Understanding healthcare practices in superdiverse neighbourhoods and developing the concept of welfare bricolage: Protocol of a cross-national mixed-methods study

Developing a realist informed framework for cultural adaptation of lifestyle interventions for the prevention of type 2 diabetes in South Asian populations in Europe

AIMS

Selected lifestyle interventions proven effective for White-European populations have been culturally adapted for South Asian populations living in Europe, who are at higher risk of type 2 diabetes. However, a limited theoretical basis underpins how cultural adaptations are believed to augment intervention effectiveness. We undertook a realist review to synthesise existing literature on culturally adapted type 2 diabetes prevention interventions, to develop a framework that shows 'how' cultural adaptation works, for 'whom' and in 'what contexts'.

METHODS

We followed the stepped methodological approach of realist review. Our work concluded a European-wide project (EuroDHYAN), and core studies were identified from the preceding EuroDHYAN reviews. Data were extracted, coded into themes and synthesised to create 'Context-Mechanism-Outcome' configurations and to generate a refined explanatory framework.

RESULTS

We identified eight core intervention papers. From this evidence, and supporting literature, we examined the 'Team' domain of cultural adaptation and identified a mechanism of shared cultural identity which we theorised as contributing to strong team-participant relationships. We also identified four key contexts which influenced intervention outcomes: 'research setting' and 'heterogeneous populations' (intrinsic to the intervention) and 'broader environment' and 'socio-cultural stress' (extrinsic barriers).

CONCLUSIONS

This work instigates research into the mechanisms of cultural adaptation which, if pursued, will allow a more nuanced understanding of how to apply adaptations, and for whom. In practice we recommend greater consideration of heterogeneous and intersecting population characteristics; how intervention design can safeguard sustainability; and how the four key contexts identified influence how, and whether, these interventions work.

"It's the First Barrier" - Lack of Common Language a Major Obstacle When Accessing/Providing Healthcare Services Across Europe

International migration is shaping and changing urban areas as well as impacting on healthcare access and provision in Europe. To investigate how residents of superdiverse neighborhoods put together their healthcare, we conducted qualitative interviews with 76 healthcare providers and 160 residents in four European cities - Bremen, Germany; Birmingham, UK; Lisbon, Portugal and Uppsala, Sweden, between September 2015 and April 2017. A common theme arising from the data was language and communication obstacles, with both healthcare providers and users experiencing language difficulties, despite all four countries having interpretation policies or guidelines to address language barriers in healthcare. Official interpreter services were seen to be unreliable and sometimes of poor quality, leading to a reliance on informal interpretation. Some coping strategies used by both service providers and users led to successful communication despite the lack of a common language. Where communication failed, this led to feelings of dissatisfaction and frustration among both users and providers. Language difficulties came up across all participating countries even though this was not prompted by interview questions, which highlights the widespread nature of language barriers and communication barriers and the need to address them in order to promote equal accessibility to good quality healthcare.

Racism in European Health Care: Structural Violence and Beyond

Research shows how racism can negatively affect access to health care and treatment. However, limited theoretical research exists on conceptualizing racism in health care. In this article, we use structural violence as a theoretical tool to understand how racism as an institutionalized social structure is enacted in subtle ways and how the "violence" built into forms of social organization is rendered invisible through repetition and routinization. We draw on interviews with health care users from three European countries, namely, Sweden, Germany, and Portugal to demonstrate how two interrelated processes of unequal access to resources and inequalities in power can lead to the silencing of suffering and erosion of dignity, respectively. The strength of this article lies in illuminating the mechanisms of subtle racism that damages individuals and leads to loss of trust in health care. It is imperative to address these issues to ensure a responsive and equal health care for all users.

Superdiversity, migration and use of internet-based health information - results of a cross-sectional survey conducted in 4 European countries

BACKGROUND

Studies of factors associated with the use of Internet-based health information generally focus on general, rather than migrant populations. This study looked into the reasons why Internet-based health information is used and the effects of migration-related factors, other socio-demographic characteristics and health-related factors on the tendency to consult the Internet.

METHODS

In a cross-sectional survey conducted in eight superdiverse neighbourhoods - two each in Birmingham, United Kingdom; Bremen, Germany; Lisbon, Portugal and Uppsala, Sweden - participants were presented with six scenarios and asked to indicate the resources they most relied on when addressing a health concern from a given list. The scenarios included establishing the underlying causes of a health concern and seeking information about prescription drugs, treatments and services available as part of the public healthcare system. The list of resources included the public healthcare system, alternative medicine, family and friends, and the Internet. Frequencies for which the Internet was consulted for each different scenario were calculated and compared across the participating cities. The association between consulting Internet-based health information and migration-related factors, and further socio-demographic characteristics as well as health-related factors such as self-reported health and health literacy was assessed using multivariable logistic regressions.

RESULTS

Of the 2570 participants from all four cities who were included in the analyses, 47% had a migrant background and 35% originated from non-EU countries. About a third reported relying on Internet-based health information for at least one of the given scenarios. The two most frequently chosen scenarios were to find out about other possible treatments and prescription drugs. Generally, using Internet-based health information was negatively associated with being a first generation migrant (OR 0.65; 95% CI 0.46-0.93), having poor local language competency (OR 0.25; 95% CI 0.14-0.45), older age (≥60 years, OR 0.21; 95% CI 0.15-0.31), low education (OR 0.35; 95% CI 0.24-0.50) and positively associated with low trust in physicians (OR 2.13; 95% CI 1.47-3.10).

CONCLUSION

Our findings indicate the need to consider migration background and language competency when promoting the provision of healthcare services via the Internet so that information and services are widely accessible.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

Healthcare bricolage in Europe's superdiverse neighbourhoods: a mixed methods study

BACKGROUND

Studies of the relationship between diverse populations, healthcare access and health outcomes have been dominated by approaches focusing on ethno-national groups or specific healthcare sectors. Healthcare bricolage conceptualises the processes by which individuals use multiple resources to address health concerns. It is relevant in superdiverse neighbourhoods with complex populations. This paper is original in its application of mixed methods to examine the extent to which, and the reasons why, individuals engage in healthcare bricolage.

METHODS

The study utilized a parallel sequential methodology. Eight superdiverse neighbourhoods were selected, two in each of Bremen, Birmingham, Lisbon and Uppsala. Ethnographic research scoping the nature of each healthcare ecosystem was followed by 160 interviews (20 each neighbourhood) with a maximum variation sample of residents undertaken October 2015 to December 2016. Interviewees were asked to recall a health concern and describe actions taken to attempt resolution. Data was coded with a MAXQDA codebook checked for inter-coder reliability. Interview findings enabled identification of five types of bricolage, the nature of healthcare resources utilised and the factors which influenced residents' tactics. Results were used to design a household survey using new questions and validated epidemiological instruments implemented January to October 2017. Respondents were identified using random address files and interviewed in person or by telephone. Multinomal logistic regressions were used to estimate the effect of changing the values of determinants on the probability of observing an outcome.

RESULTS

Age, gender, level of education, migration background and extent of functional limitation were associated with bricolage tactics. Individuals demonstrating high levels of agency were more likely than those with low levels to engage in bricolage. Residents with high levels of trust in physicians were less likely to bricolage than those with lower levels of trust. Levels of health literacy showed no significant effects.

CONCLUSIONS

The nature and severity of health concern, trust in physicians and agency shaped residents' bricolage tactics. The concept of bricolage enabled us to make visible the actions and resources utilised around public healthcare systems that would otherwise remain outwith healthcare access research. Actions were frequently undertaken via networks offering insights into healthcare-seeking behaviour.

Undoing the unspeakable: researching racism in Swedish healthcare using a participatory process to build dialogue

Background

Racism is difficult to discuss in the context of Swedish healthcare for various cultural and administrative reasons. Herein, we interpret the fragmentary nature of the evidence of racialising processes and the difficulty of reporting racist discrimination in terms of structural violence.

Methods

In response to the unspeakable nature of racism in Swedish healthcare, we propose a phased participatory process to build a common vocabulary and grammar through a consultative framework involving healthcare providers and service users as well as policy-makers. These stakeholders will be involved in an educational intervention to facilitate discussion around and avoidance of racism in service provision.

Discussion

Both the participatory process and outcomes of the process, e.g. educational interventions, will contribute to the social and political conversation about racism in healthcare settings. Creating new ways of discussing sensitive topics allows ameliorative actions to be taken, benefitting healthcare providers and users. The urgency of the project is underlined.

Superdiversity, population health and health care: opportunities and challenges in a changing world

OBJECTIVES

Ethno-national approaches to research public health and migrant outcomes have dominated for decades but lack efficacy in a globalised world and in view of the intractable nature of health outcome inequalities for migrant and minority groups. This article highlights some of the challenges and opportunities associated with a superdiversity perspective in public health research.

SUPERDIVERSITY AND ETHNO-NATIONAL APPROACHES

Migration patterns have changed with more people arriving from more places and the diversification of diversity meaning that the ethno-national categories utilised in public health research have reduced explanatory potential. THE EXAMPLE OF MATERNAL AND PERINATAL MORTALITY IN THE UNITED KINGDOM: Adjusting UK perinatal mortality rates by five ethnic groups based on assumptions of relationships between high levels of risk and ethnic groups masks the scale of inequality faced by groups wherein mortality rates are increasing and highlights some of the difficulties associated with using ethno-national classifications.

A SUPERDIVERSITY PERSPECTIVE

A superdiversity approach moves beyond ethno-nationalism to socially locate groups focussing on commonalities and differences across spaces and characteristics and employing intracategorical or anticategorical approaches.

CONCLUSIONS

Superdiversity brings new levels of demographic complexity and fluidity. Greater reflexivity is needed in diversity research with justification of classifications used for analysis necessary when research questions are developed.

Feasibility of using respondent-driven sampling to recruit participants in superdiverse neighbourhoods for a general health survey

OBJECTIVES

Respondent-driven sampling (RDS), a modified chain-referral system, has been proposed as a strategy for reaching 'hidden' populations. We applied RDS to assess its feasibility to recruit 'hard-to-reach' populations such as migrants and the unemployed in a general health survey and compared it to register-based sampling (RBS).

METHODS

RDS was applied parallel to standard population RBS in two superdiverse neighbourhoods in Bremen, Germany. Prevalences of sample characteristics of interest were estimated in RDS Analyst using the successive sampling estimator. These were then compared between the samples.

RESULTS

Only 115 persons were recruited via RDS compared to 779 via RBS. The prevalence of (1) migrant background, (2) unemployment and (3) poverty risk was significantly higher in the RDS than in the RBS sample. The respective estimates were (1) 51.6 versus 32.5% (95% CI_RDS 40.4-62.7), (2) 18.1 versus 7.5% (95% CI_RDS 8.4-27.9) and (3) 55.0 versus 30.4% (95% CI_RDS 41.3-68.7).

CONCLUSIONS

Although recruitment was difficult and the number of participants was small, RDS proved to be a feasible method for reaching migrants and other disadvantaged persons in our study.

Researching health in diverse neighbourhoods: critical reflection on the use of a community research model in Uppsala, Sweden

OBJECTIVE

A community research model developed in the United Kingdom was adopted in a multi-country study of health in diverse neighbourhoods in European cities, including Sweden. This paper describes the challenges and opportunities of using this model in Sweden.

RESULTS

In Sweden, five community researchers were recruited and trained to facilitate access to diverse groups in the two study neighbourhoods, including ethnic, religious, and linguistic minorities. Community researchers recruited participants from the neighbourhoods, and assisted during semi-structured interviews. Their local networks, and knowledge were invaluable for contextualising the study and finding participants. Various factors made it difficult to fully apply the model in Sweden. The study took place when an unprecedented number of asylum-seekers were arriving in Sweden, and potential collaborators' time was taken up in meeting their needs. Employment on short-term, temporary contracts is difficult since Swedish Universities are public authorities. Strong expectations of stable full-time employment, make flexible part-time work undesirable. The community research model was only partly successful in embedding the research project as a collaboration between community members and the University. While there was interest and some involvement from neighbourhood residents, the research remained University-led with a limited sense of community ownership.