inequalities and inequities. Furthermore, the danger of assuming that ethno-national identities equate to culture - and with the omission of a focus on structure and context - can be illustrated by recent developments in the UK and elsewhere where higher COVED-19 infection and mortality rates in some minority populations were initially correlated with cultural factors such as multi-generational living and group worship rather than socio-economic inequality (Khan, 2020).

The focus on ethnicity or country of origin was a step fonvard towards identifying inequalities across particular groups. Nevertheless, such approaches are a clear case of methodological nationalism (Wimmer & Glick Schiller, 2002) whereby ethno-national backgrounds have been utilised as an explanatory factor in shaping health inequalities at the cost of a focus on structural factors such as immigration experience and racism. Regardless of the power of such categorisations in drawing attention to inequalities in health outcomes, their usefulness in the context of what Vertovec has described as the 'diversification of diversity’ (Vertovec, 2007) is limited. Rather, there is a need for new approaches that help to explore the challenges faced by increasingly mobile, fragmented and complex superdiverse populations in their access to healthcare, and which may offer positive contributions to address issues associated with both old and new diversity.

Research exploring access to healthcare amongst diverse groups has, to date, largely adopted a siloed approach, focusing upon service provision by individual sectors instead of a hilly integrated view capable of simultaneously addressing available resources from different sectors and acknowledging the creativity developed by users and providers to address particular challenges through different strategies. Scant attention has been paid to thinking about how individuals might combine different types of healthcare resources to address their health concerns. Further, insufficient focus has been placed upon the importance of informal provision (Krause, 2008), Internet provision (Gundersen, 2011) and transnational health-seeking strategies (Bell et ah, 2015). The latter is arguably an important omission with the globalisation of migration flows and increasing levels of transnationalism, which has become very relevant in the context of the COVID-19 pandemic.

 
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