Barriers of Accessing Health Services: Refugees in South Wales

The study aims to investigate the barriers to accessing health services for refugees in South Wales. By examining people's experiences of using health services, I want to find out what are the policy implications on people's lives. This study is essential as the global refugee crisis has given rise to considerable controversies around the health policies of the refugees and asylum seeker, and because the UK government’s spending cuts on health services are targeting at this vulnerable group (NHS, Public Health England, 2019).

This proposal is in three sections; section one introduces the research question within a specific research field, where I demonstrate theoretical knowledge. In section two, I discuss how my epistemology of choice fits into the research field and how it helps answer the research question. In sections three and four, I defend my research design and offer a comprehensive account of the various research actions. Last but not least, I explain how my study meets the requirements of validity, reliability, and ethics.

In this study, I discuss the barriers that prevent refugees from accessing health services and raise ethical and practical questions around health policy gaps. I am asking questions around:

1. How does the current UK health policy cater to the particular needs of refugees?
2. What barriers prevent refugees from accessing health services?
3. What are the health policy's long-term implications on the refugees' social integration?

Health policy is a set of actions taken to achieve particular healthcare aims, such as improving the quality of life of particular groups. Health policy is split into categories, public health policy, healthcare services policy, mental health policy, and covers topics from financing to quality to care, using various conceptual models to develop and implement evidence-based programmes (Nagel & MacRae, 1980). The philosophical debates on health policy center around ideas of ethics, individual rights, and authority (Ascher, 1986). Health policy is part of policy studies and a subdiscipline of political science (Parsons, 1995). Health policy discusses the relationship between institutions and their interests, focusing on understanding policy success/failure to inform implementation (Lee et al., 2002). Health policy is often criticised for lacking focus on research design, theory, and methodology (Reich & Cooper, 1996). The broader field of policy studies includes research areas, such as environmental policy and education policy, and it incorporates analytical approaches of policymaking and analysis. Policy studies are interested in locating and resolving issues that affect society and the public sector by creating and implementing policies using interdisciplinary analysis (Sabatier, 1991).

The UK's health policy on service access for asylum seekers and refugees is split into two phases, based on the legal status of the claimant. Asylum seekers who are going through the British legal system by applying for refugee status and asylum seekers who have not been successful and face deportation; both groups are provided with the minimum standard of health care. Refugees, claimants who have been successful with their asylum claims in the UK, have legal access to secondary, optical and dental care, mental health care provision and coverage of travel costs from/ to the hospital (NHS, Public Health England, 2019). The World Health Care Report (2006) indicates that there is a shortage of appropriate services for asylum seekers and refugees, and highlights the lack of pragmatic responses and evidence-based evaluations that take into consideration the specific needs of such vulnerable populations. Significant gaps in legal and practical policy implementation have also been highlighted, such as being eligible to access health services and being able to do so.

Critical realism, as an epistemological approach, was advanced to address the limitations of relativism and positivism (Bhaskar, 1989); as it explains claims to truth and knowledge using natural and human sciences (Connelly, 2000). According to Bhaskar (1989), critical realism claims that various structures and practices can exist independently, irrespective of whether their existence or effects can be observed, is known and /or fully understood by humans. This critical realist differentiation between research and experience is crucial for health care, as reality is understood to exist beyond the observable phenomena, and it includes powers and mechanisms that impact what is seen (Bhaskar, 1989). This connotes that there are "real" connections between phenomena, and are comprised of characteristics resulting in specific outcomes (Sayer, 2000). Critical realism suggests that those characteristics in a social context contain a multitude of rules and values that produce their interpretations (Pawson & Tilley, 1998). Thus, it offers theoretical and critical focus that makes research findings consistent and easily duplicatable, essentially providing unique explanations for health policy and driving better understating of health care approaches (Riemsma et al., 2003). Critical realism is used more in empirical health policy work, as it is critical in focus and theoretical in approach, elements which are relevant and useful (Archer, 1995). Health policy's "logic" is not contradicted by critical realism, the supposition that reality exists independently of social and cultural factors, but it can be objectively adapted (Kikuchi & Simmons, 1996). Health policy critical realist approaches invite methodological multiplicity while drawing from wider theoretical debates (Ruspini, 1999). As health policy is separated into various academic fields with different knowledge and numerous characteristics, critical realism suggests an approach to merge these fields that permits theory development (Ruspini, 1999). Critical realist approaches define what can be easily applied to other areas of health policy, such as service diversity, that are primarily dominated by individualistic approaches with questionable approaches to change promotion (Smith, 2003). Critical realism advocates for less complicated concepts, especially around health policy evaluation, thus, making the underlying philosophy easily accessible, and widely understood (Smith, 2003).

Longitudinal research in the qualitative paradigm is less established than in the quantitate paradigm (Strauss & Corbin, 1998). Qualitative longitudinal research offers a variety of tools and methods for data collection and analysis, such as descriptive questions that allow the researcher to conduct in-depth analysis and rich level of interpretation (Pettigrew, 1995). In this study I conduct a qualitative longitudinal research study, as it will help me to engage with repeated observations on the barriers to accessing health services for refugees in South Wales and examine the health policy's long-term implications on the refugees' social integration; looking at the same group of refugees over the period of three years. A longitudinal design is paramount when attempting to study the effect of changes and /or barriers, discussing in-depth the changes in behaviour and/ or attitudes and debate on the development of trends over time (Pettigrew, 1995).

I'm approaching this qualitative longitudinal study from an observational standpoint, as the phenomena in question are observed without being manipulated (Merriam, 1998). The repeated observations, due to the longitudinal dimension of the study, are more likely to pick up on barriers accessing health services, as a result to policy changes that would not be captured if using a cross-sectional design (Becker & Bryman, 2004). Even though longitudinal studies are time-consuming and expensive, they are crucial for prospective evidence-based health policy, as they require new data collection to focus on future policy (Barnes et al., 2005). Unlike cross-sectional design which focuses in comparing different people with the same attributes/ characteristics, longitudinal research emphasises on the same group of individuals, and it allows researchers to observe changes/barriers over time in more detail. In evidence-based policy health policy, the longitudinal design is primarily used to identify policy gaps, possibilities, and amendments required to better a policy (Shadish et al., 2002).

This longitudinal study's sample shares the same defining characteristics; their newly appointed (less than a year) legal status of "refugee" and their choice of the location in South Wales. Longitudinal studies do not require a large number of participants (van der Krieke et al., 2016), therefore, I will include 25 participants from this vulnerable group; the main cohort characteristic, the refugee status, will remain stable throughout the study, allowing for more accurate interpretation of the findings (Milles & Huberman, 1998). Even though longitudinal studies acquire appropriate information to examine change and impact over time, they are not sample-based generalisations. It is important to note that my sample is not homogenous, as not all refugees share the same ethnic background, age, educational level or health profile, thus, further analytical challenges are posed, as not all sample parameters can be evaluated (Thordvalson et al, 2006).

The time interval will be six months, to allow for examination of the barrier manifestations, as well as their variations over time. The time interval is critical in longitudinal research for establishing causality, as changes in health policy require time to provide adequate manifestations on health. This interval is appropriate for a study of this size, as the data collection is determined by other logistical factors, such as the UK and local government policy decisions (Bolger & Laurenceau, 2013). Due to this intensive measurement design, individual diaries will be kept by the participants to track social barriers, as a form of additional assessment that will be used for analysis ((Bolger & Laurenceau, 2013). The diaries aim to trigger participant interaction, as longitudinal studies regularly suffer from missing data or critical reflections on significant changes ((Bolger & Laurenceau, 2013). The interval breath associated with longitudinal design will be short, as this study has a very narrow focus, due to the particular health needs of the sample, thus, affecting the generalisability (Bolger & Laurenceau, 2013). It is not unusual for longitudinal studies on health policy to report that the expected barriers/ changes have the opposite outcomes on the population, as the policy is influenced at local government level and by third sector initiatives but is not always evidence-based. Thus, using assessment schedules to accumulate evidence is essential in order to make clear distinctions between the social-political barrier of the health services over specific lengths of time (Bolger & Laurenceau, 2013). Cross-study comparison and evaluation of the findings generalisability is required when dealing with cross-cultural samples, such as refugees. Looking at existing longitudinal studies informs the analysis protocol, which is particularly helpful in health policy when certain aspects of existing studies can be replicated but provide widely different findings (Sztompka, 1993).

I will conduct semi-structured, one-to-one interviews to produce detailed answers (Wolcott (1994). Saldana (2016) explains that longitudinal qualitative interview questions are not linear, and clusters them into three sets of questions. I will base my interview questions on Saldana's approach. I will begin by framing questions that introduce and explain the essential administrative and management duties that will run throughout the study. I will proceed with the descriptive questions, whose answers build upon the foundations of the framing questions, addressing particular social contexts and changes that occur over time. Finally, I will focus on the analytic and interpretive questions, which are synthesised using knowledge from both the descriptive and the framing questions, focusing on critical examination and understanding. Saldana (2016) suggests that the repeat interviews in qualitative longitudinal studies identify and highlight changes, as well as the progressive developments related to such changes.

My proposed research's reliability is subject to the participants' unexpected life events and policy/ legislative changes (Carroll, 2002). I will be relying on official UK government policy documents to track the health policy changes and barriers, as they provide the political context. I will examine various UK based newspaper articles, to critically scrutinise the social perspective and will also look at related academic publications for their theoretical point of view. The semi-structured interviews will offer the real-life context. The study’s reliability is concerned with recording all the unanticipated changes and their characteristics, in order not to jeopardise the study's reproducibility (Carroll, 2002). Reproducibility in qualitative research refers to the close relationship between the findings and methodology used to reach the findings (Leek & Peng, 2015). Reproducibility is closely related to replication, which refers to achieving similar findings when there are differences in sampling (Leek & Peng, 2015). To ensure this study's reliability, I will be taking extensive field notes, convert them into formal notes, and incorporate them in the analysis. By recording the sequence of changes /barriers, a reliable account will be produced, which will strengthen the accuracy of the research (Leek & Peng, 2015). All participants will be asked to keep reflexive diaries to record thoughts, feelings, and perceived barriers, which later will be used as part of my methodology. Longitudinal reliability checks the empirical timeframe by examining the process, so if another researcher would discover the same events, in the same sequence and would arrive at the same conclusions (Carney, 1979). Ward and Street (2009) suggest that longitudinal data collection reliability can be approached through data triangulation. Triangulation allows for the data to be measured by different sources, using different methods to cover the same occurrence (Jick, 1979). Triangulation allows for overlapping perspectives on the same occurrence; measuring reliability from different sources makes the study trustworthy (Jick, 1979). Triangulation is paramount for longitudinal research because the aim is to reliably record the time when the changes occur, and what happened (Lustick, 1996). Achieving triangulation from various data sources is vital in demonstrating how accurate the timeframe has been structured and captured (Golden, 1992).

In order to ensure the validity of this study, I will investigate the three different types of longitudinal timeframe that relate to my study; time unit, time boundaries, and time period validity. Time unity creates validity by accessing the sensitivity and appropriateness of the chosen time unit (Winter, 2000). If the time unit is too large or too small to capture change it will cause inaccuracy (Lee, 1999). In policy research, the time unit validity is assessed by questioning whether the chosen time unit will be destabilised by political events, such as elections or cabinet reshuffling (Brown & Eisenhardt, 1997). I will use reports, monthly columns, and newsletters to validate the time unit. Time boundaries create validity by focusing on whether the observation window, from the beginning until the end of the study, is aligned to capture all critical occurrences over time (Ward & Street, 2009). Time boundaries validity and content validity are co-dependent; thus, if the time boundaries are not accurately mirrored the content validity is minimised (Street & Ward, 2009). Failing to explain time boundaries poses further threats to the longitudinal validity, such as data censoring, and spoiler effect. Data censoring can occur if the start and end time points are not appropriate, threatening timeframe, validity, and reliability (Ward & Street, 2009). Spoiler effect can occur if the inappropriate boundaries and data censoring highlight an unexpected result (Ward & Street, 2009). In order to deal with boundary validity, I will choose the observation window to be soon after the general election, because it is usually when new health policies are introduced. I will turn to archival documentation to clarify how much health policies for refugees change when new ministers take office. Time validity can be used independently to explain whether the observed periods are representative of the process, as time risks can indicate the start or the finish of the research process (Ward, 2007). In this study, the representative time is soon after the refugees get their legal status in order not to risk any spoiler effects.

For a study the involves vulnerable groups ethic is paramount. Qualitative longitudinal studies heighten the ethical issues around ideas of informed consent (Farrall, 2006). According to Crow at al., (2006) qualitative longitudinal research should not rely on a one-off agreement but incorporate the notion of informed consent throughout the process. Holland et al. (2006) add that a repeated consent process is imperative, especially on health-related topics and life-course studies, a strategy which I follow for this study. France at al., (2000) highlight the importance of openly discussing the ethical challenges regarding the information provided by participants who choose to withdraw from the study. In this study, I will focus on communicating such ethical challenges to my participants to gain their trust. Graham et al. (2006) explain that issues around data usage, protection, and confidentiality are especially sensitive when interviews are repeated, as the researcher – participant(-s) interactions produce large amounts of detailed data. Thomson and Holland (2003) suggest that it is the responsibility of the researcher to care and maintain the privacy and anonymity of the participants throughout the study, regardless of whether the participants have decided to withdraw from the study. I will be storing the collected data on the password-protected university's cloud. They also discuss the ethical issue of participants using the study to gain self-awareness after self-reflecting with the researchers and how this can modify the study's findings, an issue I will tackle with the use of participant diaries (Graham et al., 2005). Researchers should encourage participants to make choices regarding their participation by incorporating reflection and project the study's future outcomes, as well as working closely with the participants to accommodate their interview needs and make their involvement enjoyable and easy to access Saldana (2016). I will be contactable and using an open e-calendar throughout the study, so the participants can ask questions, raise their concerns, and be fully updated on the study's progress.

For this proposal, I formulated the main research question, identified subs equate research questions, and highlighted research aims and objectives. I proceeded to locate the appropriate epistemology and structure the research design and justified my choices by discussing the strengths and weaknesses of my ontological and epistemological methodologies and methods. Moreover, I showcased understating around the concepts of validity and reliability and raised questions about ethics.

References

• Archer, M., (1995), Critical Realist Social Theory. Cambridge University Press: Cambridge.
• Ascher, W., (1986), The evolution of the policy studies: Understanding the rise and avoiding the fall, Journal of Policy Analysis and Management. 5 (2), 365- 373. 

• Barnes, H., Hudson, M., Parry, J., Sahin-Dikmen, M., Taylor, R., Wilkinson, D., (2005), Ethnic Minority Outreach: An Evaluation, DWP Research Report No. 229, Leeds Corporate Document Services.
• Becker, S., Bryman, A., (2004), Understanding Research for Social Policy and Practice, Bristol: The Policy Press.

• Bhaskar, R., (1989), Reclaiming Reality: A Critical Introduction to Contemporary Philosophy. Verso.
• Bolger, N., Laurenceau, J-P., (2013), Intensive Longitudinal Methods: An Introduction to Diary and Experience, The Guildford Press: New York.
• Brown, S., Eisenhardt, K., (1997), The art of continuous change: linking complexity theory and time-paced evolution in relentlessly shifting organizations. Administrative Science Quarterly, 42 (1), 1-34.
• Carney, T., (1979), Content Analysis: A Technique for Systematic Inference from Communications. Winnipeg: University of Manitoba Press.
• Carroll, C., (2002), Introduction, special issue, Journal of Organizational Change Management, 15 (5), 556-563.
• Connelly, J., (2000), A realist theory of health sector management: the case for critical realism. Journal of Management in Medicine, 14 (4), 262-27.
• Crow, G., Wiles, R., Health, S., Charles, V., (2006), Research ethics and data quality: the implications of informed consent. International Journal of Social Research Methodology, 9 (2), 83-95.
• Elgar, E., (1995), Public Policy: An Introduction to the Theory and Practice of Policy Analysis. University of Michigan.
• Farrall, S., (2006), What is qualitative longitudinal research? LSE Methodology Institute Papers in Social Research Methods, Qualitative Series 11.
• France, A., Bendelow, G., Williams, S., (2000), A risky business: research the health beliefs of children and young people, Researching Children’s Perspectives, Open University Press: Buckingham.
• Golden, B., (1992), The past is in the past-or is it? The use of retrospective account as indicators of past strategy. Academy of Management Journal, 35 (4), 848-860.
• Graham, J., Tennant, R., Huxley, M., O’Connor, W., (2005), The Role of Work in Low-income Families with Children – A Longitudinal Qualitative Study, Department of Work and Pensions Research Report No. 245, Leeds: Corporate Document Services.
• Holland, J., Thomson, R., Henderson, S., (2006), Qualitative Longitudinal Research: A Discussion Paper, Families and Social Capital ESRC Group, London: South Bank University.
• Jick, T., (1979), Mixing qualitative and quantitative methods: triangulation in action. Administrative Science Quarterly, 24 (4), 602-611.
• Kikutchi, J., Simmons, H., (1996), Developing a philosophy of nursing, Sage Publications: Thousand Oaks.
• Lee, K., Buse, K., Fustukian, S., (2002), Health Policy in a Globalizing World, Cambridge University Press.
• Lee, T., W., (1999), Using Qualitative Methods in Organizational Research. Sage Publications: Thousand Oaks.
• Leek, J. T., Peng, R.D., (2015), Reproducible research can still be wrong: Adopting a prevention approach, Proceedings of the National Academy of Sciences of the United States of America. 112 (6): 1645-1646.
• Lustick, L., (1996), History, historiography, and political science: multiple historical records and the problem of selection bias. American Political Science Review. 90 (3), 605-618.
• Merriam, S., (1998), Qualitative Research and Case Study Applications. San Jossey-Bass: Francisco.
• Milles, M., Huberman, A., (1994), Qualitative Data Analysis, Sage Publications: Thousand Oaks.
• Nagel, S.S., MacRae, D., (1980), The Policy Studies Perspective, Public Administration Review. 40 (4): 391-396.
• NHS, Public Health England (2019).
• Pawson, R., Tilley, N., (1998), Realistic Evaluation, Sage Publications: London.
• Pettigrew, A., (1995), Longitudinal field research on change: Theory and practice. Longitudinal field research methods. Sage Publications: Thousand Oaks.
• Reich, M., Cooper, D., (1996), Policy maker computer-assisted political analysis. Polimap: Newton Center.
• Riemsma, R., Pattenden, J., Bridle, C., Sowden, A., Mather, L., Watt, I., Walker, A., (2002), A systematic review of the effectiveness of interventions based on a stages-of-change approach to promote individual behavior change, Health Technology Assessment, 6 (24), 1-231.
• Ruspini, E., (1999), Longitudinal research and the analysis of social change, Quality and Quantity, 33 (4), 219-227.
• Sabatier, P., (1991), Political Science and Public Policy, Political Science & Politics. 24 (2): 144-147.
• Saldana, J., (2016), The Coding Manual for Qualitative Researchers (3ed), Sage Publications: Thousand Oaks.
• Sayer, A., (2000), Realism and Social Science, Sage Publications: London.
• Shadish, W., Cook, T., Campbell, D., (2002), Experimental and quasi-experimental designs for generalized causal inference, Houghton Mifflin Company: Boston.
• Smith, N., (2003), Cross-sectional profiling and longitudinal analysis: research notes an analysis in the longitudinal qualitative study, Negotiating Transitions to Citizenship, International Journal of Social Research Methodology, 6 (3), 273-277.
• Strauss, A., Corbin, J., (1998), Basics of qualitative research. Sage Publications: Thousand Oaks.
• Sztompka, P., (1993), The sociology of social change, Blackwell Publishers: Oxford.
• Thomson, R., Holland, J., (2003), Hindsight, foresight and insight: the challenges of longitudinal qualitative research. International Journal of Social Research Methodology, 6 (3), 233-244.
• Thorvaldsson, V., Hofer, S., Berg, S., Johansson B., (2006), Effects of repeated testing in a longitudinal age-homogeneous study of cognitive aging, The Journals of Gerontology, 61 (6), 348-354.
• van der Krieke, L., Blaauw, F., Emerencia, A., Schenk, H., Slaets, J., Bos, E., de Jonge, P., Jerominus, B., (2016), Temporal dynamics of health and well-being, Psychosomatic Medicine 1 (4) 28-39.
• Ward, K., Street, C., (2009), Encyclopedia of Case Study Research, Sage Publications: Thousand Oaks.
• Winter, G., A., (2000), Comparative discussion of the notion of validity in qualitative and quantitative research. The Qualitative Report, 4 (3&4), 479-493.
• Wolcott, H. F. (1994). Transforming qualitative data: Description, analysis, and interpretation. Sage Publications: Thousand Oaks.
• World Health Organization, (2006), The World Health Report: Working together for health.