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

In the UPWEB study a multidisciplinary team uses a mixed methods design including
ethnographic observation, interviewing and a standardised health survey. The study
will be implemented in eight superdiverse neighbourhoods in four European countries
(Germany, Portugal, Sweden and UK) adopting a within and between country comparative
approach. Each country represents an a priori different type of welfare state regime
according to established regime typologies 34]. Within the countries, two neighbourhoods in one city are selected which are both
characterised by superdiversity but with one of them displaying a high degree of deprivation
and the other showing upward social mobility (Table 1). The study design comprises three stages: a mapping of health-related activities
and infrastructures of the neighbourhoods (street-mapping), in-depth interviews and
participant observation with residents and service providers and a health survey (Fig. 1). The study began in January 2015 and continues until December 2017.

Table 1. Characteristics of the comparison countries and neighbourhoods

Fig. 1. UBWEB study design

Street-mapping

The first stage consists of street-mapping wherein researchers observe and record
micro-level health-related activities underway in each superdiverse neighbourhood
35]. Undertaking online searches and participant observation in each superdiverse neighbourhood,
the research teams will immerse themselves in and familiarise themselves with the
localities. Structured ethnographic observation involving the capture of information
about the local environment, local population activity and diversity, health related
facilities and other faith based and community facilities will be conducted in each
neighbourhood. In so doing – and through the annotation of maps, taking photographs
of buildings housing health activities, talking to local people and the production
of area pen portraits –will enable the identification of informal and private sector
health services rarely appearing on official databases. The fieldwork will be carried
out by academic research staff together with so-called community researchers. Community
researchers are poly-lingual local residents who will receive post-graduate level
research training 36] and are recruited via community organisations and local networks. The community researchers
will utilise their language skills, local networks and knowledge to assist with the
identification of services and in accessing respondents. This phase of the study will
enable the development of connections with providers and residents for subsequent
interviews. Overall, the street-mapping will contribute to a detailed understanding
of the neighbourhoods and supporting a first comparison within and between the four
countries.

Mobile phone application

The data collected from the street-mapping will be entered into a database providing
the basis for a mobile phone application. The data will be inputted into the app by
our researchers, residents and providers, all of who will be trained in its use. While
smartphone usage is limited to 50 % of the general population, ownership rates are
often higher within superdiverse and deprived areas because they are viewed as more
cost effective than landlines/broadband and mobility is valued 37]. Allowing the identification of services and GIS mapping of utilisation, the app
will identify location provision-clusters and allow residents to search and locate
services. This application will eventually provide a crowd-sourced recommendation
system enabling the on-going input and updating of information about healthcare services
across all sectors via smart phone. While the primary aim of the app is to offer a
resource for local communities to improve access to health services it will also aid
us to build a resident-led picture of provision and, subject to its take-up, access
to further funding, and additional ethical approval, we will explore the possibility
of using the app to location track respondents in relation to their access to healthcare.

In-depth interviews with residents and providers

In-depth interviews will detail how residents identify, utilise and combine services.
Researchers and community researchers will undertake paired interviews with a maximum
diversity sample 38] of 20 residents from each neighbourhood, using the resident’s preferred language.
This purposive sampling suits diverse small sample sizes with limited population information.
We will identify our sample through the street-mapping, guarding against over-reliance
on community organisations and consequent under-representation of isolated or self-sufficient
residents. Residents with different combinations of variables including majority,
new and old residents, country of origin, migration status, income, education, age,
gender, religion, and linguistic ability will be included. The interviews will explore
the help-seeking experiences of all types of residents including the ways they experience,
communicate, access and address health need within and beyond neighbourhood boundaries
(i.e. national and transnational networks) – digitally and corporeally – and the factors
that impact on experiences. Each interview will be recorded and translated into the
local research team’s language.

Ten in-depth interviews with providers from public/private/third sectors identified
by residents and street-mapping in each neighbourhood will be carried out. The interviews
will focus on the systems in which professionals operate, including how they identify
and respond to need, the impact of local and national regimes and the challenges faced.

Using ATLAS Ti, the research teams from the four countries will collaboratively analyse
interview data developing an analytical framework constructed from codes created through
team systematic thematic analysis of a 20 % sample of transcripts translated into
English. Thematic analysis involves categorizing qualitative material – in this case
interviews – according to its content and sense, to discern patterns of meaning recurring
across interviews 39]. Each team will then code their own data and meet again to identify different models
of welfare bricolage. This knowledge is then used to create the set of relevant questions
for the survey.

Health survey

In each superdiverse neighbourhood, we will undertake a resident survey testing the
welfare bricolage models identified in the qualitative analysis to explore which type
of models are adopted by which type of residents within or between different neighbourhoods
and countries. The survey questions will be standardised in each country but translated
into local languages. Cognitive testing will be carried out to check question wording
and questionnaire length. Full piloting will be performed to test the questionnaire
in the field and fieldwork procedures. The community researchers, with their local
knowledge/languages, will be part of the survey team. Interviews will be conducted
face to face.

Sampling and recruitment

The target group of this survey includes all adults living in one of the eight neighbourhoods
regardless of their background. The participation of migrants or ethnic minorities
in health surveys is typically lower than in the majority population 40], 41]. Research has indicated that a combination of register-based and community-based
sampling approaches contributes to survey participation of diverse population groups
41]. Both approaches will be used in this survey. In the first step, a register-based
approach will be applied including random sampling from the residents’ registration
office. Participants will be contacted via the post and informed about the study.
Information materials will be provided in several languages. As some of the residents
in the neighbourhoods may be undocumented, it is necessary to use additional sampling
strategies. Community-based sampling strategies will, for example, entail using the
community networks established through the various research activities including street-mapping,
in-depth interviews and distribution of study materials in the neighbourhoods.

There are no exact assumptions for the survey’s sample size determination as the research
hypotheses (endpoints and determinants) will be generated via ethnographic investigation.
We roughly aim for 4,800 responses, 600 in each neighbourhood, to allow for comparisons
across neighbourhoods and countries.

Statistical analysis

Using multivariate analysis, we will systematically explore the relationships between
welfare regimes and welfare bricolage models, and develop new knowledge about the
types of models utilised by individuals with different characteristics across neighbourhood,
national and transnational levels. Descriptive statistics will initially profile each
neighbourhood. Multivariate analysis will be conducted to model welfare bricolage
based on individual and context specific factors. Depending on the measurement of
our dependent variables, possible statistical models include binary and ordinal logistic
regressions, and structured equation models.

Ethics statement and consent

Ethical approval for all study procedures was obtained from the Ethical Review Committee
of the University Birmingham. All participants in the in-depth interviews and the
health survey will receive written and/or oral information about the study. All interviewees
will give informed consent for their data to be used.